B-25: Thrombolytic Therapy, Arterial

Contraindications for Thrombolytic Therapy

Absolute
  Active internal bleeding
  CVA, intracranial or spinal surgery within 60 days
  Intracranial process with potential for bleeding
  Known hypersensitivity to thrombolytic agent
  Devitalized limb with sensory and/or motor loses

Relative
  Non-compressible arterial puncture site
  Recent GI bleeding
  Severe uncontrolled arterial bleeding
  Recent trauma including CPR
  Left heart thrombus
  Subacute bacterial endocarditis
  Cerebrovascular disease
  Diabetic hemorrhagic retinopathy
  Pregnancy
  Post partum (<10 days)
  Uncorrected hemostatic defects

  • Indications
    • Thromboembolic arterial occlusion
    • Chronic arterial occlusion
  • Contraindications
    • Contrast allergy (premedicate)
    • See Table of Contraindications for Thrombolytic Therapy
  • Patient Evaluation
    • Able to lie still, cooperate during procedures, tolerate prolonged treatment (2-3 days)
  • Preprocedure Orders
  • Tools
    • Micropuncture access set
    • Vascular sheath (5 or 6 Fr.), or Balkin sheath
    • Multiple sidehole infusion catheter (Mewissen, Angiodynamics, Cook, etc.)
    • Infusion wire (Katzen, etc.) for coaxial system
    • 2 or 3 infusion pumps
  • Entry site
    • Femoral artery
  • Technique
    • Following diagnostic arteriogram an end hole catheter and guide wire are used to probe the thrombus. After traversing the thrombosed segment a Rosen exchange wire is placed. The diagnostic catheter is exchanged for the infusion catheter which is advanced to the distal part of the thrombus. The inner coaxial infusion device (wire) is passed to the catheter tip. The catheter is withdrawn over the coaxial device until the infusion sideholes cover the entire thrombosed segment. The patient is heparinized and infusions are begun through the proximal and distal ports. A heparin drip is connected to the arterial entry sheath.
  • Post-procedure Note
    • Note extent of thrombus, type of infusion system and location of catheters
  • Post-procedure Orders
    • Use preprinted intraarterial thrombolytic therapy orders (see Appendix C4)
    • Guidelines for Medication Orders
      • Urokinase:    (See Appendix B34 for TPA protocols)
        • Individualize infusion rate(s) based on catheter system and appearance of occlusion.
        • Usually 2000 - 4000 units per min. divided between proximal and distal ports
        • Order urokinase at 4000 units/cc (usually 1 million units in 250cc's IVF)
      • Heparin:
        • 5000 unit bolus, then 1000 units/hour initial infusion rate.
        • Adjust rate to maintain PTT between 80 and 100 sec
        • Heparin is necessary in most but not all cases. When omitted, PT and PTT orders are also omitted.
      • IV Fluid:
        • Orders are to be individualized
        • Consider that full dose UK and Heparin infusions equal 100cc/hr.
      • ADD: Demerol 50mg IV or Zantac 50mg IV for shaking chills
        • IV Demerol is usually more effective but must be used with caution in elderly or debilitated patients

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