Keywords
thrombosis - needle-directed pulse-spray pharmacomechanical thrombolysis - recanalization
Case Report
A 55-year-old male patient was admitted to the hospital with complaints of acute severe
left upper limb pain since 1 day. He has a heavy smoking history for more than 30
years and also history of intermittent claudication for which he underwent peripheral
angioplasty 1 year back. On examination, his left upper limb was cold and clammy without
any appreciable pulse. He complained of excruciating pain along the medial aspect
of the forearm and the hand.
Doppler’s examination was requested which revealed complete thrombosis of the brachial
artery from the proximal upper arm ([Fig. 1A]
[B]) extending across the bifurcation into both proximal radial and ulnar arteries.
The distal forearm arteries were collapsed. In view of the symptoms, he was advised
catheter directed thrombolysis. As the patient had financial constraints, it was decided
to offer him ultrasound guided needle-directed thrombolysis.
Fig. 1 (A) Ultrasound showing acute thrombosis of the brachial artery (yellow arrow). (B) No demonstration of flow on color Doppler.
This procedure was done bedside. A thrombolytic solution was prepared by dissolving
5 lakh units of urokinase in 20 mL of heparinized saline (2,000U). Under all aseptic
precautions, multiple 26 gauge needles were inserted into the left brachial artery
at an equal distance of 5 cm and three-way stopcocks were connected ([Fig. 2A]). Under ultrasound guidance, 0.5 mL of this thrombolytic solution was injected forcefully
into each of these needles with pressure ([Fig. 2B]). Care was taken to exclude air bubble into the system. At the end of each session
of injection, Doppler’s examination was performed to look for restoration of flow.
There was near total recanalization of the brachial artery within 30 minutes with
mild residual clots ([Fig. 3A]
[B]). About 4 lakh units of urokinase were administered.
Fig. 2 (A) Image demonstrating the needle placements. (B) Two 26-gauge needles placed in criss-cross manner (yellow arrows) in the brachial
artery at the proximal point of thrombus.
Fig. 3 (A) Color Doppler at the end of 30 minutes demonstrating near total recanalization with
mild residual clots. (B) Follow-up Doppler after 24 hours demonstrating complete recanalization of the artery.
Postprocedure, the patient was kept on low-molecular-weight heparin in addition to
antiplatelets for a couple of days. The patient had complete resolution of pain postprocedure
and was discharged in a stable condition. Followup Doppler after 1 week was normal.
Discussion
Acute limb ischemia is a serious and limb threatening condition and immediate active
intervention is required if the patient has severe clinical symptoms. Surgical thrombo-embolectomy
used to be the procedure of choice previously, but with the advances in intervention
radiology, catheter directed thrombolysis became the procedure of choice for treating
these patients.[1]
Catheter directed thrombolysis requires a cath-laboratory suite for positioning of
infusion catheter. Prolonged infusion is usually required for several hours with intermittent
Doppler or check angiograms. In addition, monitoring in high dependency unit (HDU)
is mandatory during continuous thrombolytic infusion to monitor and detect any complication
at the earliest. These procedures can be done in tertiary care centers with well-equipped
laboratory and proper HDU care. Also, the cost factor for the intervention hardware
and patient affordability has also to be considered.[2]
Needle-directed pulse-spray pharmacomechanical thrombolysis is a novel technique,
which can be done bedside, under portable ultrasound guidance.[3] It is an economical procedure as no intervention hardware is required. Each aliquot
of injection can be monitored under ultrasound guidance and the procedure can be stopped
at the earliest, once there is recanalization. We have performed needle-directed thrombolysis
for more than 20 patients in our institution in salvaging acute thrombosis of dialysis
arteriovenous grafts and fistulas.
This procedure requires proper intraluminal placement of needles at regular intervals.
The proximal and distal needles have to be placed at the proximal and distal end of
the thrombus as recanalization can be achieved only once there is both inflow and
outflow. Each injection needs to be given forcefully for proper dissipation of the
urokinase to achieve uniform thrombolysis. The procedure is stopped once there is
optimal recanalization irrespective of clot burden. This is to prevent systemic infusion
of urokinase. Low-molecular-weight heparin postprocedure will prevent rethrombosis,
and it can be stopped once complete recanalization is achieved.
Conclusion
Needle-directed pulse-spray pharmacomechanical thrombolysis is an effective, economical,
and easy technique for acute brachial artery thrombosis which can be done bedside
under ultrasound guidance. However, larger studies are required to prove its safety
and to compare its efficacy with catheter directed thrombolysis.
