Use of systemic bivalirudin with catheter-directed thrombolysis in a patient with heparin-induced thrombocytopenia: A case report.

In patients with submassive pulmonary embolism, the use of catheter-directed thrombolysis (CDT), using low-dose alteplase is associated with improvement in overall hemodynamics. The data for use of CDT in patients with heparin-induced thrombocytopenia are limited. We report a case of CDT in a patient with HIT using bivalirudin anticoagulation. Data of the use of bivalirudin and argatroban for systemic anticoagulation with CDT are limited.

Badreldin HA ，Rimsans J ，Connors JM ，Wiviott SD ... -  《-》

Catheter-directed thrombolysis with alteplase and bivalirudin in a patient with heparin-induced thrombocytopenia.

The case of a patient with confirmed heparin-induced thrombocytopenia (HIT) and anticoagulation failure undergoing catheter-directed thrombolysis (CDT) with alteplase and bivalirudin for extensive thrombosis is reported. A 48-year-old, morbidly obese Caucasian woman was admitted to a trauma-surgical intensive care unit (TSICU) after a motor vehicle accident. The patient suffered aortic and renal lacerations, multiple rib and spinal fractures, pleural effusion, bilateral subdural hematomas, and cerebral edema. An inferior vena cava (IVC) filter was placed on hospital day 3, and prophylactic enoxaparin was initiated. The patient was diagnosed with HIT on hospital day 10. Systemic bivalirudin was initiated, and the patient was transitioned to therapeutic fondaparinux on hospital day 13. The patient continued to improve and was transferred from the TSICU to a step-down unit a few days later; the IVC filter remained in place. On hospital day 20, the patient developed respiratory distress and was transferred back to the TSICU. Computed tomography angiography was performed and revealed a questionable pulmonary embolism and distended IVC and iliac veins. Lower-extremity Doppler ultrasound revealed extensive thrombosis. On hospital day 21, the patient underwent CDT with alteplase and bivalirudin infusions through two CDT sheaths for approximately 36 hours, after which most of the thrombus had dissipated. The IVC filter and drug administration sheaths were removed. After the procedure, the patient received bivalirudin and was later transitioned to warfarin. A 48-year-old woman with HIT and anticoagulation failure possibly due to the presence of an IVC filter was successfully treated with CDT using alteplase and bivalirudin.

Martinez LA ，Burnett AE 《-》

Treatment of pulmonary embolism with argatroban and ultrasound-assisted catheter-directed thrombolysis with alteplase in a patient with heparin-induced thrombocytopenia.

Successful ultrasound-assisted catheter-directed thrombolysis (USAT) with low-dose alteplase and argatroban in a patient with bilateral pulmonary embolism (PE) secondary to heparin-induced thrombocytopenia (HIT) is reported. HIT is a life-threatening complication associated with a high risk of thromboembolism. Systemic anticoagulation for the treatment of thrombosis may not be sufficient in the presence of PE. Catheter-directed treatment may be indicated in patients with PE and associated right ventricular dysfunction. Literature describing the use of nonheparin anticoagulation with catheter-directed thrombolysis in the setting of HIT, particularly in the context of PE, is limited. A 76-year-old Caucasian woman with recent cardiac surgery was hospitalized with bilateral PE. Unfractionated heparin was initiated, but the patient was switched to argatroban upon suspicion of HIT due to recent heparin exposure. The patient clinically improved and was switched to rivaroxaban on hospital day 7 for long-term anticoagulation. She developed worsening dyspnea on hospital day 9, and a computed tomography angiogram revealed an increased clot burden. On hospital day 12, the patient underwent USAT with alteplase and argatroban using the EkoSonic Endovascular System (EKOS Corporation, Bothell, WA). The catheters and sheaths were removed after approximately 20 hours, and the patient had marked hemodynamic improvement with reduced bilateral pulmonary arterial pressure. She was transitioned to warfarin therapy and discharged on hospital day 19. A woman with HIT and bilateral PE was successfully treated with the combination of argatroban and USAT with alteplase.

Bethea BT ，Elliot JW ，Richardson JB ，Ahmed MI ... -  《-》

Bivalirudin anticoagulation for left ventricular assist device implantation on an extracorporeal life support system in patients with heparin-induced thrombocytopenia antibodies.

Heparin-induced thrombocytopenia (HIT) requires alternative anticoagulation strategies. We investigated outcomes in patients with HIT antibodies undergoing low-dose bivalirudin anticoagulation during left ventricular assist device implantation on an extracorporeal life support system (ECLS) and compared the results with non-HIT patients treated with heparin and receiving left ventricular assist device implantation with ECLS support. The institutional ventricular assist device database was searched for the period from March 2012 to March 2016. The primary end-point was the need for early (<7 days) surgical re-exploration due to persistent haemorrhage or cardiac tamponade postoperatively. The secondary clinical end-points were delayed chest closure, stroke, intracranial bleeding, re-thoracotomy >7 days and mortality up to 1 year. Unadjusted comparison was used for the entire groups. Because of non-random group assignment, propensity score matching was also performed to compare treatment effects. Twenty-one patients were treated with bivalirudin and 36 patients with heparin. INTERMACS levels were lower, inotropic score was higher and the prevalence of mechanical ventilation and preoperative ECLS implants was also significantly higher in the heparin group than in the bivalirudin group (P-values <0.05). The primary end-point was reached by 19% in the bivalirudin group and 16.7% in the heparin group (bivalirudin group: odds ratio 1.18, 95% confidence interval 0.29-4.76; P = 0.820). The propensity score-matched groups also showed no difference in this regard (P = 0.455). All secondary clinical end-points were comparable between groups, both in the unadjusted analysis and in the propensity score-matched groups. In patients with HIT antibodies, low-dose bivalirudin anticoagulation on ECLS support appears to be a feasible option for left ventricular assist device implantation.

Ljajikj E ，Zittermann A ，Morshuis M ，Börgermann J ，Ruiz-Cano M ，Schoenbrodt M ，Gummert J ，Koster A ... -  《-》

Comment on: Bivalirudin during thrombolysis with catheter-directed tPA in a heparin-refractory patient: A case report.

Han JH 《-》