Treatment of high-risk venous thrombosis patients using low-dose intraclot injections of recombinant tissue plasminogen activator and regional anticoagulation

Abstract

Seven patients with venous thrombosis and contraindications to traditional thrombolytic therapy, consisting of recent intracranial surgery, recent pineal or retroperitoneal hemorrhage, active genitourinary or gastrointestinal bleeding, epidural procedures, and impending surgery, were successfully treated with a modified thrombolytic regimen. To improve safety, prolonged continuous infusions of tissue plasminogen activator (tPA) was eliminated in favor of once-daily low-dose intraclot injections of tPA to minimize the amount and duration of tPA in the systemic circulation, and low-therapeutic or regional anticoagulation was used to reduce anticoagulant risks. These modifications may allow thrombolytic treatment for selected patients with severe venous thrombosis who are deemed to be at high risk.

Conflict of interest statement

None of the authors have identified a conflict of interest.

Copyright © 2013 SIR. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1

Images from case 1. A 34-year-old woman with Von Hippel–Lindau syndrome developed dural sinus thrombosis 5 days after resection of right cerebellar hemangioblastoma. (a) MR scan shows right cerebellar hemangioblastoma (arrow) with adjacent edema that was successfully resected. (b) Noncontrast CT scan 5 days later shows dense clot sign (arrow) in torcular herophili. (c) Venogram through 3-F microcatheter shows acute thrombus filling and distending left transverse sinus (arrows). Six milligrams of tPA was injected into thrombus over a period of 1 hour. (d) Repeat venogram 1 day later shows improved flow and reduction in thrombus. Residual thrombus (arrows) was treated with a second dose (3 mg) of tPA. (e–h) Gadolinium-enhanced MR blood pool images before thrombolytic therapy (e, f) show absence of flow in straight and left transverse sinuses. (g, h) Images at 3-month follow-up show flow restored in left transverse and sigmoid sinus (arrows, g) and straight sinus (arrows, h).

Figure 2

Images from case 2. A 57-year-old man presented with right-leg DVT and a CSF leak that required epidural blood patch. (a–c) Development and resolution of CSF hypotension/hypovolemia is documented on axial CT images through the midthalamus obtained several months before diagnosis (a), at time of diagnosis (b), and 1 week after blood patch (c). Signs of CSF hypovolemia include subdural effusions, possibly with hemorrhage (arrows, b), decreased size of lateral ventricles (asterisk, b), and sulcal effacement (normal sulci indicated by arrows, a and c). (d–f) DVT thrombolysis and regional anticoagulation were performed. Right-leg DVT involved calf veins and the popliteal and femoral vein, stopping at the junction with deep femoral vein (arrow, d). (e, f) After thrombolytic therapy, regional anticoagulation was continued for 1 week via infusion of unfractionated heparin into a retrograde 3-F catheter (arrows, e) with its tip in the distal peroneal vein (arrow, f) at a rate of 700 U/h. Anti–factor Xa levels determined by a catheter inserted via jugular vein access show a therapeutic level (0.4 IU/mL) in the proximal superficial femoral vein (e), whereas systemic levels drawn from the right atrium were subtherapeutic (0.1 IU/mL). Note the chronic phlebitic changes revealed in peroneal veins (absence of valves and presence of narrow and irregular luminal changes) after thrombolysis.