Determination of the appropriate transcatheter endovenous tissue plasminogen activator dose for the treatment of extensive acute proximal DVT

Abstract

Background: Transcatheter delivery of thrombolytic therapy is an effective tool in the treatment of acute deep venous thrombosis (DVT). We sought to determine an effective and safe thrombolytic regimen with tPA in the treatment of severe DVT when used in conjunction with percutaneous endovenous intervention (PEVI). Methods: Eighty consecutive patients with acute symptomatic DVT were randomized to receive four different doses of tPA. They had all undergone PEVI from 0.5 to 18 h following presentation to the hospital. PEVI consisted of any or a combination of the following: Trellis, Angiojet, or manual suction thrombectomy, balloon venoplasty, or stenting. Following initial PEVI, if N50% thrombus remained, tPA was given via an infusion catheter for 16–20 h. Patients were randomized to receive tPA at 0.5, 1, 2, or 4 mg/h and were assigned to Groups I–IV, respectively, with 20 in each group. Warfarin was continued, and during tPA administration heparin dose was reduced to 12 U/kg per hour. The end points evaluated were venous patency post-tPA (b5% residual thrombus), bleeding, and length of hospital stay. Results: The results are demonstrated in the Table 1. Venous patency rate was similar in Groups II–IV. Bleeding was seen more in Group IV, lengthening hospital stay. Venous patency was low in Group I. Conclusions: We conclude that transcatheter endovenous administration of tPA following suboptimal PEVI at 1 mg/h for 16–20 h is highly safe and effective in the treatment of DVT allowing for high patency rate, no complications, and early discharge.