Drugs and devices for pharmacologic and interventional reperfusion treatment of VTE
| . | Systemic thrombolysis for acute PE (approved regimens) . | |
|---|---|---|
| Dose regimen . | Practical issues or device used for reperfusion . | |
| Thrombolytic agent | ||
| Recombinant tissue-type plasminogen activator | 100 mg over 2 hours or 0.6 mg/kg over 15 minutes (maximum dose, 50 mg) | Absolute contraindications: History of hemorrhagic stroke, stroke at ≤6 months, central nervous system tumor, major trauma, surgery, or head injury at ≤3 weeks, bleeding diathesis, active bleeding |
| Streptokinase | 250 000 IU loading dose over 30 minutes, followed by 100 000 IU/h over 12 to 24 hours; accelerated regimen: 1.5 million IU over 2 hours | Relative contraindications: Transient ischemic attack at ≤6 months, oral anticoagulation, pregnancy or first postpartum week, non-compressible puncture sites, traumatic resuscitation, refractory hypertension (systolic blood pressure >180 mmHg), advanced liver disease, infective endocarditis, active peptic ulcer |
| Urokinase | 4400 IU/kg loading dose over 10 minutes followed by 4400 IU/kg per hour over 12 to 24 hours; accelerated regimen: 3 million IU over 2 hours | |
| Catheter interventions | ||
| With thrombolysis for acute PE | ||
| Catheter-directed thrombolysis | Alteplase 25 mg | UniFuse, Cragg-McNamara |
| Ultrasound-assisted catheter-directed thrombolysis | Alteplase 24 mg (1 mg/h for 24 hours if unilateral; 1 mg/h via catheter for 12 hours if bilateral) | EkoSonic 5.2F 12-cm treatment zone device |
| Rheolytic thrombectomy plus catheter-directed thrombolysis | 4 to 12 mg alteplase per lung and infusion duration from 2 to 6 hours | AngioJet thrombectomy with Power Pulse thrombolysis |
| Combined techniques | Urokinase 250 000 to 500 000 U or alteplase 25 mg | Pigtail fragmentation plus AngioJet thrombectomy |
| Without thrombolysis for acute PE | ||
| Aspiration thrombectomy (suction pump or manual) | Start UFH bolus and delay continuous infusion until the completion of the procedure (additional unfractionated heparin boluses to be given during the procedure at the physician’s discretion) | Angiovac suction cannula: Indigo Mechanical Sheath with detachable hemostatic valve, multipurpose guide catheter, aspiration syringe. |
| Mechanical thrombectomy | Flowtriever, AngioJet catheter, Pigtail catheter | |
| Rheolytic thrombectomy | ||
| Thrombus fragmentation combined techniques | ||
| With thrombolysis for acute DVT | ||
| Catheter-directed thrombolysis | Alteplase 0.5-1.0 mg/h or 0.01 mg/kg per hour | AngioJet device |
| Ultrasound-assisted catheter-directed thrombolysis | Concomitant intravenous infusion of unfractionated heparin at subtherapeutic levels | EkoSonic treatment zone device |
| Isolated thrombolysis power pulse technique | Need for vena cava filter insertion debated | Trellis Peripheral Infusion System, Angiojet Rheolytic Thrombectomy Catheter |
| . | Systemic thrombolysis for acute PE (approved regimens) . | |
|---|---|---|
| Dose regimen . | Practical issues or device used for reperfusion . | |
| Thrombolytic agent | ||
| Recombinant tissue-type plasminogen activator | 100 mg over 2 hours or 0.6 mg/kg over 15 minutes (maximum dose, 50 mg) | Absolute contraindications: History of hemorrhagic stroke, stroke at ≤6 months, central nervous system tumor, major trauma, surgery, or head injury at ≤3 weeks, bleeding diathesis, active bleeding |
| Streptokinase | 250 000 IU loading dose over 30 minutes, followed by 100 000 IU/h over 12 to 24 hours; accelerated regimen: 1.5 million IU over 2 hours | Relative contraindications: Transient ischemic attack at ≤6 months, oral anticoagulation, pregnancy or first postpartum week, non-compressible puncture sites, traumatic resuscitation, refractory hypertension (systolic blood pressure >180 mmHg), advanced liver disease, infective endocarditis, active peptic ulcer |
| Urokinase | 4400 IU/kg loading dose over 10 minutes followed by 4400 IU/kg per hour over 12 to 24 hours; accelerated regimen: 3 million IU over 2 hours | |
| Catheter interventions | ||
| With thrombolysis for acute PE | ||
| Catheter-directed thrombolysis | Alteplase 25 mg | UniFuse, Cragg-McNamara |
| Ultrasound-assisted catheter-directed thrombolysis | Alteplase 24 mg (1 mg/h for 24 hours if unilateral; 1 mg/h via catheter for 12 hours if bilateral) | EkoSonic 5.2F 12-cm treatment zone device |
| Rheolytic thrombectomy plus catheter-directed thrombolysis | 4 to 12 mg alteplase per lung and infusion duration from 2 to 6 hours | AngioJet thrombectomy with Power Pulse thrombolysis |
| Combined techniques | Urokinase 250 000 to 500 000 U or alteplase 25 mg | Pigtail fragmentation plus AngioJet thrombectomy |
| Without thrombolysis for acute PE | ||
| Aspiration thrombectomy (suction pump or manual) | Start UFH bolus and delay continuous infusion until the completion of the procedure (additional unfractionated heparin boluses to be given during the procedure at the physician’s discretion) | Angiovac suction cannula: Indigo Mechanical Sheath with detachable hemostatic valve, multipurpose guide catheter, aspiration syringe. |
| Mechanical thrombectomy | Flowtriever, AngioJet catheter, Pigtail catheter | |
| Rheolytic thrombectomy | ||
| Thrombus fragmentation combined techniques | ||
| With thrombolysis for acute DVT | ||
| Catheter-directed thrombolysis | Alteplase 0.5-1.0 mg/h or 0.01 mg/kg per hour | AngioJet device |
| Ultrasound-assisted catheter-directed thrombolysis | Concomitant intravenous infusion of unfractionated heparin at subtherapeutic levels | EkoSonic treatment zone device |
| Isolated thrombolysis power pulse technique | Need for vena cava filter insertion debated | Trellis Peripheral Infusion System, Angiojet Rheolytic Thrombectomy Catheter |