title: Use of argatroban and catheter-directed thrombolysis with alteplase in an oncology patient with heparin-induced thrombocytopenia with thrombosis.
abstract: OBJECTIVE
  The case of an oncology patient who developed heparin-induced thrombocytopenia with thrombosis (HITT) and was treated with argatroban plus catheter-directed thrombolysis (CDT) with alteplase is presented.
  
  
  CONCLUSIONS
  A 63-year-old Caucasian man with renal amyloidosis undergoing peripheral blood stem cell collection for an autologous stem cell transplant developed extensive bilateral upper-extremity deep venous thrombosis (DVT) and pulmonary embolism secondary to heparin-induced thrombocytopenia. A continuous i.v. infusion of argatroban was initiated, and the patient was managed on the general medical floor. After one week of therapy, he was transferred to the intensive care unit with cardiopulmonary compromise related to superior vena cava (SVC) syndrome. A percutaneous mechanical thrombectomy and CDT with alteplase were attempted, but the procedure was aborted due to epistaxis. The epistaxis resolved the next day, and the patient was restarted on argatroban. A second percutaneous mechanical thrombectomy was performed six days later and resulted in partial revascularization of the SVC and central veins. Postthrombectomy continuous CDT with alteplase was commenced while argatroban was withheld, and complete patency of the SVC and central veins was achieved after three days of therapy. Alteplase was discontinued, and the patient was reinitiated on argatroban; ultimately, he was transitioned to warfarin for long-term anticoagulation. Although the patient recovered, he experienced permanent vision and hearing loss, as well as end-stage renal disease.
  
  
  CONCLUSIONS
  A 63-year-old man with renal amyloidosis and SVC syndrome secondary to HITT was successfully treated with argatroban and CDT with alteplase.
authors.affiliation: Brian Dee, Pharm.D., BCPS, BCNSP, is Clinical Pharmacy Specialist-Critical Care/Nutrition Support; Lindsey Lombardi Thomas, Pharm.D., BCOP, is Clinical Pharmacy Specialist-Stem Cell Transplantation; and Alison Gulbis, Pharm.D., BCOP, is Clinical Pharmacy Specialist-Stem Cell Transplantation, Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston.
authors.forename: Brian
authors.initials: B
authors.lastname: Dee
authors.forename: Lindsey
authors.initials: L
authors.lastname: Lombardi Thomas
authors.forename: Alison
authors.initials: A
authors.lastname: Gulbis
mesh_terms: D000991:Antithrombins / Q000627:therapeutic use*; D001120:Arginine / Q000031:analogs & derivatives; D064592:Autografts; D002404:Catheterization; D004359:Drug Therapy, Combination; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006493:Heparin / Q000009:adverse effects; D006801:Humans; D008297:Male; D008875:Middle Aged; D036102:Peripheral Blood Stem Cell Transplantation; D010875:Pipecolic Acids / Q000627:therapeutic use*; D013449:Sulfonamides; D013921:Thrombocytopenia / Q000139:chemically induced / Q000188:drug therapy*; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D020246:Venous Thrombosis / Q000188:drug therapy*
chemical_list: D000991:Antithrombins; D005343:Fibrinolytic Agents; D010875:Pipecolic Acids; D013449:Sulfonamides; D006493:Heparin; D001120:Arginine; D010959:Tissue Plasminogen Activator; C031942:argatroban