Hemodialysis catheter-associated fibrin sheaths: Treatment with a low-dosert-PA infusion

PURPOSE: To prospectively evaluate the efficacy of a low-dose, 3-hour recom binant tissue plasminogen activator (rt-PA) infusion for the treatment of h emodialysis catheter (HDC)-associated fibrin sheaths. MATERIALS AND METHODS: Seventeen patients with end-stage renal disease (fem ale, n = 11; male, n = 6), who were undergoing catheter-directed hemodialys is, were evaluated for 28 episodes of HDC dysfunction. This patient group r anged in age from 25 to 92 years (mean, 57 years). Radiographic contrast an d/or clinical evaluation were consistent with the presence of a fibrin shea th on either the arterial and/or venous port in all cases. Patients subsequ ently underwent a thrombolytic infusion consisting of 2.5 mg rt-PA in 50 mL normal saline at a rate of 17 mL/h (3-hour infusion) per port. All infusio ns were performed in the interventional radiology recovery room, on an outp atient basis. Patients were followed-up prospectively for technical success , complications, catheter patency, and long-term outcome. RESULTS: The immediate technical success rate, defined as return. of manual aspiration and infusion capabilities to both ports, was 100%. No potential patients required exclusion from thrombolytic therapy secondary to contrai ndications, and no procedure-related complications occurred. The arithmetic mean and median catheter patency at the end of the study was 41 and 25 day s, respectively (range, 1-116 days). A Kaplan-Meier survival analysis yield ed a 30-, 60-, and 90-day probability of patency of 0.67, 0.61, and 0.51, r espectively. At the end of the study period, all 17 patients remained on ca theter-directed hemodialysis and 13 (76%) were utilizing the same catheter present at the time of entrance into the study. CONCLUSION: Thrombolytic therapy utilizing a 2.5-mg rt-PA infusion through each port during a 3-hour period would appear to be a safe, efficient metho d for treating HDC-associated fibrin sheaths. Three-month patency rates are comparable to those reported for other methods of restoring function to HD C catheters, including new catheter placement, catheter exchange over a gui de wire, thrombolytic infusions with urokinase, and percutaneous fibrin she ath stripping.