Challenges in Treating Neonatal Acute Limb Ischemia: Conservative Management With Successful Limb Salvage

Acute limb ischemia (ALI) in neonates is a rare but critical condition often resulting from iatrogenic causes, such as arterial catheterization. This case highlights the unique challenges in diagnosing and managing ALI in this population, where evidence-based guidelines are scarce and treatment decisions rely heavily on expert consensus and extrapolation from adult data. We report the case of a premature neonate, born at 30 weeks' gestation, who developed ALI secondary to femoral artery thrombosis following arterial line insertion. The patient presented with bluish discoloration, diminished capillary refill, and absent distal pulses in the affected limb. Duplex ultrasonography confirmed occlusion of the right common femoral artery. Conservative management with anticoagulation and close observation was adopted by multidisciplinary consensus involving neonatology and vascular surgery. Despite signs of worsening ischemia and skin necrosis during therapeutic anticoagulation, the team opted to continue conservative management due to the high surgical risk posed by the patient's prematurity and multiple comorbidities. Over the next week, gradual clinical and imaging improvements were noted, including recanalization of the occluded artery and restoration of arterial flow, ultimately leading to successful limb salvage. This case underscores the importance of individualized, multidisciplinary decision-making in managing neonatal ALI. Conservative management with therapeutic anticoagulation can achieve favorable outcomes, even in cases with worsening ischemia, provided that close monitoring and optimal supportive care are ensured. It also highlights the need for further research to develop standardized pediatric guidelines for this rare but potentially devastating condition.