Use of Tissue Plasminogen Activator for Reopening of Clotted Dialysis Catheters

Abstract

The use of central venous catheters as permanent vascular access in chronic hemodialysis is complicated by clotting. We have tried a nonallergenic thrombolytic agent, tissue plasminogen activator (t-PA), to dissolve catheter luminal thrombosis. Eight patients, 7 in chronic hemodialysis and 1 treated by immune adsorption had 18 treatments with locally applied t-PA (2 mg/2 cm³). Fifteen out of 16 treatments with longer bolus dwell than 60 min were successful. No side effects occurred. t-PA dissolves clot formation efficiently and safely, the drug is nonallergenic and can therefore be given repeatedly.

A Case Review: Anticoagulation in Hemodialysis Patients with Heparin-Induced Thrombocytopenia

“…Low concentration citrate or tissue plasminogen activator (tPA) have both been shown to be safe alternatives, and would be indicated in HIT patients with intravascular devices, such as a catheter used for hemodialysis [29][30][31].…”

Tissue plasminogen activator for occluded peritoneal dialysis catheter

“…TPA is being used with increasing frequency in dialysis patients to open thrombosed grafts and restore the function of tunneled silastic hemodialysis catheters [12]. TPA has reduced the development of postoperative adhesions and abscesses in animal models with peritonitis [13,14].…”

Interventional Nephrology

“…Another potential option in management of catheter dysfunction is the use of thrombolytic agents, which may be left to dwell as catheter-lock solutions (48)(49)(50) or may be (29) Randomized (n5291) Heparin (5000 U/ml) versus citrate 30% Similar patency as measured by thrombolytic therapy or catheter removal; citrate associated with lower costs and decreased CRB Macrae et al, 2008 (31) Randomized (n561) Heparin (5000 U/ml) versus citrate 4% Similar patency as measured by thrombolytic therapy Power et al, 2009 (42) Randomized (n5232) Heparin (5000 U/ml) versus citrate 46.7% Thrombolytic use more common in citrate group, but higher adverse events with high-concentration citrate Hemmelgarn et al, 2011 (39) Randomized (n5225) Heparin (5000 U/ml) versus rtPA (1 mg/ml) Catheter malfunction significantly less in rtPA group Maki et al, 2011 (40) Randomized (n5225) Heparin (5000 U/ml) 0.24 M of (7.0% sodium citrate, 0.05% methylene blue, 0.15% methylparaben, and 0.015% propylparaben Treatment group had significantly lower incidence of CRBSI; catheter loss due to patency failure in treatment group less likely CRB, catheter-related bacteremia; rtPA, recombinant tissue plasminogen activator; CRBSI, catheter-related bloodstream infection.…”

“…Thrombolytics are advantageous because if they are successful, catheter patency is restored noninvasively, missed HD treatments are minimized, and the primary access site is preserved. Early thrombolytics included urokinase and streptokinase, but these are no longer used because of the potential risks for anaphylaxis with repeated streptokinase infusions and contamination concerns with urokinase (48). Reteplase safely restores flow through occluded and poorly functioning catheters.…”