Thrombolytic Therapy for Arterial Disease

Pearls 1. Patient workup and evaluation is key to a successful intervention while limiting complications. In addition to physical exam and laboratory evaluation, review of prior imaging studies and surgical interventions is important to understanding the etiology of the occlusion and to guide therapy. 2. Use of arterial thrombolysis should be avoided in patients with evidence of irreversible limb or bowel ischemia. 3. Catheter directed thrombolysis for treatment of acute peripheral arterial occlusive disease compares favorably with surgical intervention with regards to technical success, patency rates and limb salvage. 4. Patients with duration of symptoms less than 14 days have lower amputation rates and shorter hospital stays with catheter directed thrombolysis. 5. Patients with embolic or thrombotic arterial occlusions without a source or evidence of ongoing thrombosis despite appropriate therapy should be worked up for hypercoagulable states. 6. Factors favoring successful thrombolysis include acute thrombus, short occlusion, intact runoff and absence of hypercoagulable state. 7. Despite its short half life and high affinity for bound plasminogen, t-PA has a second, latent half life of 1.3hrs and can cause a systemic lytic state through binding with fibrin degredation products. 8. Arterial access sites are the most common site of significant hemorrhagic complication during thrombolysis. Careful attention to initial arterial access with use of ultrasound guidance can minimize vessel trauma and decrease access site complications. 9. When using t-PA for thrombolysis, sub-therapeutic heparin dosing is most appropriate. 10. Use of standard order sets will improve patient care and ensure appropriate monitoring of the patient during thrombolysis.