title: Catheter-directed thrombolysis with alteplase and bivalirudin in a patient with heparin-induced thrombocytopenia.
abstract: OBJECTIVE
  The case of a patient with confirmed heparin-induced thrombocytopenia (HIT) and anticoagulation failure undergoing catheter-directed thrombolysis (CDT) with alteplase and bivalirudin for extensive thrombosis is reported.
  
  
  CONCLUSIONS
  A 48-year-old, morbidly obese Caucasian woman was admitted to a trauma-surgical intensive care unit (TSICU) after a motor vehicle accident. The patient suffered aortic and renal lacerations, multiple rib and spinal fractures, pleural effusion, bilateral subdural hematomas, and cerebral edema. An inferior vena cava (IVC) filter was placed on hospital day 3, and prophylactic enoxaparin was initiated. The patient was diagnosed with HIT on hospital day 10. Systemic bivalirudin was initiated, and the patient was transitioned to therapeutic fondaparinux on hospital day 13. The patient continued to improve and was transferred from the TSICU to a step-down unit a few days later; the IVC filter remained in place. On hospital day 20, the patient developed respiratory distress and was transferred back to the TSICU. Computed tomography angiography was performed and revealed a questionable pulmonary embolism and distended IVC and iliac veins. Lower-extremity Doppler ultrasound revealed extensive thrombosis. On hospital day 21, the patient underwent CDT with alteplase and bivalirudin infusions through two CDT sheaths for approximately 36 hours, after which most of the thrombus had dissipated. The IVC filter and drug administration sheaths were removed. After the procedure, the patient received bivalirudin and was later transitioned to warfarin.
  
  
  CONCLUSIONS
  A 48-year-old woman with HIT and anticoagulation failure possibly due to the presence of an IVC filter was successfully treated with CDT using alteplase and bivalirudin.
authors: Larissa A. Martinez, Pharm.D., is Clinical Pharmacist, University of New Mexico Hospital, Albuquerque. Allison E. Burnett, Pharm.D., Ph.C., CACP, is Clinical Team Lead-Inpatient Anticoagulation Service, University of New Mexico Hospital, and Clinical Assistant Professor, College of Pharmacy, University of New Mexico, Albuquerque. lamartinez@salud.unm.edu.
authors: Larissa A
authors: LA
authors: Martinez
authors: Larissa A. Martinez, Pharm.D., is Clinical Pharmacist, University of New Mexico Hospital, Albuquerque. Allison E. Burnett, Pharm.D., Ph.C., CACP, is Clinical Team Lead-Inpatient Anticoagulation Service, University of New Mexico Hospital, and Clinical Assistant Professor, College of Pharmacy, University of New Mexico, Albuquerque.
authors: Allison E
authors: AE
authors: Burnett
mesh_terms: D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use; D002404:Catheterization / Q000379:methods; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000627:therapeutic use; D006493:Heparin / Q000009:adverse effects; D006629:Hirudins / Q000008:administration & dosage; D006801:Humans; D008875:Middle Aged; D009767:Obesity, Morbid / Q000503:physiopathology; D010446:Peptide Fragments / Q000008:administration & dosage / Q000627:therapeutic use*; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000627:therapeutic use; D013921:Thrombocytopenia / Q000139:chemically induced / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D006629:Hirudins; D010446:Peptide Fragments; D011994:Recombinant Proteins; D006493:Heparin; D010959:Tissue Plasminogen Activator; C074619:bivalirudin