title: Pulmonary embolism from pulse-spray pharmacomechanical thrombolysis of clotted hemodialysis grafts: urokinase versus heparinized saline.
abstract: OBJECTIVE
  To compare the frequency and extent of pulmonary embolism (PE) occurring during pulse-spray pharmacomechanical thrombolysis (PSPMT) of clotted hemodialysis grafts with use of either urokinase (UK) or heparinized saline (HS). Postintervention primary patency and complication rates were compared for each method of thrombolysis.
  
  
  METHODS
  Twenty-seven patients were enrolled in this prospective, randomized, double-blind study evaluating PE with two PSPMT agents. The doses of heparin were similar between groups. The only variable was that one group of patients received UK and the other received HS. In two cases, the venous anastomosis could not be crossed. Eleven patients were treated with UK and 14 with HS. Nuclear medicine perfusion lung scans were performed before treatment and after graft declotting procedures. Lung perfusion was quantified to 10% of a pulmonary segment (0 = normal perfusion, 1 = segmental perfusion defect), with nine segments counted for each lung.
  
  
  RESULTS
  Baseline nuclear medicine perfusion lung scan results were abnormal (> or = 20% segmental perfusion defect) in 19 patients (70.4%). New PE (one or more pulmonary segments) occurred in two patients treated with UK (18.2%) and nine patients treated with HS (64.3%; P = .04). All cases of PE were asymptomatic. Quantitative global pulmonary perfusion analyses revealed that treatment with UK improved flow to 0.2 +/- 2.0 pulmonary segments, whereas treatment with HS decreased perfusion to 1.0 +/- 1.7 segments (P = .16, NS). Although postintervention primary patency rates were similar according to life-table analysis (P = .76, NS), complication rates were higher with use of HS (n = 4, 28.6%) than with use of UK (n = 2, 18.2%) (P = .6, NS).
  
  
  CONCLUSIONS
  All PE were asymptomatic during PSPMT, but treatment with UK reduced the rate of PE and tended to result in smaller defects in lung scan results. Most patients undergoing hemodialysis have abnormal baseline perfusion scan results, but PSPMT with UK improved many of them. The postintervention primary patency rates were similar between groups, but complications were more frequent after treatment with HS.
authors.affiliation: Department of Radiology, University of California San Diego Medical Center, USA.
authors.forename: T B
authors.initials: TB
authors.lastname: Kinney
authors.forename: K
authors.initials: K
authors.lastname: Valji
authors.forename: S C
authors.initials: SC
authors.lastname: Rose
authors.forename: D D
authors.initials: DD
authors.lastname: Yeung
authors.forename: S B
authors.initials: SB
authors.lastname: Oglevie
authors.forename: A C
authors.initials: AC
authors.lastname: Roberts
authors.forename: D M
authors.initials: DM
authors.lastname: Ward
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D001807:Blood Vessel Prosthesis / Q000009:adverse effects*; D004311:Double-Blind Method; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects*; D006083:Graft Occlusion, Vascular / Q000188:drug therapy*; D006493:Heparin / Q000009:adverse effects*; D006801:Humans; D015993:Life Tables; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000139:chemically induced / Q000209:etiology* / Q000517:prevention & control; D015641:Radiography, Interventional; D006435:Renal Dialysis / Q000295:instrumentation*; D015912:Thrombolytic Therapy / Q000009:adverse effects*; D016896:Treatment Outcome; D014568:Urokinase-Type Plasminogen Activator / Q000009:adverse effects*; D014654:Vascular Patency
chemical_list: D005343:Fibrinolytic Agents; D006493:Heparin; D014568:Urokinase-Type Plasminogen Activator