Local infusion of urokinase for the lysis of thrombosis associated with permanent central venous catheters in cancer patients.

Abstract

We assessed the efficacy of local fibrinolytic therapy in 35 axillary-subclavian vein thromboses (SVT) that occurred in cancer patients with percutaneous central venous catheters (CVC). These catheters were indwelling for a median of 1 month (range, one day to 10 months) before thrombosis developed. Urokinase was administered at a dose of 500 to 2,000 U/kg/h. Complete lysis occurred in 25 of 30 thrombi that were directly infused, after a median of four days. Complete lysis occurred in one of 12 thrombi that could not be directly infused with urokinase and in two of six with associated phlebitis. Eighty-one percent of the thrombi that were symptomatic for less than 1 week before treatment resolved, compared with 56% present for longer than 1 week. Sixteen patients who had complete (12) or partial (four) thrombolysis did not have their CVCs removed. All four patients with partial thrombolysis had recurrent thrombosis at a median of eight days (range, one to 90). Only two patients who had complete thrombolysis had recurrent thrombosis, at 8 and 16 months. Only minor hemorrhagic toxicity was seen.

A Case of Idiopathic Upper Extremitiy Deep Vein Thrombosis

“…The catheter should be positioned as close to the clot as possible; otherwise, collateral circulation will carry the medication away from the thrombus. 25 Thrombolysis works best if used within several weeks of the onset of symptoms, because progressive thrombus organization will limit its effectiveness at later dates. [17,25,26]Many case series of thrombolysis in carefully selected patients have reported excellent outcomes with only minor bleeding complications, such as occasional hematomas or oozing at venipuncture or catheter sites.…”

“…25 Thrombolysis works best if used within several weeks of the onset of symptoms, because progressive thrombus organization will limit its effectiveness at later dates. [17,25,26]Many case series of thrombolysis in carefully selected patients have reported excellent outcomes with only minor bleeding complications, such as occasional hematomas or oozing at venipuncture or catheter sites. [25,[27][28][29] The thrombolysis studies are small, however, so the risks of intracranial or gastrointestinal hemorrhage may not be fully appreciated, although they probably approximate those for catheter-directed thrombolysis of lower extremity DVT The best thrombolysis candidates are young, otherwise healthy patients with primary UEDVT, patients with symptomatic SVC syndrome, and those who require preservation of a mandatory central venous catheter.…”

Paget-Schroetter Syndrome in the Young and Active

“…Most of the studies used thrombolytics in patients with a history of signs and symptoms a duration of up to 3 weeks if other variables coexist, such as age, cause of the condition, coexistent hematologic disorders, or malignancy. 12,19,22 This was considered in our patient before the therapy in addition to other variables that would affect the success of the intervention. The best candidates tend to be the young and healthy, with primary UEDVT or Paget-Schroetter syndrome.…”

“…21 Repositioning of the catheter after a serial assay based on venography may be necessary to prevent collateral circulation from diverting the medication away from the thrombus. 19 Good prognostic indicators for success with thrombolysis include the duration of the thrombus formation and time interval to the onset of therapy with thrombolytics (earlier treatment leads to better outcome). Most of the studies used thrombolytics in patients with a history of signs and symptoms a duration of up to 3 weeks if other variables coexist, such as age, cause of the condition, coexistent hematologic disorders, or malignancy.…”

“…The best candidates tend to be the young and healthy, with primary UEDVT or Paget-Schroetter syndrome. 12,19,22 To prevent clot or fibrin formation around the catheter during treatment with thrombolytics, heparin is usually given concurrently.…”