Thrombolytic Therapy for Catheter-Related Thrombosis Edward L. Seigel, MD, Amie C. Jew, Mo, Romano Delcore, ~D, John I. Iliopoulos, MD, James H. Thomas, MD, Kansas City, Kansas Thrombosis of the central venous system (CVT) oc- curs in 20% to 30% of patients with indwelling catheters. This eomplieation is usually treated with antieo~ation, extremity elevation, and catheter removal. Thirty-eight patients with CVT at our in- stitution were treated with thrombolytie therapy to rapidly resolve symptoms and avoid removal of the catheters. Complete elot lysis occurred in 36 of 38 patients (95%) within 1 to 5 days (mean: 2.4 days). Symptoms resolved with clot resolution. Throndmlytie therapy detected stenoses in 22 pa- tients. Angioplasty was sueeessful in 64% of these patients. Five catheters were removed. Complica- tions oeeurred in six patients: nonfatal pulmonary embolus, three bleeding episodes, pain with infu- sion of urokinase, and an episode of septic phlebi- tis. This experience suggests that thrombolytic ther- apy is safe, rapidly resolves symptoms of throndmsis, uncovers anatomic abnormalities ame- nable to angioplasty, and allows central venous catheters to remain in place despite central venous thrombosis. Fromthe Departments ofSurgery (ACJ,RD, JII, JHT) and Radiology (ELS), University of KansasMedicalCenter,KansasCity,Kansas. Requests for reprints should be addressedto James H. Thomas, MD, Departmentof Surgery, University of Kansas Medical "Center, 3901 Rainbow Boulevard, 4002Murphy Building, Kansas City, Kansas 66160-7308. Presentedat the 45th AnnualMeeting of the Southwestern Surgi- cal Congress, Monterey, California, April 18-21, 1993. M ' cDonough and Altemeier [1] described catheter- related central venous thrombosis (CVT) in 1971. Approximately one third of the cases of CVT are related to indwelling central venous catheters [2,3]. Although clinical symptoms are evident in only 0% to 4% of patients [4], venography has demonstrated thrombosis in 33% to 46% of asymptomatic patients with central venous cathe- ters [5,6]. Catheter-related CVT presents several potential problems: loss of central venous access, interruption of therapy, and continuation of thrombus propagation if left untreated. The goal of therapy should be to relieve symp- toms, re-establish catheter function, and promote lysis of existing thrombus. Although several authors have advo- cated anticoagulation and removal of the catheter to treat catheter-related CVT [5,7], we believe thrombolytic therapy with angioplasty of venous strictures offers sever- al therapeutic advantages. This approach results in prompt resolution of symptoms, allows for salvage of the central venous catheter, and is associated with few signifi- cant complications. PATIENTS AND METHODS The records of all patients treated with thrombolytic therapy for catheter-related CVT at the University of Kansas Medical Center from January 1991 to February 1993 were reviewexl. CVT was documented by contrast venography in all patients. Following venography, a 4F or 5F multiple sidehole catheter was placed into the throm- bus under radiologic guidance, and urokinase was deliv- ered by continuous infusion at 25,000 to 120,000 U/h. Intravenous heparin was administered concomitantly with infusion of urokinase. Complete blood cell counts and coagulation profiles weremonitored, and patients were assessed for evidence of bleeding and other compli- cations. Therapeutic progress was monitored by repeat venograms at intervals ranging from 12 to 24 hours. An- gioplasty balloons were used to macerate areas of throm- bus resistant to lytic therapy alone. Treatment was con- tinued until radiographic evidence of complete thrombolysis was obtained. If a stenosis was discovered after thrombolytic therapy, balloon angioplasty was per- formed. Patients were followed clinically for recurrent symptoms of CVT. RESULTS Thirty-eight patients with catheter-related CVT were treated. This group had a mean age of 52 years and included 23 women (61%). Thirty-one patients (82%) were receiving chemotherapy. Four patients had central venous catheters for prolonged antibiotic therapy, and three others were receiving parenteral nutrition for short 716 THE AMERICAN JOURNAL OF SURGERY VOLUME166 DECEMBER 1993