Differentiating Pharmacologic Agents Used In Catheter-Directed Thrombolysis

Abstract

The use of catheter-directed thrombolysis is a proven treatment for arterial ischemia, deep vein thrombosis, and severe pulmonary embolism. For arterial ischemia, thrombolysis has resulted in improved amputation-free survival and fewer subsequent surgeries to reestablish blood flow to the ischemic limb. The management of patients with thromboembolic diseases is complex, and the multiple thrombolytic drugs available to choose from compound this complexity. Although some believe the available thrombolytic agents are interchangeable, real biochemical differences exist that may prove otherwise. This article describes these pharmacologic differences and how they may affect the clinical practice of catheter-directed thrombolysis.

Outcomes of Catheter-Directed Thrombolysis for Arteriovenous Fistula Thrombosis in Singapore: Is It Still Relevant Today?

“…Surgical approaches tend to be associated with more serious complications such as infection, as well as risks of anaesthesia. 15,16) This has resulted in endovascular approaches largely replacing surgical ap- proaches and thus being recommended as the first line of treatment in thrombosed AVFs today. 4) We have achieved a technical success rate of 92% ( Table 2), which is consistent with the rates (90% or better) reported in the National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF KDOQI) guidelines for stenosed and occluded AVFs.…”

“…Surgical approaches tend to be associated with more serious complications such as infection, as well as risks of anaesthesia. 15 , 16 ) This has resulted in endovascular approaches largely replacing surgical approaches and thus being recommended as the first line of treatment in thrombosed AVFs today. 4 )…”

Outcomes of catheter-directed treatment of lower extremity deep vein thrombosis of patients presenting to a tertiary care hospital

“…The recommended dose ranges for the commonly used thrombolytic agents are 80,000–120,000 IU/h of urokinase or 0.2–0.5 mg/h of r-tPA. [ 16 ]…”

Review of Pharmacology and Physiology in Thrombolysis Interventions

“…One important concept introduced by Swischuk and Smouse to explain this discrepancy is that a distinction should be made of two separate processes: fibrinolysis-the breakdown of crosslinked fibrin and fibrinogenolysis-the breakdown of freely circulating fibrinogen. 23 tPA, like other lytic agents, causes fibrinolysis that involves the breakdown of fibrin into fibrin degradation products (FSPs). One moiety of FSPs subsequently enters the circulation and functionally serves to stimulate tPA activation of systemic plasminogen to plasmin, which in turn breaks down further fibrin.…”

“…Swischuk and Smouse (2005) demonstrated that using tPA in doses greater than 1.5 mg/h in conjunction with full heparinization led to higher rates of major bleeding. 23,25 Their subsequent report in a nonrandomized dose ranging study demonstrated that using lower doses of tPA as outlined earlier with subtherapeutic heparinization significantly reduced bleeding. Therefore, the newer fibrinspecific agents such as tPA should be used with caution because they have a relatively narrower window of dosing safety.…”