title: Catheter-directed thrombolysis in deep venous thrombosis with use of reteplase: immediate results and complications from a pilot study.
abstract: OBJECTIVE
  To prospectively determine the thrombolytic success and complication rates of catheter-directed thrombolytic infusions in deep vein thrombosis (DVT) with use of reteplase.
  
  
  METHODS
  After approval by the institutional review board, prospective, detailed data were obtained for 25 consecutive patients with acute and chronic DVT of the upper or lower extremity (seven upper extremity; 14 lower extremity; four vena cava). Infusion rates were 1.0 U/h in five patients and 0.5 U/h in the remaining 20. Subtherapeutic heparin doses of 300-400 U/h were administered. Thrombolytic success was defined as 95% thrombolysis with return of antegrade flow. Data, including complications such as bleeding, need for transfusions, and laboratory values (fibrinogen, platelets, hematocrit, hemoglobin, and prothrombin time) were obtained throughout the infusions.
  
  
  RESULTS
  The total dose of reteplase administered ranged from 2.5 to 42 U (median, 16.5 U). The total infusion time ranged from 0.3 to 84 hours (median, 29 h). Thrombolytic success was achieved in 92% of patients. Endovascular stent placement and/or percutaneous transluminal angioplasty were required in 52% of patients to ensure maintenance of patency. Pre- and postprocedural average fibrinogen levels were 340 mg/dL and 315.3 mg/dL, respectively. The lowest mean fibrinogen levels for the two dose groups were 265.86 mg/dL for the 0.5 U/h group and 314.18 mg/dL for the 1.0 U/h group. The lowest fibrinogen level during the procedure was 252.3 mg/dL (range, 35 to >700). There were only two instances of fibrinogen levels that decreased to below 90 mg/dL: 35 mg/dL and 43 mg/dL. Thrombolytic failures occurred in two patients: one with acquired immune deficiency syndrome in a hypercoagulable state and one with a major bleeding complication. This was the only patient with a bleeding complication (4%). Hemorrhage occurred from the site of a previous mediastinal biopsy-which should have rendered her ineligible for the study-performed 18 hours before the thrombolysis. If thrombolysis had not been attempted in this patient, the complication rate would have been 0%.
  
  
  CONCLUSIONS
  Although there are reports of thrombolytic therapy in peripheral vascular occlusive disease, this study is one of the first to evaluate thrombolytic drugs in the deep venous system exclusively. Reteplase was found to be effective in the thrombolytic treatment of acute and chronic DVT.
authors.affiliation: Department of Radiology, University of Illinois College of Medicine at Peoria, 1 Illini Drive, Box 1649, Peoria, Illinois 61656, USA. flavio@miit.com
authors.forename: Flavio
authors.initials: F
authors.lastname: Castaneda
authors.forename: Ruizong
authors.initials: R
authors.lastname: Li
authors.forename: Kate
authors.initials: K
authors.lastname: Young
authors.forename: James L
authors.initials: JL
authors.lastname: Swischuk
authors.forename: Bob
authors.initials: B
authors.lastname: Smouse
authors.forename: Terry
authors.initials: T
authors.lastname: Brady
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002404:Catheterization / Q000009:adverse effects*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D035002:Lower Extremity / Q000098:blood supply; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D011446:Prospective Studies; D011994:Recombinant Proteins / Q000627:therapeutic use*; D015912:Thrombolytic Therapy / Q000009:adverse effects*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D034941:Upper Extremity / Q000098:blood supply; D020246:Venous Thrombosis / Q000188:drug therapy*
chemical_list: D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; C087896:reteplase; D010959:Tissue Plasminogen Activator