title: Adjunctive intrapleural tissue plasminogen activator administered via chest tubes placed with imaging guidance: effectiveness and risk for hemorrhage.
abstract: OBJECTIVE
  To retrospectively determine the effectiveness of and risk for hemorrhage with intrapleural adjunctive tissue plasminogen activator (tPA) administered via chest tubes placed with imaging guidance.
  
  
  METHODS
  This HIPAA-compliant study was approved by the institutional review board of Massachusetts General Hospital, with informed consent waived. A retrospective review of 66 patients (age range, 1-95 years; mean age, 55 years; 44 male, 22 female) who received intrapleural tPA between 2000 and 2006 was performed. Overall effectiveness of tPA was defined as successful drainage without need for additional decortication or video-assisted thoracoscopic surgery. Primary and secondary effectiveness were defined as effectiveness after one and two cycles of tPA, respectively. Imaging findings and complications were recorded. Hemorrhagic complications were noted, and the Fisher exact test was used to show whether concurrent systemic anticoagulation increased bleeding risk.
  
  
  RESULTS
  Fifty-seven (86%) of 66 patients underwent complete drainage with tPA without further surgical procedures. Primary effectiveness was seen in 52 (87%) of 60 patients and secondary effectiveness was seen in five (83%) of six. Loculation of fluid was the most common finding in this selected cohort. Number of fluid pockets, pleural heterogeneity, and pleural thickness were not predictors of effectiveness. There were five major pleural hemorrhages in four patients across five tPA cycles. Hemorrhages occurred only in patients receiving therapeutic anticoagulation (four of 12) and in none of the other patients (P < .001). No hemorrhages occurred in the 38 patients receiving prophylactic anticoagulation.
  
  
  CONCLUSIONS
  Intrapleural tPA is effective in improving drainage of loculated effusions not drained with catheters alone; prophylactic systemic anticoagulation does not increase bleeding risk with intrapleural tPA, but therapeutic anticoagulation is associated with a significantly increased risk of pleural hemorrhage.
authors.affiliation: Department of Radiology, Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA 02114, USA. dgervais@partners.org
authors.forename: Debra A
authors.initials: DA
authors.lastname: Gervais
authors.forename: Diane A
authors.initials: DA
authors.lastname: Levis
authors.forename: Peter F
authors.initials: PF
authors.lastname: Hahn
authors.forename: Raul N
authors.initials: RN
authors.lastname: Uppot
authors.forename: Ronald S
authors.initials: RS
authors.lastname: Arellano
authors.forename: Peter R
authors.initials: PR
authors.lastname: Mueller
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects; D015505:Chest Tubes / Q000009:adverse effects; D002648:Child; D002675:Child, Preschool; D004322:Drainage / Q000379:methods; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D006470:Hemorrhage / Q000209:etiology*; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D015641:Radiography, Interventional; D012189:Retrospective Studies; D012307:Risk Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000009:adverse effects*; D014057:Tomography, X-Ray Computed
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator