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Venous Thromboembolism and Anticoagulation
Published in Vincenzo Berghella, Maternal-Fetal Evidence Based Guidelines, 2022
The use of thrombolytic agents during pregnancy has been limited to life-threatening situations because of the risk of substantial maternal bleeding, especially at the time of delivery and immediately postpartum [96]. The risk of placental abruption and fetal death due to these drugs is currently unknown. Systemic thrombolysis must be considered in pregnant patients with life-threatening hemodynamic instability due to massive PE. A recent literature review summarized 23 case reports on the use of systematic thrombolysis as a treatment for massive PE in pregnant patients. No maternal deaths occurred, and fetal deaths were reported in 2 of 23 (9%) cases. Bleeding complications were reported in 9 of 23 (39%) cases of which 5 of 23 (22%) were major bleeding. The authors concluded that thrombolysis is beneficial with a relatively low risk of complications [13]. The 2018 American Society of Hematology guideline suggests administering systemic thrombolytic therapy in addition to anticoagulant therapy in pregnant women with acute PE and life-threatening hemodynamic instability [13].
Emergency Surgery
Published in Tjun Tang, Elizabeth O'Riordan, Stewart Walsh, Cracking the Intercollegiate General Surgery FRCS Viva, 2020
Alastair Brookes, Yiu-Che Chan, Rebecca Fish, Fung Joon Foo, Aisling Hogan, Thomas Konig, Aoife Lowery, Chelliah R Selvasekar, Choon Sheong Seow, Vishal G Shelat, Paul Sutton, Colin Walsh, John Wang, Ting Hway Wong
What is thrombolysis?This is a mode of therapy in which thrombus or embolus is actively broken down by administration of pharmacological agents capable of fibrinolysis. It differs from anticoagulation (e.g. heparin, enoxaparin), whose primary role is to prevent further clot formation and propagation, while the body's endogenous thrombolytic mechanisms break down the existing clot. Catheter-directed thrombolysis is safer, with less bleeding risks compared to systemic thrombolysis.Most thrombolytic agents work by activating plasminogen, which then breaks down fibrin.Available agents include urokinase, tissue plasminogen activator (tPA) and alteplase.Their efficacy can be improved by direct intra-arterial administration (intra-thrombus, via infusion catheters), pulse-wave spray application (Angiojet®) into the clot followed by suction thrombectomy, and ultrasound sonification enhanced infusion catheters (EKOS®). Small clots may be retrieved with aspiration catheters.
Thrombolytic Therapy
Published in Hau C. Kwaan, Meyer M. Samama, Clinical Thrombosis, 2019
Hau C. Kwaan, M. M. Samama, G. Nguyen
As in the case of pulmonary embolism, long-term benefits have also been observed with thrombolytic therapy of deep vein thrombosis.21–23 This reaffirms the concept that early resolution of a thrombosed vein by lysis can minimize damage to the valvular function and reduce the incidence of the postphlebitic syndrome and also the recurrence of thrombosis.
Central Venous Catheter as a Novel Approach to Postoperative Thrombolysis in Patients with Acute Iliofemoral Deep Venous Thrombosis
Published in Clinical and Experimental Hypertension, 2023
Biyun Teng, Fenghe Li, Xuehu Wang, Hao Tian, Yu Zhao, Qiu Zeng
The mean waiting time from admission to CVC placement was 1.56 ± 1.35 days. Apart from 4 patients who already had an IVCF before this admission, 35 patients received IVCF before PMT-based thrombus removal and had the filter retrieved after thrombolytic procedures with a mean in-place duration of 3.72 ± 1.08 days; 32 (91.43%) of these patients had successful removal immediately following thrombolysis, and 3 kept the filters in place until 20–30 days after discharge due to captured thrombus by the filter (Table 2). Thrombus aspiration was performed for all 39 patients, who were further stratified as 17 with MAT alone, 14 with PCDT alone, and 8 with PCDT in combination with MAT. Thirty-two patients (82.05%) had May‒Thurner syndrome (MTS), and 29 (90.63%) of these patients underwent adjuvant PTA with stent placement, of whom 17 patients required only one stent placement, 7 required two stents, and 5 patients had three stents placed in either the common iliac vein, the common femoral vein, and in between. The success rate of the technique was 100%, and the thrombosed veins all regained linear blood flow after thrombolysis.
Extracorporeal membrane oxygenation for large pulmonary emboli
Published in Baylor University Medical Center Proceedings, 2023
Timothy J. George, Jenelle Sheasby, Rahul Sawhney, J. Michael DiMaio, Aasim Afzal, Dennis Gable, Sameh Sayfo
Acute pulmonary embolism (PE) is a common and growing problem.1 Large submassive and massive PE large enough to cause significant obstruction of the pulmonary arteries can cause hypoxia, hypercapnia, right ventricular failure, and hemodynamic instability.1,2 In some cases, patients will suffer cardiovascular collapse requiring cardiopulmonary resuscitation (CPR). In patients requiring CPR, in-hospital mortality is high, ranging from 25% to 80%.2–5 Although the first line of therapy consists of anticoagulation, treatment options include systemic thrombolysis, directed thrombolysis, percutaneous thrombectomy, and open surgical embolectomy. These therapies have been employed with varying degrees of success in different clinical situations.
Clinical controversies in the management of acute pulmonary embolism: evaluation of four important but controversial aspects of acute pulmonary embolism management that are still subject of debate and research
Published in Expert Review of Respiratory Medicine, 2023
Dieuwke Luijten, Frederikus A Klok, Thijs E van Mens, Menno V Huisman
It has been proposed that reduced dose thrombolytic therapy may avoid the risk of bleeding while preserving the increased rate of thrombus resolution. Several small studies have been performed to investigate the safety and efficacy of reduced dose systemic thrombolysis. Two studies have shown that reduced systemic thrombolysis (recombinant tissue plasminogen activator at 0.5–0.6 mg/kg) is more effective than placebo in the normalization of perfusion defects and that systemic thrombolysis resulted in a reduced combined endpoint of persistent pulmonary hypertension or recurrent PE [9,10]. Moreover, three randomized studies suggested that a reduced dose of thrombolytic treatment (recombinant tissue plasminogen activator at 0.5–0.6 mg/kg or at 50 g per 2 hours) was equally effective as full dose in prevention of death, change in total pulmonary resistance, and residual vascular obstruction [11–13]. In a network meta-analysis, low-dose thrombolysis was indeed associated with the lowest probability of dying and bleeding compared to other reperfusion options [14]. The ongoing PEITHO-3 trial (NCT04430569) is formally evaluating the efficacy and safety of a reduced-dose alteplase regimen (0.6 mg/kg) with standard heparin anticoagulation in patients with intermediate-high-risk PE and at least one clinical criterion of severity (i.e. a systolic blood pressure ≤110 mmHg, a respiratory rate >20 breaths/min, and/or chronic heart failure) and will ultimately determine the role of half-dose thrombolysis in the management of intermediate-high-risk acute PE [15].