The association of periprocedural hypertension and adverse outcomes in patients undergoing catheter-directed thrombolysis.
BACKGROUND
Peripheral thrombolysis is an indispensible tool in the treatment of occlusive peripheral vascular disease (PVD). However, the use of intravascular thrombolytic agents carries a significant risk of morbidity and mortality. The aim of this study is to review a contemporary series of patients treated with catheter-directed thrombolytics in the treatment of occlusive PVD.


METHODS
A retrospective analysis was performed reviewing all patients who underwent catheter-directed thrombolytic therapy for PVD with recombinant tissue plasminogen activator (rt-PA) between 2005 and 2008. Data included clinical and demographic variables potentially associated with endpoints of technical success, hemorrhagic complications, and death. Data were analyzed with univariate and multivariate measures. Significance was assigned with p <0.05.


RESULTS
Over the 36-month study, 125 thrombolytic procedures were performed. Indication for treatment was occlusive thrombus in native artery (49 cases, 37.6%), vein (13 cases, 10.4%), or arterial bypass graft (63 cases, 49.6%). Twenty three cases (14.3%) used ultrasound-assisted catheter technology. Mean patient age was 57.9 +/- 1.1 years. Technical success was achieved in 82% of cases. Mean rt-PA dose was 47.3 +/- 1.4 mg (13.5 +/- 4.5 mg with ultrasound assisted catheter technology). Hemorrhagic complications occurred in 22.4% of patients with a 5.6% stroke rate. Intracranial hemorrhage (ICH) correlated with poor hypertensive control (systolic blood pressure >160 mmHg; OR, 13.67; CI, 1.59-117.68; p = 0.006) and advanced age (>80 years; OR, 9.04; CI, 1.40-58.57, p = 0.049). Hemorrhagic complications (including minor access site hematomas) correlated with poor hypertensive control (systolic blood pressure >180 mmHg; OR, 3.48; CI, 1.22-9.94; p = 0.021) and in patients with congestive heart failure (OR, 3.26; CI, 1.09-9.76; p = 0.036). Overall mortality occurred in 7 patients (5.6%), 4 as a result of hemorrhagic complications. Correlates of mortality were patients with diabetes mellitus (OR, 8.85; CI, 1.62-48.26; p = 0.003), end stage renal disease (OR, 15.33; CI, 2.07-113.39; p < .001) and congestive heart failure (OR, 6.06; CI, 1.22-30.13; p = .014). Serum fibrinogen levels, pre-procedural hypertension, and rt-PA dosage did not correlate with hemorrhagic complication or death.


CONCLUSIONS
Peripheral thrombolysis with catheter-based technologies has a high incidence of technical success. However, the procedure continues to carry a significant complication rate. This study emphasizes the importance of periprocedural hypertensive control and identifies subgroups of patients at risk of untoward complications. On the basis of these data, the authors advocate stricter blood pressure parameters in patients undergoing peripheral thrombolysis.
Agle
Steven C
SC
Department of Cardiovascular Sciences, East Carolina University Brody School of Medicine, Greenville, NC 27834, USA.
McNally
Michael M
MM
Powell
C Steven
CS
Bogey
William M
WM
Parker
Frank M
FM
Stoner
Michael C
MC
D001157:Arterial Occlusive Diseases / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D001794:Blood Pressure; D002406:Catheterization, Peripheral; D016009:Chi-Square Distribution; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D006406:Hematoma / Q000139:chemically induced; D006801:Humans; D006973:Hypertension / Q000150:complications* / Q000188:drug therapy / Q000503:physiopathology; D020300:Intracranial Hemorrhages / Q000139:chemically induced; D016015:Logistic Models; D008875:Middle Aged; D009657:North Carolina; D016017:Odds Ratio; D011994:Recombinant Proteins / Q000009:adverse effects; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000139:chemically induced; D015912:Thrombolytic Therapy / Q000009:adverse effects* / Q000401:mortality; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000009:adverse effects*; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional; D020246:Venous Thrombosis / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology
D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator