Hemodialysis catheter-associated fibrin sheaths: treatment with a low-dose rt-PA infusion.
OBJECTIVE
To prospectively evaluate the efficacy of a low-dose, 3-hour recombinant tissue plasminogen activator (rt-PA) infusion for the treatment of hemodialysis catheter (HDC)-associated fibrin sheaths.


METHODS
Seventeen patients with end-stage renal disease (female, n = 11; male, n = 6), who were undergoing catheter-directed hemodialysis, were evaluated for 28 episodes of HDC dysfunction. This patient group ranged in age from 25 to 92 years (mean, 57 years). Radiographic contrast and/or clinical evaluation were consistent with the presence of a fibrin sheath on either the arterial and/or venous port in all cases. Patients subsequently underwent a thrombolytic infusion consisting of 2.5 mg rt-PA in 50 mL normal saline at a rate of 17 mL/h (3-hour infusion) per port. All infusions were performed in the interventional radiology recovery room, on an outpatient basis. Patients were followed-up prospectively for technical success, complications, catheter patency, and long-term outcome.


RESULTS
The immediate technical success rate, defined as return of manual aspiration and infusion capabilities to both ports, was 100%. No potential patients required exclusion from thrombolytic therapy secondary to contraindications, and no procedure-related complications occurred. The arithmetic mean and median catheter patency at the end of the study was 41 and 25 days, respectively (range, 1-116 days). A Kaplan-Meier survival analysis yielded a 30-, 60-, and 90-day probability of patency of 0.67, 0.61, and 0.51, respectively. At the end of the study period, all 17 patients remained on catheter-directed hemodialysis and 13 (76%) were utilizing the same catheter present at the time of entrance into the study.


CONCLUSIONS
Thrombolytic therapy utilizing a 2.5-mg rt-PA infusion through each port during a 3-hour period would appear to be a safe, efficient method for treating HDC-associated fibrin sheaths. Three-month patency rates are comparable to those reported for other methods of restoring function to HDC catheters, including new catheter placement, catheter exchange over a guide wire, thrombolytic infusions with urokinase, and percutaneous fibrin sheath stripping.
Savader
S J
SJ
Department of Radiology, Methodist Hospital, Indianapolis, IN 46202, USA. ssavader@clarian.com
Haikal
L C
LC
Ehrman
K O
KO
Porter
D J
DJ
Oteham
A C
AC
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002405:Catheterization, Central Venous; D002408:Catheters, Indwelling; D004868:Equipment Failure; D005260:Female; D005337:Fibrin; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015641:Radiography, Interventional; D006435:Renal Dialysis / Q000295:instrumentation*; D016019:Survival Analysis; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D016896:Treatment Outcome; D014654:Vascular Patency
D005343:Fibrinolytic Agents; D005337:Fibrin; D010959:Tissue Plasminogen Activator