Thrombosed hemodialysis grafts: Lyse and wait with tissue plasminogen activator or urokinase compared to mechanical thrombolysis with the Arrow-Trerotola Percutaneous Thrombolytic Device

PURPOSE: To determine if the lyse and wait (L&W) technique with a 4-mg dose of alteplase (tissue plasminogen activator; tPA) is a safe and effective m ethod of declotting dialysis grafts as compared to use of the Arrow-Treroto la Percutaneous Thrombectomy Device (PTD) or the L&W technique with use of urokinase (UK). MATERIALS AND METHODS: Forty patients were randomized prospectively to unde rgo L&W declotting with use of 4 mg of tPA or mechanical thrombolysis with the PTD. The time interval to restored graft flow, total procedure time, he mostasis time, and anatomic success, clinical success, complications, and p atency rates were analyzed. These were compared with historic results in 20 patients treated with the L&W technique with use of 250,000 U UK. RESULTS: The immediate anatomic success rate was 95% in the tPA L&W and PTD groups. The mean in-room lysis time with restored flow was 10 minutes for L&W with tPA and 19 minutes for PTD (P =.002). The mean in-room procedure t ime was 39 minutes for L&W and 45 minutes for PTD (P = NS). Mean hemostasis time with use of manual compression was 44 minutes for L&W with tPA and 23 minutes for PTD (P = .057). The historic group of 20 patients who underwen t L&W with UK had a 95% anatomic success rate, a mean of 14 minutes of lysi s time, a mean of 34 minutes of procedure time, and a mean of 26 minutes of time to hemostasis. No bleeding complications occurred in the PTD group. S even episodes of bleeding occurred in six patients given tPA; four were del ayed 60-90 minutes after the procedure, one necessitated hospitalization, a nd two required additional therapies. Four of the 20 patients undergoing L& W with UK had minor puncture site bleeding during the procedure. The 3-mont h primary patency rates were 65%, 65%, and 60% for L&W with tPA, PTD, and L &W with UK, respectively (P = NS). CONCLUSION: The 4-mg dose of tPA is effective but results in more bleeding complications and longer hemostasis times than mechanical thrombolysis with use of the PTD. Unlike in our experience with UK, bleeding complications w ith tPA were both major and delayed.