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Asian Cardiovasc Thorac Ann 1998;6:125-126
© 1998 Asia Publishing EXchange Pte Ltd

CASE STUDY

Recombinant Tissue Plasminogen Activator Therapy for Pacemaker-Induced Thrombosis

Erdogan Ilkay, MD, Ilgin Karaca, MD, Selami Serhatlioglu, MD1, Nadi Aslan, MD, Mutlu Cihangiroglu, MD1

Department of Cardiology
1 Department of Radiology Firat University School of Medicine Elazig, Turkey
For reprint information contact: Erdogan Ilkay, MD Cardiac Department Firat University School of Medicine Fevzi Cakmak Mah Elazig 23200, Turkey Tel: 90 424 238 8080 Fax: 90 424 238 8096

   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 
A 50-year-old male who developed subclavian vein thrombosis following insertion of a demand pacemaker was treated with a short period of high-dose recombinant tissue plasminogen activator (100 mg over 3 hours). Total thrombolysis was achieved without complications.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
CASE REPORT
 DISCUSSION
 REFERENCES
 
Thrombolytic agents are being used more frequently for the treatment of deep venous thrombosis. They have shown benefits over anticoagulant therapy in prevention of postphlebitic syndrome, lysis of thrombosis, reestablishment of venous circulation, and avoidance of chronic venous hypertension. Recombinant tissue plasminogen activator (rt-PA), anisoylated plasminogen-streptokinase activator complex, streptokinase, and urokinase have been used for this purpose.1 We recently treated a case of subclavian vein thrombosis due to permanent pacemaker electrode insertion, using high-dose rt-PA.


   CASE REPORT
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
DISCUSSION
 REFERENCES
 
A 50-year-old male was admitted to our clinic after two syncopal attacks. We detected a 5.5-second sinusal pause by carotid massage. A vasoinhibitor-type hypertensive carotid syndrome was diagnosed and a DDD pacemaker (Sorin Biomedica, Saluggia, Italy) was positioned on the pectoralis major muscle via the right subclavian vein. Three weeks after implantation, the patient complained of tenderness and dilatation of the superficial vein of the right arm. A subclavian vein thrombosis measuring 40 x 18 mm caused by the demand pacemaker electrode was detected by color-flow Doppler ultrasound scan (Figure 1Go). A 100-mg dose of rt-PA was administered over a 3-hour period. Continuous heparin infusion was not given. The tenderness and dilatation of the right arm superficial veins resolved at the end of the treatment period. Complete lysis of thrombus was seen by color-flow Doppler ultrasound scan the following day (Figure 2Go). The patient was started on oral warfarin anticoagulation. At the end of one month, the subclavian vein was found to be completely normal.



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  		Figure 1. Color-flow Doppler ultrasound scan showing a subclavian vein thrombosis caused by the demand pacemaker electrode.

 


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  		Figure 2. Color-flow Doppler ultrasound scan indicating complete lysis of the thrombus one day after treatment with high-dose recombinant tissue plasminogen activator.

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
REFERENCES
 
Effective treatment of proximal vein thrombosis is necessary to prevent potentially fatal pulmonary emboli. Thrombolytic agents are increasingly used in the treatment of deep vein thrombosis. Thrombolytic therapy is reported to achieve early lysis with avoidance of post-thrombotic reactions.2 It was found that a 250,000-unit streptokinase injection with an infusion of 100,000 units per hour for 2 days was 3.7 times more effective than anticoagulant therapy.3 Short-term streptokinase therapy (1.5 x 106 units over 6 hours) resulted in degrees of thrombolysis ranging from 36% to 73%.4 Subsequently, rt-PA was found to be more effective than streptokinase in the early lysis of deep venous thromboses.5 Doses of rt-PA used in various clinical studies ranged from 40 to 120 mg infused over periods up to 24 hours and it was found that a high dose given over a short period was more effective than prolonged treatment.1 Marder and colleagues6 used rt-PA at doses ranging from 54 to 185 mg over 4, 22, or 34 hours and showed that both total dose and infusion time directly correlated with the degree of lysis. AbuRahman and colleagues7 reported that 22% of patients who received anticoagulant therapy and 80% of patients who were given thrombolytic therapy demonstrated recanalization during 36 months of follow-up after subclavian vein thrombosis.

Low-dose rt-PA therapy does not achieve complete lysis of a deep venous thrombus and heparin infusion after rt-PA therapy does not improve the degree of lysis.1 The risk of development of postphlebitic syndrome is higher in patients with incomplete thrombolysis. Therefore, we used a high dose of rt-PA (100 mg) delivered over a short period (3 hours) in our patient. Heparin infusion was not used in this case. Heparin and warfarin were the standard treatment modalities for deep vein thrombosis before the greater effectiveness of thrombolytic therapy compared to anticoagulants was demonstrated. There is currently no standardization of rt-PA dosage. The amount and timing of the dose used in this patient resulted in total lysis without complications.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 

  1. Turpie AGG. Thrombolytic therapy in venous thrombosis. In: Agnelli G, editor. Thrombolysis yearbook-1994. Amsterdam: Excerpta Medica, 1994:137–47.

  2. Marder VJ, Bell WR. Fibrinolytic therapy. In: Colman RW, Hirsh J, Marder VJ, Salzman EW, editors. Hemostasis and thrombosis. Philadelphia: Lippincott, 1982;1393–437.

  3. Kalikar N, Flanc C, Howe CT, et al. Treatment of deep vein thrombosis: a trial of heparin, streptokinase and arvin. Br Med J 1969;1:806–10.

  4. Johansson L, Nylander GM, Hedner U, Nilsson IM. Comparison of streptokinase with heparin: late results in the treatment of deep venous thrombosis. Acta Med Scand 1979;206:93–8.[Medline]

  5. Weimar W, Stibbe J, Van Seyen AJ, et al. Specific lysis of an iliofemoral thrombus by administration of extrinsic (tissue type) plasminogen activator. Lancet 1981;2:1018–20.[Medline]

  6. Marder VJ, Brenner B, Tottermans, et al. Comparison of dosage schedules of rt-PA in the treatment of proximal deep vein thrombosis. J Lab Clin Med 1992;119:485–95.[Medline]

  7. AbuRahman AF, Short YS, White JF, Boland JP. Treatment alternatives for axillary subclavian vein thrombosis: long-term follow-up. Cardiovasc Surg 1996;4:783–7.[Medline]





This Article
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Right arrow Articles by Cihangiroglu, M.

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