Arterial Thrombolysis When

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Arterial Thrombolysis When ? And How ?:

Arterial Thrombolysis When ? And How ? Mr. Mohamed Omar Elfarok M.S c , FRCSED , FRCSENG, IME

Learning Objectives:

Learning Objectives To know the indications of arterial thrombolysis To know the complications of arterial thrombolysis To know types and doses of the common used drugs in thrombolysis To know how to effectively treat patient with arterial thrombolysis

Definitions ::

Definitions : therapeutic thrombolysis is defined as enzymatically induced or accelerated thromboembolus dissolution. There should be a multidisciplinary approach to thrombolytic therapy, which should involve angiologists , hematologists , interventional radiologists, and vascular surgeons

Severity of acute ischemia :

Severity of acute ischemia

Never IV thrombolysis for occluded arteries :

Never IV thrombolysis for occluded arteries Systemic intravenous infusion for limb artery occlusion was investigated in the 1960s and 1970s but has been almost completely abandoned: it is inferior to intra-arterial infusion for leg arterial occlusion because the initial lytic success rates are lower and the complication rates higher

Guidewire traversal test:

Guidewire traversal test Guidewire traversal test: A guidewire is passed through the length of the thrombus before the initiation of prolonged infusion with the catheter embedded in the proximal thrombus. If a nonhydrophilic guidewire is passed, initial successful lysis of “acute ” thrombi (7 days old) was thought to be more likely

Absolute contraindication :

Absolute contraindication 1. Established cerebrovascular event ( including TIAs within last 2 months ) 2. Active bleeding diathesis 3. Recent gastrointestinal bleeding ( 10 d) 4. Neurosurgery (intracranial, spinal ) within last 3 months 5. Intracranial trauma within last 3 months

Relative Major contraindications:

Relative Major contraindications 1. Cardiopulmonary resuscitation within last 10 d 2. Major nonvascular surgery or trauma within last 10 d 3. Uncontrolled hypertension: 180 mm Hg systolic or 110 mm Hg diastolic 4. Puncture of noncompressible vessel 5. Intracranial tumor 6. Recent eye surgery

Relative minor contraindications :

Relative minor contraindications 1. Hepatic failure, particularly those with coagulopathy 2. Bacterial endocarditis 3. Pregnancy 4. Diabetic hemorrhagic retinopathy

Steps of Thombolysis:

Steps of Thombolysis Patient history and examination Admission to ITU and consent high risk Vascular imaging duplex , CT angio , MRA , or combination Vascular acess and 24000 Heparing through the sheath and Aspirin Cross the lesion with GW and insert thrombolystic catheter and start proximal to distal

Steps of Thombolysis:

Steps of Thombolysis 6 - Follow-up every 4 to 6 hours with imaging 7 - After 24 h to 48 h either success or partial success or failure 8 - Assessment and discharge

How to do infusion Stepwise infusion:

How to do infusion Stepwise infusion consists of placing the tip of the catheter within the proximal thrombus and infusing a fixed dose of lytic agent over a short period of time. As the thrombus dissolves, the catheter is advanced and the process is repeated until all of the thrombus has dissolved.

Dose of r TPA and UK:

Dose of r TPA and UK

Different regimen for r TPA:

Different regimen for r TPA

Recommendation no 5:

Recommendation no 5 Intravenous heparin at full anticoagulant dosage should be administered as soon as possible (unless there is a specific contraindication to such therapy) and continued until other interventions , such as thrombolysis, are initiated . This is intended to reduce recurrent emboli and to prevent propagation of thrombus

Streptokinase dropped out:

Streptokinase dropped out In recent years , UK and rt -PA have largely superseded SK as preferred agents in clinical use. For UK, dosage schemes varied initially, but the low-dose concept was gradually abandoned in favor of higher doses.

Recommendation 12:

Recommendation 12 Surgical or endovascular therapy (excluding thrombolysis ) is superior as the initial treatment strategy for chronic arterial occlusion leading to limb threatening ischemia . If these 2 approaches are not available or appropriate, thrombolysis should be considered.

Recommendation 18:

Recommendation 18 Suprainguinal emboli should be preferentially removed surgically .

Recommendation 28:

Recommendation 28 On completion of thrombolysis, every attempt should be made to identify and correct underlying lesions .

Recommendation 30:

Recommendation 30 Aspirin should be continued or initiated as soon as convenient , unless contraindicated

Recommendation 7:

Recommendation 7 Full imaging by angiography or duplex scanning should be obtained.

Recommendation 19:

Recommendation 19 In situations where there is a focal discrete infrainguinal embolus producing ischemia without propagated thrombus, surgical thromboembolectomy , percutaneous clot aspiration, or lysis are all appropriate management strategies.

Foundation of knowledge :

Foundation of knowledge Tow corner stones papers At 2003 At 2011

Example of live recorded case:

Example of live recorded case

Digital handout :

Digital handout On whatsapp[ group

Thank you:

Thank you

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