Treatment of pulmonary embolism with argatroban and ultrasound-assisted catheter-directed thrombolysis with alteplase in a patient with heparin-induced thrombocytopenia.

Abstract

PURPOSE:

Successful ultrasound-assisted catheter-directed thrombolysis (USAT) with low-dose alteplase and argatroban in a patient with bilateral pulmonary embolism (PE) secondary to heparin-induced thrombocytopenia (HIT) is reported.

SUMMARY:

HIT is a life-threatening complication associated with a high risk of thromboembolism. Systemic anticoagulation for the treatment of thrombosis may not be sufficient in the presence of PE. Catheter-directed treatment may be indicated in patients with PE and associated right ventricular dysfunction. Literature describing the use of nonheparin anticoagulation with catheter-directed thrombolysis in the setting of HIT, particularly in the context of PE, is limited. A 76-year-old Caucasian woman with recent cardiac surgery was hospitalized with bilateral PE. Unfractionated heparin was initiated, but the patient was switched to argatroban upon suspicion of HIT due to recent heparin exposure. The patient clinically improved and was switched to rivaroxaban on hospital day 7 for long-term anticoagulation. She developed worsening dyspnea on hospital day 9, and a computed tomography angiogram revealed an increased clot burden. On hospital day 12, the patient underwent USAT with alteplase and argatroban using the EkoSonic Endovascular System (EKOS Corporation, Bothell, WA). The catheters and sheaths were removed after approximately 20 hours, and the patient had marked hemodynamic improvement with reduced bilateral pulmonary arterial pressure. She was transitioned to warfarin therapy and discharged on hospital day 19.

CONCLUSION:

A woman with HIT and bilateral PE was successfully treated with the combination of argatroban and USAT with alteplase.

• Authors: Brittany T Bethea, John W Elliot, John B Richardson, Mustafa I Ahmed
• Journal: American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists (Am J Health Syst Pharm) Vol. 74 Issue 15 Pg. 1153-1157 (Aug 01 2017) ISSN: 1535-2900 [Electronic] England
• PMID: 28743779 (Publication Type: Case Reports, Journal Article)
• Copyright: Copyright © 2017 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Chemical References

• Fibrinolytic Agents
• Pipecolic Acids
• Platelet Aggregation Inhibitors
• Sulfonamides
• Heparin
• Arginine
• Tissue Plasminogen Activator
• argatroban

Topics

• Aged
• Arginine (analogs & derivatives)
• Catheterization (methods)
• Drug Therapy, Combination
• Female
• Fibrinolytic Agents (administration & dosage, adverse effects)
• Heparin (adverse effects)
• Humans
• Pipecolic Acids (administration & dosage)
• Platelet Aggregation Inhibitors (administration & dosage)
• Pulmonary Embolism (diagnostic imaging, drug therapy)
• Sulfonamides
• Thrombocytopenia (chemically induced, diagnostic imaging, drug therapy)
• Thrombolytic Therapy (methods)
• Tissue Plasminogen Activator (administration & dosage)
• Treatment Outcome
• Ultrasonography, Interventional (methods)