title: Safety of Intra-arterial Catheter Directed Thrombolysis: Does Level of Care Matter?
abstract: The aim was to assess whether the level of care influenced the safety related outcomes of catheter directed thrombolysis (CDT) for patients presenting with limb ischaemia and dialysis access thrombosis.
  
  
  
  This was a retrospective cohort study. All consecutive patients at two tertiary referral centres for vascular surgery undergoing CDT for limb ischaemia and dialysis access thrombosis (N = 252) between 2012 and 2014 were included. Patients at Centre 1 were cared for on a general vascular ward and patients at Centre 2 were kept on a post-operative recovery unit with an increased level of care including invasive haemodynamic monitoring. Patient medical records were retrospectively scrutinised and data collected on comorbidities, anti-thrombotic medication, indications for CDT, technical success of CDT, bleeding and non-bleeding related complications, and transfer to a higher level of care.
  
  
  
  There were no differences in the frequency of non-bleeding related complications between Centre 1 and Centre 2. Patients on the vascular ward had a higher frequency of minor bleeding (p = .002) but there was no difference in major bleeding (p = .12). Eleven patients on the ward required an increased level of care for medical reasons and six were moved for a lack of resources. The presence of cardiac disease was an independent risk factor for patient transfer (OR 3.2; 95% CI 1.04-9.8, p = .04).
  
  
  
  CDT may be undertaken outside of a high dependency setting without a significantly increased risk of complications. Pre-existing cardiac disease was an independent risk factor for transfer to a higher level of care. These findings could have an implication for the clinical cost-effectiveness of CDT.
authors.affiliation: Department of Vascular Surgery, Karolinska Institutet and the Karolinska University Hospital, Stockholm, Sweden. Electronic address: linn.smith@karolinska.se.
authors.forename: L
authors.initials: L
authors.lastname: Koraen-Smith
authors.affiliation: Department of Vascular Surgery, Karolinska Institutet and the Karolinska University Hospital, Stockholm, Sweden.
authors.forename: M
authors.initials: M
authors.lastname: Wängberg
authors.affiliation: Department of Vascular Surgery, Karolinska Institutet and the Karolinska University Hospital, Stockholm, Sweden.
authors.forename: C
authors.initials: C
authors.lastname: Montán
authors.affiliation: Section of Vascular Surgery, Department of Surgery, Södersjukhuset, Institution of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden.
authors.forename: P
authors.initials: P
authors.lastname: Gillgren
authors.affiliation: Department of Vascular Surgery, Karolinska Institutet and the Karolinska University Hospital, Stockholm, Sweden.
authors.forename: C-M
authors.initials: CM
authors.lastname: Wahlgren
mesh_terms: D002406:Catheterization, Peripheral; D006801:Humans; D007511:Ischemia; D012189:Retrospective Studies; D015912:Thrombolytic Therapy; D016896:Treatment Outcome; D020246:Venous Thrombosis
keywords: Haemorrhage; Patient selection; Thrombolytic therapy