Intra-arterial Catheter-directed Thrombolysis Research Articles

Outcome of Secondary Interval Rheolytic Thrombectomy after Localized Intra-Arterial Catheter-Directed Thrombolysis through Power-Pulse Spray Technique in Cases of Partially Successful or Failed Primary Rheolytic Thrombectomy

Abstract Objectives The aim of this study was to evaluate the safety and effectiveness of secondary interval AngioJet rheolytic thrombectomy after localized intra-arterial catheter-directed thrombolysis (CDT) through power-pulse spray (PPS) technique in partially successful or failed primary AngioJet rheolytic thrombectomy cases of acute and subacute peripheral artery thrombosis. Materials and Methods This retrospective study included 12 acute (< 2 weeks) and subacute (2–4 weeks) peripheral arterial thrombosis patients who underwent primary thrombectomy alone without CDT and patients who received secondary thrombectomy after CDT through PPS at our institute between May 2022 and December 2022. Technical success, procedure-related complications (local and systemic), amputations, and 1-year patency were evaluated. Results The angiographic success after primary thrombectomy was evaluated in 12 patients (9 acute and 3 subacute), and the results were categorized into three groups. Of 12 patients, complete success, partial success, and failure were noted in three (25%), five (41.7%), and four (33.3%) patients, respectively, after primary thrombectomy alone. Complete luminal patency was restored in all nine cases of partial success and failure in postprimary thrombectomy through adjunctive PPS thrombolysis and secondary thrombectomy. Technical and clinical success was achieved in all patients (100%). Transient hemoglobinuria was seen in five (41.7%) patients, and all had long-segment occlusion. At 1 year follow-up, no reocclusion, limb loss, or death was noted. Conclusion Complete success after primary thrombectomy was more likely in the setting of short-segment occlusion and small-caliber arteries. In patients with partial success or failure after the primary thrombectomy alone, secondary thrombectomy may be performed after the adjuvant PPS thrombolysis to achieve complete recanalization.

Short-term outcomes of intra-arterial catheter-directed thrombolysis for acute limb ischemia: a single-center experience

Short-term outcomes of intra-arterial catheter-directed thrombolysis for acute limb ischemia: a single-center experience

Novel Endovascular Therapy, AGET, for In-Stent Occlusions in Iliac and Femoropopliteal Arteries.

Catheter-directed intra-arterial thrombolysis (CDT) is useful for not only patients with acute limb ischemia but also those with chronic total occlusions (CTOs) of the lower extremity arteries. However, it is difficult to determine whether CTO lesions have significant thrombi, which can be treated by CDT, or not in a clinical setting. Angioscopy can accurately detect thrombi. We investigated the clinical impact of angioscopy guided endovascular therapy following thrombolysis (AGET) for in-stent occlusions (ISOs) in iliac or femoropopliteal arteries.We performed AGET in 7 patients with ISOs whose occlusion duration was less than 1 year. We performed angioscopy to evaluate the area of the thrombi after a successful wire crossing of an ISO lesion. In addition, we performed biopsies of ISO lesions to confirm whether the angioscopic findings coincided with the histopathological findings at 20 sites. We selectively performed a continuous infusion of urokinase using a fountain infusion catheter for ISO lesions. The next day, we evaluated the lesion flow and performed intervention only at the plaque stenosis site if necessary.AGET could achieve TIMI 3 flow in all patients, and preserved a 1-year patency in 5 patients (71.4%). The angioscopic findings of thrombi and plaque perfectly coincided with the histopathological findings.In conclusion, this new endovascular therapy technique, AGET, was observed to be feasible and safe for iliac or femoropopliteal artery ISO lesions.

Prognostic Risk Factors for the Development of Compartment Syndrome in Acute Lower Limb Ischemia Patients Treated With Catheter-Directed Thrombolysis

To determine predisposing factors that may lead to the development of compartment syndrome (CS) in patients with acute lower limb ischemia (ALLI) managed with intra-arterial catheter-directed thrombolysis (CDT). This is a retrospective study of patients admitted between 01/2002 and 12/2015 to three university hospitals in Tampere, Turku, and Oulu, Finland, with acute or acute-on-chronic lower limb ischemia (Rutherford I-IIb). Patients managed with CDT and aspiration thrombectomies (AT) as an adjunct to CDT were included in the study. Multivariable binary logistic regression models were used to detect possible risk factors for the development of CS and its impact on the limb salvage and survival. Amputation-free survival (AFS) rates of CS and non-CS patients were compared using Kaplan-Meier survival analysis. The length of hospitalization was calculated and compared between the CS and non-CS groups. A total of 292 CDTs with or without ATs were performed on patients with a mean age of 71 years (standard deviation 13 years), 151 (51.7%) being male. Altogether, 12/292 (4.1%) treatment-related CS cases were registered. Renal insufficiency (odds ratio [OR] 4.27, P=0.07) was associated with an increased risk of CS. All CS cases were managed with fasciotomies. Treatment with fasciotomy was associated with a prolonged hospitalization of a median of 7 days versus the 4 days for non-CS patients, P < 0.001. During the median follow-up of 51 months (interquartile range 72 months), 152/292 (52.1%) patients died and 51/292 (17.5%) underwent major amputations. CS was not associated with an increased risk of mortality, but it was associated with a higher risk of major amputation (OR 3.87, P=0.027). The AFS rates of patients with or without CS did not significantly differ from each other in the long term. CS after CDT for the treatment of ALLI is uncommon. Renal insufficiency is associated with an increased risk of CS. Fasciotomy prolongs the hospitalization. Patients with CS are exposed to an increased risk of major amputation.

Abstract No. 181 Catheter-directed intra-arterial thrombolysis for the management of frostbite injuries: a systematic review

Abstract No. 181 Catheter-directed intra-arterial thrombolysis for the management of frostbite injuries: a systematic review

Catheter-directed intra-arterial thrombolysis for lower extremity arterial occlusions.

Catheter-directed intra-arterial thrombolysis (CDT) is a rational treatment method in patients with acute/subacute and even some chronic occlusions of lower extremity arteries and bypass grafts having salvageable limb ischemia. Immediate vessel patency can be achieved with an acceptable complication rate in many patients, especially those with fresh thrombus or emboli. It can be also an adjuvant treatment modality for endovascular interventions for chronic occlusions. There is no standard method of CDT including thrombolytic agent dose and technique. Selection of treatment strategy should be based on individual judgment based on viability of limb, lesion characteristics, and risks of hemorrhage.

Survival of Patients and Treatment-Related Outcome After Intra-Arterial Thrombolysis for Acute Lower Limb Ischemia

The aim of this study is to evaluate the long-term survival and treatment-related outcome in patients treated with intra-arterial thrombolysis for acute lower limb ischemia. The study was based on a prospective vascular database with retrospectively obtained supplementary information from the patients' files. Additionally, data on the patients' date and cause of death were obtained from Statistics Finland. A total of 155 patients with symptoms or signs of category I-IIa acute lower limb ischemia and angiographic evidence of native artery or bypass graft thromboembolic events were treated with intra-arterial catheter-directed thrombolysis (CDT). Patients with severe ischemic stages at admission or those with contraindications for thrombolysis (n=185) were treated with conventional surgical modalities and excluded from further analysis. The mean age of the patients at admission was 73years (95% confidence interval 70.1-74.6). For descriptive purposes, age quartiles were used (≤64, 65-74, 75-82.5, ≥83). The mean follow-up time was 126.3months. The primary patency rates of native arteries/bypass grafts were 59.8%/31.7%, 35.4%/17.1%, and 18.7%/15.2% at 1, 5, and 10 years, respectively (P=0.01). Correspondingly, the respective secondary patency rates were 65.2%/55.6%, 46.7%/39.8%, and 22.8%/30.5% (P=0.88). A total of 190 additional procedures on 122 patients were required to preserve the patency after hospital discharge. At 1 year the cumulative survival was 78%, at 5 years 56%, and at 10 years 29%. The most common cause of death was cardiovascular (68.5%), predominantly presented by an acute coronary syndrome, while 9.6% died of cancer, 6.8% of pulmonary diseases, 8.2% of cerebrovascular causes, and 19.2% owing to trauma and other reasons. Atrial fibrillation (hazards ratio [HR] 2.31) and age over 83years (HR 5.23 per age category) were significantly and independently associated with poorer cumulative post-procedural survival. Bypass graft thrombosis was associated with an increase in major amputations after CDT (HR 14.77). However, the presence of synthetic bypass grafts had a protective influence on limb salvage (HR 0.086). A total of 39 (25.2%) major amputations were performed during the follow-up period. Age over 75years was the only significant and independent factor to negatively impact on amputation-free survival (HR 2.01), which was 24% at 10years. The long-term patency after CDT is unfavorable, and additional procedures are needed to preserve adequate distal perfusion. Approximately 30% of the patients are alive at 10years after the initial CDT. Increasing age and atrial fibrillation have a negative effect on the patients' survival.

Double Trouble: Acute Pulmonary Embolism in a Patient With Acute Inferior Wall Stemi

SESSION TITLE: Pulmonary Vascular Disease SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pulmonary embolism (PE) and myocardial infarction are two of the most feared medical emergencies. Both carry a high mortality, demand radically different interventions, yet are often indistinguishable. Differentiating between a right ventricular myocardial infarction and PE is a challenging clinical scenario; however, correctly ascertaining the pathologic process is imperative, as decision making drastically impacts patient outcome. There have been a few case reports of PE masquerading as a myocardial infarction; however, we report the first ever case of a PE that presented with inferior wall STEMI and how it offered a uniquely difficult clinical dilemma in determining which intervention would confer survivability for our patient. CASE PRESENTATION: This is a 72-year-old male with hypertension, IDDM and recent cholecystectomy who presented with lower extremity edema, dyspnea and hypoxia. An EKG showed ST elevation in leads II, III, and aVF with reciprocal ST depression in aVL and lead I. The troponin was 1.770 with a BNP of 3546. A CT chest angiography demonstrated an acute PE with an RV:LV of 1.32. An echocardiogram demonstrated severe hypokinesis of the base, mid-to-distal-inferior and inferolateral walls. After considerable interdisciplinary debate, a decision was made to perform a coronary angiogram, which demonstrated 99% stenosis of the mid right coronary artery, resulting in drug-eluting stent deployment. Subsequently, the patient underwent successful catheter-directed intra-arterial thrombolysis. A repeat echocardiogram with agitated saline demonstrated a right to left shunt with persistent inferior wall motion abnormalities, suggesting a parodoxical thromboembolism through a pre-existing patent foramen ovale. DISCUSSION: Three proposed mechanisms can possibly explain the co-existing processes. An existing plaque could have ruptured from increased myocardial demand resulting from the PE or profound hypoxia generated a catecholamine surge triggering myocardial ischemia. However, only one mechanism fully accounts for the concurrence of both pathologies: a paradoxical thromboembolism propagating through the patent foramen ovale resulting in acute RCA stenosis. CONCLUSIONS: There have been cases of a PE that have mimicked a STEMI, but yielded negative coronary angiograms for significant obstructive coronary artery disease.1,2 Only Goslar et al. reported a paradoxical thromboembolism from a PE into the conus artery, resulting in an antero-septal myocardial infarction; however, the initial transthoracic echocardiogram findings could not be explained independently by the two processes.3 Therefore, our case demonstrates that a PE and STEMI can occur simultaneously and present identically, resulting in a complicated clinical picture that demands timely decision making. Reference #1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4264717/ Reference #2: https://www.ncbi.nlm.nih.gov/pubmed/25414218 Reference #3: https://cardiovascularultrasound.biomedcentral.com/articles/10.1186/1476-7120-8-50 DISCLOSURE: The following authors have nothing to disclose: Shahniwaz Labana, Marwah Hussein, Sandip Saha, Mohammad Khan No Product/Research Disclosure Information

Microbubbles and UltraSound-accelerated Thrombolysis (MUST) for peripheral arterial occlusions: protocol for a phase II single-arm trial

IntroductionAcute peripheral arterial occlusions can be treated with intra-arterial catheter-directed thrombolysis as an alternative to surgical thromboembolectomy. Although less invasive, this treatment is time-consuming and carries a significant risk of...

Outcomes of accelerated catheter-directed thrombolysis in patients with acute arterial thrombosis.

Current intra-arterial catheter-directed thrombolysis (CDT) protocols recommend treatment with small doses of a thrombolytic agent, which excludes patients in need of urgent revascularization. We evaluated the effects of accelerated thrombolysis utilizing increased recombinant tissue plasminogen activator (rt-PA) doses. Forty-one patients with acute, thrombotic limb ischemia (ALI) were treated using accelerated CDT. The treatment consisted of an initial dose of 10 mg rt-PA for 30 minutes followed by a 3-hour course of a continuous intra-arterial 10 mg/hour rt-PA infusion. Simultaneously, intravenous unfractionated heparin (500 IU/hour) was administered. No deaths occurred. Satisfactory lysis was achieved in 37 of the 41 patients (90.2%). All significant underlying lesions were corrected (89.2%). Complications developed in nine patients (22%); the most frequent complication (four patients, 9.8%) was puncture site hematoma. The reintervention rate was 2.6% and 15.4% at the 1 and 6-month follow-ups, respectively. The major amputation rate was 10.3% and 12.8% at the 1 and 6-month follow-ups, respectively. Outflow compromise was adversely related to successful outcome at the 6-month follow-up (p=0.01). In conclusion, this study confirms the effectiveness and safety of the accelerated CDT regimen for treatment of thrombotic ALI at a single center, but requires confirmation in further studies.

Catheter-Directed Intraarterial Thrombolysis as Part of a Multidisciplinary Management Protocol of Frostbite Injury

PurposeTo evaluate intraarterial catheter-directed thrombolysis for prediction and prevention of delayed surgical amputation as part of multidisciplinary management of frostbite injury. Materials and MethodsA retrospective review was performed of 13 patients (11 men, 2 women; median age, 33.4 y; range, 8–62 y) at risk of tissue loss secondary to frostbite injury and treated with catheter-directed tissue plasminogen activator (t-PA) thrombolysis. Amputation data were assessed on follow-up (mean, 23 mo; range, 9–83 mo). Angiographic findings were classified into complete, partial, and no angiographic response and assessed for association with follow-up amputation rates. Correlation between amputation outcome and duration of cold exposure (mean, 23 h; range, 5–96 h), time between exposure and rewarming therapy (mean, 25.5 h; range, 7–95 h), and time between exposure and t-PA thrombolysis (mean, 32 h; range, 12–96 h) was assessed. Complications were recorded. ResultsOf 127 digits at risk on baseline angiography that were treated with catheter-directed thrombolysis, complete recovery was seen in 106 (83.4%). Total mean t-PA dose per extremity was 27.5 mg (range, 12–48 mg) over a mean period of 34 hours (range, 12–72 h). Patients with complete angiographic response (8 patients; 79.5% of digits) did not require amputations; 4 of 5 patients (80%) with partial angiographic response (20.5% of digits) underwent amputation (P = .007). There was no significant correlation between amputation rates and duration of cold exposure (P = .9), time to rewarming therapy (P = .88), and time to thrombolysis (P = .56). Femoral access site bleeding in 2 patients was managed conservatively. One patient underwent surgical exploration for brachial artery hematoma. ConclusionsIntraarterial catheter-directed thrombolysis should be included in initial management of frostbite injury, as it may prevent delayed amputations. The degree of angiographic response to thrombolysis can potentially predict amputation outcomes.

Hybrid technique to treat superior mesenteric artery occlusion in patients with acute mesenteric ischemia.

Acute mesenteric ischemia is a condition with a high mortality rate. In the present study, a novel hybrid technique for the treatment of acute mesenteric ischemia was investigated. The retrospective study population included six patients, of which five were male and one was female, with a mean age of 69 years (age range, 59-73 years). The hybrid technique involved isolating the superior mesenteric artery (SMA) for cannulation and subsequently performing a fluoroscopically-assisted embolectomy, retrograde balloon angioplasty and stenting. Intra-arterial, catheter-directed thrombolysis was performed if required. Bowels showing evident necrosis were resected, while ischemic bowels with the potential for recovery were left for 48 h before being re-examined during the second-look surgery. Retrograde open mesenteric stenting (ROMS) was successfully performed on two patients without bowel resection. Four patients were successfully treated by intra-arterial catheter-directed thrombolysis following recanalization of the SMA, and the ischemic bowels had exhibited a full recovery by the second-look operation. Three patients underwent a massive bowel resection, but did not develop short bowel syndrome. Two patients developed acute renal failure, one of which recovered after 10 days of dialysis, while the other patient succumbed to acute renal failure. In the five surviving patients, the SMA remained patent for the duration of the follow-up period. Therefore, ROMS was shown to be a viable alternative procedure for emergent SMA revascularization. In addition, intra-arterial catheter-directed thrombolysis following recanalization of the SMA was demonstrated as an alternative technique for inhibiting necrosis in bowels with acute mesenteric ischemia.

Left Arterial Thoracic Outlet Syndrome

A 21-year-old previously healthy woman presented with left-hand pain after a fall onto outstretched hands 10 weeks earlier. On examination, her left hand was cool and pale, with absent brachial and wrist pulses. Duplex ultrasonography showed a thrombus in the left brachial artery (Fig. 1). Computed tomography with 3-dimensional reconstruction revealed a superiorly displaced left subclavian artery in association with an anomalous left cervical rib and a prominent left first rib (Fig. 2). Angiography revealed luminal irregularity of the distal left subclavian artery consistent with residual thrombus (Fig. 3). Fig. 1 Duplex ultrasonogram shows a thrombus in the left brachial artery. Fig. 2 Computed tomogram of the chest (3-dimensional reconstruction) reveals a superiorly displaced left subclavian artery in association with both an anomalous left cervical rib (arrow) and a prominent left first rib (arrowhead). Fig. 3 Left upper-extremity angiogram shows luminal irregularity of the distal left subclavian artery (arrow), consistent with residual thrombus. The patient was treated initially with catheter-directed intra-arterial thrombolysis for her left-hand ischemia. Arterial thoracic outlet syndrome (TOS) was managed by resection of the left cervical and left first ribs via the supraclavicular approach. The distal subclavian artery had a fibrous plaque with intimal irregularity and was primarily excised. She did well and was discharged from the hospital with no complication. She underwent elective resection of her right first rib 6 months later.

The combination of surgical embolectomy and endovascular techniques may improve outcomes of patients with acute lower limb ischemia

Surgical arterial thromboembolectomy (TE) is an efficient treatment for acute arterial thromboemboli of lower limbs, especially if a single large artery is involved. Unfortunately, residual thrombus, propagation of thrombi, chronic atherosclerotic disease, and vessel injuries secondary to balloon catheter passage may limit the clinical success rate. Intraoperative angiography can identify any arterial imperfection after TE, which may be corrected simultaneously by endovascular techniques (so-called "hybrid procedures," HP). The aim of this study is to compare outcomes of surgical TE vs HP in patients with acute lower limb ischemia (ALLI). From 2006 to 2012, 322 patients with ALLI were admitted to our department. Patients received urgent surgical treatment using only a Fogarty balloon catheter (TE group = 112) or in conjunction with endovascular completion (HP group = 210). In-hospital complications, 30-day mortality, primary and secondary patency, reintervention rate, limb salvage, and overall survival rates were calculated using the Kaplan-Meier method and compared by log-rank test. HPs (n = 210) following surgical TE consisted of angioplasty (PTA) ± stenting in 90 cases, catheter-directed intra-arterial thrombolysis + PTA ± stenting in 24, thrombus fragmentation and aspiration by large guiding catheter + PTA ± stenting in 67, vacuum-based accelerated thromboaspiration by mechanical devices in 9, and primary covered stenting in 12. Estimated primary patency was 90.4% vs 70.4% at 2-year and 87.1% vs 66.3% at 5-year follow-up, respectively, for HP and TE patients (hazard ratio, 3.1; 95% confidence interval, 1.78-5.41; P < .01). A hazard ratio of 2.1 for limb salvage was noted for the HP group (95% confidence interval, 1.01-4.34; P = .03). Estimated freedom from reintervention at 1 year was 94.4% for HP vs 82.1% for TE patients, and 89% vs 73.7% at 5 years, respectively (P = .04). HPs for ALLI may represent the tools that, when applied to specific clinical scenarios, hold the potential to reduce the morbidity previously associated with acute arterial occlusion.

Independent Factors Predicting Early Lower Limb Intra-arterial Thrombolysis Failure

Risk factors for early catheter-directed intra-arterial thrombolysis failure in acute lower limb ischemia remain unclear. One hundred forty-nine limbs with acute artery or bypass graft thrombosis underwent catheter-directed thrombolysis (maximum of 48 hours). A retrospective data analysis was carried out to assess possible risk factors for early, 30-day treatment failure. Seventy-nine men (53%) and 70 women (47%) with a median age of 70 (range 32-93) years were treated. Treatment outcomes were determined as success (N = 115, 77%) or failure (N = 34, 23%). The failure criteria comprised rapid progression of ischemia (N= 4, 2.7%) and major bleeding complications (N = 2, 1.3%), both requiring thrombolysis termination and surgery. Inability to reopen native arteries/grafts (N = 10, 6.7%), run-off vessels (N = 10, 6.7%), in-hospital death (N = 4, 2.7%), the need for major amputation (N = 13, 8.7%), and reocclusions (N = 5, 3.4%) within the 30-day follow-up period were also considered as failures. Multivariate analysis of the risk factors' impact on the success of thrombolysis revealed such independent parameters as hypercholesterolemia (OR 0.16, 95% CI 0.06-0.42, P < 0.0001), previous bypass grafting of the ipsilateral limb (OR 0.18, 95% CI 0.06-0.53, P=0.002), and duration of ischemia prior to the initiation of thrombolysis (OR 0.95, 95% CI 0.91-0.99, P=0.009, per day). According to our results, factors independently predicting early failure include hypercholesterolemia, previous bypass grafting, and a delay in treatment initiation. Moreover, catheter-directed intra-arterial thrombolysis can be considered safe and effective in the treatment of acute lower limb ischemia.

A hybrid technique: intra-arterial catheter-directed thrombolysis following the recanalization of superior mesenteric artery in acute mesenteric ischemia

A hybrid technique: intra-arterial catheter-directed thrombolysis following the recanalization of superior mesenteric artery in acute mesenteric ischemia

Quality Improvement Guidelines for Percutaneous Catheter-Directed Intra-Arterial Thrombolysis and Mechanical Thrombectomy for Acute Lower-Limb Ischemia

Percutaneous catheter-directed intra-arterial thrombolysis is a safe and effective method of treating acute and subacute lower limb ischemia, as long as accurate patient selection and procedural monitoring are ensured. Although larger, controlled trials are needed to establish the role of PTDs in ALI, mechanical thrombectomy could currently be applied combined with lytic infusion in selected cases where rapid recanalization is required or as a stand-alone therapy when the administration of thrombolytic agents is contraindicated.

Long-term Outcomes of Low-dose Catheter-directed Thrombolytic Therapy: A 5-year Single-center Experience

To determine immediate and long-term outcomes following catheter-directed intraarterial thrombolysis of occluded native arteries and infrainguinal vein grafts by using low-dose tissue-type plasminogen activator (tPA) in patients with lower limb ischemia. One hundred eleven intraarterial thrombolysis procedures were performed in 96 patients during the 2-year study period. Patient records were available for retrospective review in 85 thrombolytic procedures performed in 74 (77%) of the 96 patients. Forty-one native vessels (four iliac, 24 superficial/common femoral, and 13 popliteal/below-knee vessels), six iliac stents, and 38 infrainguinal vein grafts were treated by using a low-dose (0.5 mg/h recombinant tPA) catheter-directed thrombolytic regimen. Procedural success was based on angiographic and clinical outcomes, and the need for further reconstructive surgery or amputation was documented. Intraarterial thrombolysis was successful in 76%, was partially successful in 11%, and failed in 13%. Adjunctive angioplasty was performed in 33 of 55 patients (60%) with successful lysis, and immediate reconstructive surgery was required in five patients. There was one episode of puncture site bleeding and one gastrointestinal hemorrhage but no procedure-related deaths at 30 days. After a median follow-up of 6.5 years, 30 of the 55 patients (55%) who underwent successful thrombolysis required no further surgical intervention; however, further surgery was required in 45% of patients after a mean interval of 301 days (range, 2-1,344 days), including 10 (18%) amputations (six major and four minor). Low-dose intraarterial thrombolysis is safe and effective, delaying and dramatically reducing the need for surgical intervention in lower limb ischemia due to native vessel or infrainguinal graft occlusion.

Successful Thrombolysis of a Stroke with a Pulmonary Embolism in a Young Woman

Paradoxical embolism is a rare event, accounting for < 2% of all arterial emboli. The diagnosis is often difficult, and consequences for the patient can be severe. We describe the case of a 35-year-old female physician who presented to our Emergency Department (ED) in severe hemodynamic compromise, with an altered level of consciousness and major expressive aphasia 1 day after undergoing a leg varicosal stripping procedure under regional anesthesia. She was successfully thrombolyzed with 0.9 mg/kg of Recombinant Tissue Plasminogen Activator (rtPA, Alteplase) and had a full recovery. To our knowledge, this is the first description of a case of massive pulmonary embolism associated with a paradoxical stroke related to patent foramen ovale that was thrombolyzed for both conditions with a "neurological dose" of rtPA. Although thrombolysis was completely successful in this case, indications and contraindications should be thoroughly respected. A more conservative approach with anticoagulation, or a more aggressive approach with surgical thrombectomy, can each potentially have a place in particular cases. Intra-arterial catheter-directed thrombolysis and percutaneous embolectomy are additional options to be considered when available, especially if there are contraindications for systemic thrombolysis.

Catheter-Directed Thrombolysis for Acute Renal Artery Thrombosis: Report of 4 Cases

Acute renal artery occlusion is a rare but threatening problem; optimal therapeutic treatment remains a challenge, and ultimate outcomes are still to be defined. In the last decades, several reports or short-case experiences have been reported describing the use of selective infusion of lytic agents into renal artery to treat acute occlusion. We report 4 cases of acute renal artery occlusion treated by catheter-directed intraarterial thrombolysis.