Indications

• Systemic anticoagulation remains the mainstay, but consider catheter directed lysis for:

• Treating severe manifestations of DVT: Threatening limb (phlegmasia) or other organ

• Reducing short-term effects of DVT: progression of DVT despite anticoag, speed relief of DVT-associated symptoms

Contraindications

• Absolute (for tPA use):

  • • Active hemorrhage or potential for bleeding

    • Intracranial process (e.g. recent CVA, neoplasm)

    • Recent head trauma / neurosurgery (<3 mo)

• Major Relative:

  • • Remote CVA (>3 mo)

    • Major thoracoabdominal surgery (<3 wks)

    • Major trauma (<4 wks)

    • GI bleed (<3 mo)

    • Uncontrolled HTN

• Minor Relative

  • • Pregnancy

    • Infected thrombus

    • Renal or hepatic insufficiency

Imaging Review

• CTV / Extremity Dopplers: eval extent of clot, acute vs chronic

Tips for Workup

• Pt will need ICU bed for tPA monitoring post-op.

• How bad are sx? Phlegmasia is concerning sign. Concern for PE? IVC filter present? Placement is controversial in this setting.

• HIT or allergy to heparin? Discuss alternatives (argatroban, bivalrudin, etc)

• Consent:

  • • Hemorrhage: 3.2% major bleed with catheter-directed tPA

    • Other: PE, venous perforation, technical failure, re-thrombosis, infection, contrast nephropathy, access site complications.