Bethea Brittany T, Elliot John W, Richardson John B, Ahmed Mustafa I
Department of Pharmacy, Princeton Baptist Medical Center, Birmingham, AL
Department of Medicine, Princeton Baptist Medical Center, Birmingham, AL.
Am J Health Syst Pharm. 2017 Aug 1;74(15):1153-1157. doi: 10.2146/ajhp160368.
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.
报告一例继发于肝素诱导的血小板减少症（HIT）的双侧肺栓塞（PE）患者使用低剂量阿替普酶和阿加曲班成功进行超声辅助导管定向溶栓（USAT）的病例。
HIT是一种危及生命的并发症，与血栓栓塞的高风险相关。在存在PE的情况下，全身性抗凝治疗血栓可能并不充分。对于伴有右心室功能障碍的PE患者，可能需要进行导管定向治疗。关于在HIT情况下，特别是在PE背景下使用非肝素抗凝与导管定向溶栓联合治疗的文献有限。一名近期接受心脏手术的76岁白人女性因双侧PE住院。开始使用普通肝素，但由于近期接触肝素，怀疑发生HIT后，该患者改用阿加曲班。患者临床症状改善，在住院第7天改用利伐沙班进行长期抗凝治疗。她在住院第9天出现呼吸困难加重，计算机断层血管造影显示血栓负荷增加。在住院第12天，患者使用EkoSonic血管内系统（EKOS公司，华盛顿州博塞尔），采用阿替普酶和阿加曲班进行USAT。大约20小时后拔除导管和鞘管，患者血流动力学明显改善，双侧肺动脉压降低。她转为华法林治疗，并于住院第19天出院。
一名患有HIT和双侧PE的女性患者通过阿加曲班与阿替普酶USAT联合治疗获得成功。
