[Severe acquired protein S deficiency with thrombophlebitis after febrile infection in a 7-year-old girl]

The importance of the anticoagulant properties of protein S is illustrated by the high incidence of thromboembolic events in individuals with protein S-deficiency. A 7 year old girl was hospitalized with purpura-like bruises and lesions on both thighs after she had suffered from febrile infection. A subsequently developing thrombosis of the left V. femoralis was treated successfully with urokinase. Haemostaseological investigations showed no signs of disseminated intravascular coagulation. However, isolated severe degradation or all protein S-components due to the presence of a circulating autoantibody to protein S was found. After several months the antibody was detectable not any more, activity and antigens of protein S were normal.

Thrombolysis of peripheral graft occlusion in patients with hypertension

The objective of this study was to evaluate the effect of hypertension on the use of thrombolytic therapy in patients with occluded synthetic peripheral bypass grafts. Thrombolysis with urokinase was performed in 44 cases of occluded lower extremity bypass grafts. The cases were divided into two groups: Group I consisted of patients currently being treated for hypertension. Group II consisted of patients without a history of hypertension. A comparison of pre- or intra-lytic data revealed that there was no significant difference in each group. Complications occurred in 15 (32.6%) out of 46 cases. There was no significant increase in complication when the risk factors were compared. In Group I, the one, two, and three year patency rates were 42.7%, 23.0%, and 7.7% and the limb salvage rates were 93.3%, 73.9%, and 73.9% for one, two, and three years respectively. The Group II patency rates were 70.6%, 41.6%, and 41.6% and the limb salvage rates were 94.1%, 86.9%, and 86.9%. The patency rate was significantly reduced when Group I was compared to Group II (p < 0.05). There was no statistically significant difference in limb salvage rates between Groups I and II. In conclusion, hypertension is one of the important risk factors that reduce the patency rate after thrombolytic therapy in patients with peripheral arterial bypass graft.

Successful thrombolysis in the vertebrobasilar artery after endovascular occlusion of a recently ruptured large basilar tip aneurysm

The treatment of a patient who had iatrogenic basilar artery thrombosis after endovascular occlusion of a recently ruptured wide-necked basilar apex aneurysm with a nondetachable silicone balloon is described. The rationale for the choice of a nondetachable balloon, the need for anticoagulation in the postoperative period, the timing of thrombolysis, and the choice of thrombolytic agents are discussed.

Changes in coagulation and fibrinolytic system after local intra-arterial thrombolysis for acute ischemic stroke

Intracerebral hemorrhagic transformation is one of the most important complications of thrombolytic therapy for acute ischemic stroke. The relationship between changes in markers for the coagulation and fibrinolytic systems and occurrence of hemorrhagic transformation was determined after local intra-arterial thrombolytic therapy using urokinase (UK) (24 patients) or recombinant tissue plasminogen activator (t-PA) (10 patients) within 6 hours of onset. All 34 patients had no hypodensity areas on initial computed tomography scans. Plasma concentrations of fibrinogen-fibrin degradation products (FDP), fibrinogen, alpha 2-plasmin inhibitor (alpha 2-PI), plasmin-alpha 2 plasmin inhibitor complex (PIC), thrombin-antithrombin III complex (TAT), and D-dimer were measured. Hemorrhagic transformation occurred in seven patients (21%) with complete or partial recanalization; four in the UK group and three in the t-PA group. Doses of the thrombolytic agents did not correlate with the incidence of hemorrhagic transformation. The FDP levels in the hemorrhagic transformation group treated with UK significantly increased immediately and 1 hour after the therapy. The alpha 2-PI activities decreased and PIC levels increased in both the hemorrhagic transformation and the nonhemorrhagic groups after the therapy. The TAT levels in both groups tended to be higher than the normal range, but there was no significant difference from the pretreatment levels. The D-dimer levels in the hemorrhagic transformation group were higher than those in the nonhemorrhagic group at 24 hours after the therapy. Furthermore, the D-dimer levels were significantly higher in patients with complete recanalization compared with those with none or partial recanalization.(ABSTRACT TRUNCATED AT 250 WORDS)

Urokinase infusion for severe intraventricular haemorrhage

The purpose of this study was to explore in patients with intraventricular haematomas the effectiveness and complication rate of a treatment protocol including standard ventriculostomy and application of urokinase via the catheter. Our series includes 16 patients with severe CT-diagnosed intraparenchymal and predominantly intraventricular haemorrhages. In all cases, ventricular drainage was performed. Urokinase treatment was started immediately with intraventricular infusions of 10,000 U urokinase in 5 ml sterile physiological saline every 12 hours. Twelve patients had an excellent outcome, three good and one poor. There were no complications related to urokinase therapy. Side effects of the infusion volume were profuse sweating and headache which were present at 10 ml total infusion volume, but disappeared after reduction to 5 ml. A group of five patients with comparable lesions treated only with ventriculostomy served as controls. Two of them had a good outcome, two a poor one and one died. The late results in the urokinase-treated group were also favourable. Only one of the patients developed hydrocephalus and was shunted. In the control group, two patients required shunting for delayed hydrocephalus. We conclude that this protocol for urokinase treatment is safe and effective and can be used in almost all patients with intracerebroventricular haemorrhage.

Urokinase therapy in neonates with catheter related central venous thrombosis

The results of fibrinolytic therapy with urokinase were evaluated in 26 neonates with catheter related central venous thrombosis. Complete thrombolysis could be achieved in 13 patients (50%), partial thrombolysis in 3 patients (12%). No effect was seen in 10 patients (38%). Therapy success was influenced by age, size and location of the thrombus. Coincidence of infection occurred in 16 patients (62%). Mild hemorrhagic complications were seen in 2 patients (8%), no other significant side effects were observed. Nine patients with residual thrombosis were treated with oral anticoagulants following urokinase resulting in resolution of the thrombus in 6 patients within 3 months (67%). The incidence of asymptomatic recurrent thrombosis was high (28%). Urokinase might be an effective and safe treatment for central venous thrombosis in neonates. Prophylactic antibiotic therapy during the infusion of urokinase and long-term treatment with oral anticoagulants after thrombosis are advisable. Early detection of thrombosis might enhance the success rate of fibrinolytic therapy. Therefore, we strongly recommend routine echocardiographic screening of central venous catheters.

Cost-effectiveness of emergency intraarterial intracerebral thrombolysis: a pilot study

PURPOSE

To assess the clinical efficacy and cost-effectiveness of emergency thrombolysis as a treatment strategy for thromboembolic intracerebral events.

METHODS

Thirty-four patients with symptoms suggestive of middle cerebral artery occlusion were included. Eight of these patients were treated with intraarterial urokinase. Effectiveness was determined by comparing the admission National Institutes of Health stroke score to the 24-hour National Institutes of Health stroke score. The cost and length of stay of both populations were derived and used as measures of direct cost. The likelihood of admission to extended care facilities and estimated length cost of admission was used as a measure of indirect cost.

RESULTS

The control population became slightly worse, with a change in National Institutes of Health score of -0.5, whereas the treated population improved slightly, with a change in National Institutes of Health score of +5.12. Analysis of the direct costs data between the two populations revealed a slight increased mean for the treated population ($15,202) as compared with the control population ($13,478). The unpaired t test, however, revealed no significant cost difference between the two groups. By reducing the number of completed strokes by one third or by decreasing the severity by the same factor (as shown in our study), the likelihood of admission to an extended nursing facility also is decreased. The cost saving per patient from extended care facilities is approximately $3435.

CONCLUSION

The emergency application of intraarterial thrombolysis with urokinase results in a statistically significant positive change in National Institutes of Health score by at least five points. A statistically significant benefit is realized through the use of intraarterial urokinase. A statistically insignificant additional cost is shown by this study. This insignificant cost is more than offset by the saved nursing home costs.

Thrombolytic therapy in acute occlusion of the intracranial internal carotid artery bifurcation

PURPOSE

To evaluate efficacy and clinical benefit of early thrombolytic therapy in intracranial internal carotid artery occlusion.

METHODS

Thirty-two patients (mean age, 56 years) with acute intracranial internal carotid artery occlusion were studied clinically and with CT and angiography before and after thrombolytic therapy with intravenous alteplase (n = 16), superselective intraarterial alteplase (n = 8), and superselective intraarterial urokinase (n = 8).

RESULTS

Initial CT showed a large parenchymal hypodensity in 11 (34%) patients, a small hypodensity in 15 (47%) patients, and no hypodensity in 6 (19%) patients. Recanalization after thrombolytic therapy was observed in 4 patients (12.5% in each treatment group). Follow-up CT showed six hemorrhagic infarcts and four parenchymal hematomas unrelated to recanalization, alteplase, or urokinase administration, but commonly associated with intraarterial treatment. Clinical outcome was fatal in 53%, poor in 31%, and moderate or good in 16% of the patients. Outcome was equal in different treatment groups and closely linked to both the quality of leptomeningeal collaterals and the extent of parenchymal hypodensity on the first CT.

CONCLUSION

Because intravenous or intraarterial treatment with alteplase or urokinase fails to recanalize the vascular obstruction, it does not improve the prognosis of intracranial internal carotid artery occlusion over that of the natural course. Improved results may be possible with novel recanalization techniques.

Site-specific, catheter-based thrombolysis: a new technique for treating intracoronary thrombus and thrombus-containing stenosis

Site-specific thrombolysis is a new technique for treating intracoronary thrombus and thrombus-containing stenoses that is currently under active investigation and that involves the local delivery of thrombolytic agents directly to intraluminal clot using catheter-based technology. The theoretic mechanisms of thrombolysis underlying this approach involves the "trapping" of thrombus in an environment of high thrombolytic drug concentration, mechanical disruption of intraluminal clot by the drug delivery catheter itself, and intramural deposition of lytic agents with the creation of a drug reservoir that may provide for prolonged local thrombolysis. To date, preliminary studies have documented enhanced local thrombolysis with urokinase using two new drug delivery systems--the Dispatch catheter and the hydrogel-coated balloon. In 68 patients that have been reported to date, use of these two new systems has resulted in enhanced intracoronary thrombolysis using much less urokinase than involved in standard infusion protocols, and with low complication rates. These preliminary observations will be further studied in two multicenter randomized protocols comparing local drug delivery with standard techniques for treating intracoronary thrombus.

[Pro-urokinase for infarct therapy]

The development of new thrombolytic agents is concentrating on substances which are more effective and more fibrin specific than streptokinase. Prourokinase is a single chain urokinase-type plasminogen activator (scu-PA). The recombinant unglycosylated prourokinase (saruplase) is synthesized in transformed E coli bacteria. The dominant half life is 9 minutes. With the standard dosage regimen about 28% of saruplase is converted into two chain urokinase-type plasminogen activator (tcu-PA), which is rapidly inactivated by plasma inhibitors whereas saruplase is not. Saruplase is fibrin-specific since it predominantly activates plasminogen bound to fibrin. Even without measurable conversion to tcu-PA, saruplase appears able to activate fibrin. The fibrin specific action is dose dependent and correlates inversely with the rate of saruplase converted to tcu-PA. Dose finding studies have shown that a 20 mg bolus followed by 60 mg given intravenously over 60 minutes is an effective thrombolytic regimen. In the PASS-study 1,698 patients were treated with saruplase. The results of the PASS-study (Table 1) confirmed the efficacy and safety of the 20/60 mg dosage. This standard dosage has been compared with streptokinase, urokinase and alteplase in randomized multicenter-studies. The systemic fibrinolytic activity is less in comparison to streptokinase but higher than the systemic fibrinolytic activity of alteplase. In the PRIM1-study the early patency (60: minutes) was significantly higher with saruplase in comparison to streptokinase (Figure 1). Patency after 90 minutes and 24 to 36 hours did not differ significantly between both substances. Bleeding complications were less frequent with saruplase. Urokinase was compared with saruplase in the SUTA-MI-study. The patency rates (TIMI-flow 2 and 3) at 24 to 72 hours were similar in both groups (saruplase 75.4%, urokinase 74.2%). Hospital mortality was higher in the urokinase group (8.1% vs 4.4%), but this difference was not significant. The efficacy and safety of saruplase (80 mg, 1 hour) was compared with alteplase (100 mg, 3 hours) in the SESAM-study. There was a non significant trend towards earlier patency with saruplase at 45 min (Figure 2). Complication rates and hospital mortality were similar in both groups. The importance of heparin comedication was investigated in the LIMITS-study.(ABSTRACT TRUNCATED AT 400 WORDS)

Safety and efficacy of delayed intraarterial urokinase therapy with mechanical clot disruption for thromboembolic stroke

PURPOSE

To evaluate safety and efficacy of delayed intraarterial urokinase therapy with mechanical disruption of clot to treat thromboembolic stroke.

METHODS

Thirteen patients with cerebral thrombolic disease (10 carotid territory, 3 basilar territory) were treated with catheter-directed intraarterial urokinase therapy with mechanical disruption of the clots. All patients were excluded from a 6-hour multicenter thrombolytic trial by either time, recent surgery, age, seizure, or myocardial infarction. Time elapsed before treatment ranged from 3.5 to 48 hours (12 +/- 13 hours), with 200,000 to 900,000 U of urokinase used.

RESULTS

Ten patients had successful vessel recanalization, confirmed by repeat angiography. Cases with distal branch vessel occlusions were less likely to recanalize. Asymptomatic hemorrhagic conversion occurred in 2 patients on repeat scans. Both acute neurologic and functional outcomes were assessed with significant improvement occurring in 9 (69%) of 13 patients at 48 hours (greater than four-point change on the National Institutes of Health scale) and in 100% of 3-month survivors. All patients who improved had normal initial CT scans.

CONCLUSIONS

Intraarterial cerebral thrombolysis with mechanical disruption of clot seems to be a useful therapy in selected stroke cases even after 6 hours.

Local intra-arterial thrombolysis with urokinase combined with balloon angioplasty in the lower extremities

OBJECTIVE

To assess the effect of thrombolysis with urokinase in the treatment of acute and subacute arterial thrombosis or graft occlusion.

DESIGN

Open study.

SETTING

County hospital, Sweden.

SUBJECTS

20 selected patients with lower limb arterial or graft occlusions of less than six months' duration, 17 of whom presented with rest pain (four with ulceration) and the rest with claudication.

INTERVENTIONS

High dose urokinase (4,000 IU/minute for up to 8 hours) given intra-arterially, followed by oral anticoagulation for 6 months.

MAIN OUTCOME MEASURES

Patency at one month and one year, morbidity and mortality.

RESULTS

At one month 6/17 who presented with rest pain could walk unlimited distances, 8 had claudication between 50 and 500 m, and 3 had no improvement; 2 had had below knee amputations. At one year only 4 could walk unlimited distances, 5 had claudication between 50 and 500 m, 2 had rest pain, 4 had had major amputations, and 1 was dead and 1 was lost to follow up. Five patients had had 10 additional procedures. Of the 3 who presented with claudication, 2 improved their walking distance to at least 100 m, and one had total relief of symptoms after one month; after a year one had no symptoms, one had mild claudication, and one had severe claudication (120 m). Three developed complications: one bleeding 12 hours after treatment was successfully treated by transfusion, one embolism to the midpopliteal artery was successfully treated by embolectomy, and one episode of bleeding during lysis ceased when treatment was stopped.

CONCLUSION

Thrombolysis is at best only an adjunct to balloon angioplasty or traditional vascular operations.

[An allergic reaction due to i.v. urokinase administration]

We notify a case of anaphylactic reaction due to urokinase which was administered to a patient with extended anterior acute myocardial infarction. He showed some allergic reaction symptoms such as: cutaneas eritema and dyspnea with bronchial spasm which disappeared with an intravenous cortisone drug. Therefore we think that urokinase too might give rise to anaphylactic reaction.

A pilot study of pro-urokinase in the treatment of deep vein thrombosis

Safety and efficacy of the thrombolytic agent pro-urokinase (pro-UK) in the treatment of deep vein thrombosis of the lower limbs (DVT) have been investigated in an open, uncontrolled, pilot study. Fifteen patients were infused with 800.000 IU (5 mg)/h of pro-UK over 24 h (120 mg), together with unfractionated heparin adjusted to maintain the activated partial thromboplastin time between 1.5 and 2.5 times the basal value. Efficacy was assessed comparing venographic changes in the 11 evaluable limbs before and after pro-UK infusion. The Marder score decreased from a median pre-thrombolysis value of 28 (range 4-40) to 16 (3-38) (p < 0.05). One major hemorrhagic event (retroperitoneal bleeding 4 days after the end of the pro-UK infusion) occurred. Fibrinogen, alpha 2-antiplasmin and plasminogen significantly decreased from baseline values after 12 and 24 h, fibrin(ogen) degradation products significantly increased. Changes in hemostasis parameters were unrelated to thrombolytic efficacy. The results of this pilot study indicate that pro-UK is thrombolytic in DVT and that it can be administered simultaneously with conventional heparin treatment.

[Recurrent ST segment elevations in continuous ECG analysis in the acute phase of myocardial infarct treated with thrombolytic therapy]

Early fluctuations of the ST-segment elevation indicating intermittent opening and reocclusion of the infarct artery has been well documented by angiographic monitoring in individual acute myocardial infarction patients undergoing thrombolytic therapy. However, the frequency of such episodes has not been studied in a consecutive patient group. Furthermore, it is not known what impact this finding has on the reinfarction risk during hospitalization and on left ventricular healing. The present investigation included 79 patients with acute myocardial infarction (pain < or = 6 h). Continuous Holter monitoring of the infarct-related ST elevation was initiated before or directly after starting thrombolytic therapy. During the 24-h observation period, 34 patients (43%) showed episodes of recurrent ST elevation after an initial resolution (group 1). Among those without episodes, ST elevation resolved within 4 h in 34 (43%, group 2) and persisted > or = 4 h in 11 (14%, group 3). Episodes of re-elevation were more frequent during the first 4 h (0.25 episodes per hour) than in the late part of the observation period (0.04 episodes per hour). Most episodes were transient and short lasting; only nine patients showed persistent re-elevations longer than 60 min. During hospitalization, group 1 patients had a higher incidence of reinfarctions and severe ischemic events than those without episodes (group 1 12/34 (35%) vs. group 2 4/34 (12%) vs. group 3 1/11 (9%), p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Thrombolysis versus thrombectomy for occluded hemodyalisis grafts

Graft thrombosis is the most frequent complication of polytetrafluoroethylene grafts for hemodialysis. Many of these patients arrive at the dialysis unit with fluid and metabolic abnormalities that require prompt dialysis. Rapid declotting of the graft is important to avoid having to create temporary access. Thrombolysis with urokinase has been evaluated by recent retrospective studies and found to be successful in 60% to 90% of cases. Our prospective, randomized trial was initiated to compare thrombolysis with standard surgical thrombectomy; and to evaluate the safety, effectiveness, efficiency, and durability of these modalities. In this study, 15 patients underwent thrombolysis and 16 had thrombectomy. The success rate was 67% for the thrombolysis group compared with 94% for the surgical group. Patency rates were similar for both modalities, but the complication rates were higher and the time to completion longer with thrombolysis. Although both treatments can be used successfully, surgical thrombectomy remains the optimal choice for treating occluded dialysis grafts.

Treatment of dural sinus thrombosis by urokinase infusion

PURPOSE

To gain a preliminary understanding of the role of thrombolytic therapy for the thrombosed dural sinus, we retrospectively reviewed our initial experience.

METHODS

Seven patients, ages 25 to 71, who presented with symptomatic dural sinus thrombosis and who failed a trial of medical therapy were treated with direct infusion of urokinase into the thrombosed sinus. Patients received urokinase doses ranging from 20,000 to 150,000 U/h with a mean infusion time of 163 hours (range 88 to 244 hours).

RESULTS

Patency of the affected dural sinus was achieved with antegrade flow in all patients. Six patients either improved neurologically over their prethrombolysis state or were healthy after thrombolysis; one of them required angioplasty. The other patient improved after surgical repair of a residual dural arteriovenous fistula. The only complications were an infected femoral access site which resolved after treatment with antibiotics and hematuria which cleared after discontinuation of anticoagulation.

CONCLUSIONS

Thrombolysis of the thrombosed dural sinus shows promise as a safe and efficacious treatment. The results of this study should provide the impetus for further research.

Acute hypoxemic respiratory failure following intrapleural thrombolytic therapy for hemothorax

Intrapleural instillation of thrombolytic agents has been useful in the treatment of hemothorax when thoracostomy tube drainage is unsuccessful. We present a patient who developed acute hypoxemic respiratory failure following the intrapleural instillation of both streptokinase and urokinase 24 h apart. Hypoxemia most likely resulted from a direct effect of the products of fibrinolysis on the pulmonary circulation.

Recent development of rigors during infusion of urokinase: is it related to an endotoxin?

PURPOSE

This study was undertaken to determine the prevalence of rigors associated with the use of urokinase (UK) and to assay for the presence of an endotoxin in the UK solution.

PATIENTS AND METHODS

Records of 75 patients who underwent 86 UK infusions between January 1988 and July 1992 were reviewed to evaluate for the development of UK-associated rigors. A modified chromogenic limulus amebocyte lysate (LAL) test was performed to determine the presence of endotoxin in four samples of UK from lots associated with rigors, one sample of UK not associated with rigors, sterile water, nonionic contrast medium, and ionic contrast medium.

RESULTS

Between January 1, 1988, and July 10, 1990, 43 patients underwent 46 UK treatments (group 1) with no documented rigors (0% prevalence). In 45 of these 46 treatments, a standard, non-pulse-spray bolus of 75,000-500,000 IU of UK (mean dose, 182,222 IU) was used. Between July 11, 1990, and July 6, 1992, 38 patients underwent 40 UK treatments (group 2). In 33 of these 40 treatments, a standard bolus was given. Five patients received a pulse-spray bolus. The mean bolus was 213,768 IU (range, 100,000-500,000 IU). Eleven group 2 patients developed rigors (28% prevalence; P = .0005 vs group 1). The chromogenic LAL tests demonstrated no endotoxin in sterile water, nonionic contrast media, or ionic contrast media. Endotoxin was detected in small concentrations in the four samples of UK associated with rigors and in the UK sample not associated with rigors.

CONCLUSION

The increase in the prevalence of rigors associated with the use of UK does not appear to be related to an endotoxin in UK, since the concentration of endotoxin detected is well below the threshold pyrogenic dose in humans.

Intracerebral hemorrhage complicating urokinase infusion into an occluded aortocoronary bypass graft

Selective infusion of urokinase into occluded coronary bypass vein grafts is effective in restoring patency. We report the occurrence of intracerebral hemorrhage complicating an intra-graft urokinase infusion protocol. The patient had known cerebral vascular structural pathology without recent clinical complications. Caution with the use of thrombolysis in this setting is suggested.

[Paradoxical cerebral embolism during fibrinolysis therapy in deep vein thrombosis and pulmonary embolism]

A 37-year-old woman with increasing dyspnoea over several months suddenly developed severe ortho- and tachypnoea as well as cyanosis of the lips and acrocyanosis. Pulmonary angiography revealed massive bilateral pulmonary emboli with a systolic pulmonary artery pressure of 75 mm Hg. Phlebography demonstrated a thrombotic occlusion of the deep veins of the left leg extending to the distal femoral vein. Thrombolysis treatment was started via an indwelling pulmonary artery catheter (500,000 IU urokinase and 10,000 IU heparin as bolus, then 1 mill. IU urokinase and 1,000 IU heparin per hour). After two hours an incomplete left-sided paresis occurred (involving ocular and facial muscles, dysarthria, left arm and left leg) and the thrombolytic infusion was stopped. But cerebral computed tomography (CT) did not demonstrate any intracerebral haemorrhage. The heparin infusion was restarted (partial thromboplastin time between 70 and 90 s). CT examinations during the next few days showed the development of an ischaemic infarction in the distribution of the right medial cerebral artery. Angiography demonstrated occlusion of the right internal carotid artery. The diagnosis of a paradoxical embolus was supported by easy cardiac catheter passage through a patent foramen ovale. Subsequent pulmonary angiography demonstrated a thrombus-free pulmonary arterial circulation with a normal pulmonary arterial pressure. There was gradual and extensive regression of the incomplete hemiparesis.

[Intracranial hemorrhage following thrombolytic therapy in acute myocardial infarct]

INTRODUCTION

Intracranial hemorrhage in acute myocardial infarction, under thrombolytic therapeutic, ranges from 0.3 to 3% in different trials. We carried out a study to stabilised the incidence of this complication in ours patients, as well as to analyze its characteristics and asses the presence the predictive factors.

METHODS

We retrospectively reviewed 997 consecutive patients with acute myocardial infarction treated with thrombolytic agents. We used two different protocols in two consecutive periods of time. Protocols differ in the age of the patients, the thrombolytic agent and its interval of applications. We analyze the intracranial hemorrhage incidence rate in each period, as well as its relations with the age of the patients, the sex and the thrombolytic agent used. We also analyze the possible predictive risk factors: cerebral-vascular disease, hypertension, diabetes, etc.

RESULTS

The overall rate of intracranial hemorrhage was 1.6%, higher in the patients of the second period (0.9% vs 1.9%, p = NS). The age over 70 years don't show a significant increase of this incidence (1.7% vs 1.5%). The APSAC group have shown a greater rate of hemorrhage (4%) than streptokinase (0.8%) and rTPA (1.2%). Cerebral-vascular disease and hypertension background were the two factors more frequently related to hemorrhage. The mortality rate was 68.7%.

CONCLUSION

The intracranial hemorrhage is a severe complication of thrombolytic therapy with a relative low incidence, but in our experience, higher than described in multicenter studies. There are several factors related that we would to take into account when is applied this therapy.

[Spontaneous retroperitoneal hemorrhage induced by anticoagulation treatment]

Contribution of one case of spontaneous retroperitoneal haemorrhage presented after therapy with anticoagulants. Review of causes of transperitoneal haemorrhage, relative frequency, as well as signs and symptoms, and diagnosis. The sparse number of haemorrhagic complications after anticoagulant therapy with heparin and urokinase-associated adjusted heparin are described. Treatment is instituted based on precipitating condition and, in the present case, with suppression of medication and volume replacement together with an strict evolutive monitoring by means of ultrasound, computerized axial tomography (CT) and magnetic nuclear resonance (MNR).

Evaluation of risk of hemorrhagic transformation in local intra-arterial thrombolysis in acute ischemic stroke by initial SPECT

BACKGROUND AND PURPOSE

Thrombolytic therapy was carried out on patients with acute ischemic stroke, and the risk of hemorrhagic transformation was evaluated from the residual cerebral blood flow (CBF) by pretherapeutic single-photon emission-computed tomography (SPECT).

METHODS

Local intra-arterial thrombolytic therapy was carried out using urokinase or recombinant tissue plasminogen activator (rt-PA) within 6 hours from the onset in 34 patients in whom no hypodensity areas were observed on the initial computed tomography examination. In the 20 patients with carotid territory occlusion who underwent 99mTc-labeled hexamethylpropyleneamine oxime (99mTc-HMPAO) SPECT, the residual CBF of the ischemic region was evaluated semiquantitatively by calculating two parameters: the ischemic regional activity to cerebellar activity ratio (R/CE ratio) and asymmetry index (AI).

RESULTS

The occluded vessels could be recanalized in 22 (92%) of the 24 patients in the urokinase group and in all 10 of the patients in the rt-PA group. Hemorrhagic transformation appeared in 4 patients in the urokinase group and 3 patients in the rt-PA group. Among the 20 patients who underwent SPECT before the treatment, the residual CBF was lower in the 5 patients who developed hemorrhagic transformation than in the 15 who did not (P < .05). Hemorrhagic transformation occurred in all patients with R/CE ratio of less than 0.35 and AI of more than 1.5.

CONCLUSIONS

The risk of hemorrhagic transformation after recanalization of occluded vessels by local intra-arterial thrombolytic therapy was considered to be high when the pretherapeutic residual CBF was markedly reduced.

Vasospasm prevention with postoperative intrathecal thrombolytic therapy: a retrospective comparison of urokinase, tissue plasminogen activator, and cisternal drainage alone

The authors report the results of a retrospective review, between January 1986 and December 1991, of the results of early surgery and intrathecal thrombolytic therapy in 111 patients with aneurysmal subarachnoid hemorrhage. Effects on clot lysis, angiographic and symptomatic vasospasm, cerebral infarction, and clinical outcome were compared in 60 patients treated with urokinase (UK) 60,000 IU/d for 7 days (UK group), 22 patients treated with 0.042 to 1 mg tissue plasminogen activator (tPA) every 6 to 8 hours for 5 days (tPA group), and 29 patients who did not receive treatment with either thrombolytic agent (no-treatment group). The no-treatment group consisted of all patients treated before July 1986 and of patients in whom thrombolytic therapy was attempted but failed to start or in whom the therapy was not used intentionally because of small subarachnoid clot. Treatment with UK was employed between July 1986 and March 1991, and tPA was employed during the remainder of the study for patients at a higher risk for vasospasm. The severity of angiographic vasospasm and the incidence of infarction in the UK and the tPA groups were less than those of the no-treatment group (P < 0.01), in spite of a larger amount of initial subarachnoid blood clot in both thrombolytic groups. This appears to be the result of the more rapid clearance of cisternal clot in the thrombolytic groups than the no-treatment group (P < 0.01). Only tPA therapy reduced the incidence of symptomatic vasospasm (P < 0.05). No serious complications were observed, although in the tPA group, asymptomatic intraventricular hemorrhage occurred in one patient, and transient confusion in another. Both received 4 mg tPA/d. Meningitis was suspected in 16 patients of the UK group. However, in this relatively small retrospective series, there were no differences among the three groups in overall outcome at 3 months. This study indicates that postoperative intrathecal thrombolytic therapies, especially with less than 4 mg/d of tPA, are effective in lysing subarachnoid clot and preventing vasospasm and infarction safely.

Efficacy and safety of repeated boluses of urokinase in the treatment of deep venous thrombosis

The only Food and Drug Administration-approved thrombolytic regimen for treatment of deep venous thrombosis (DVT) is a 24- to 72-hour continuous infusion of intravenous streptokinase. This approach to DVT thrombolysis is not entirely satisfactory because of the bleeding complications that may accompany this therapy. In the current study, we treated 27 patients with DVT with a novel dosing regimen of urokinase: 1,000,000 U administered as a 10-minute bolus, with a total of 3 boluses given over approximately 24 hours. Patients were given heparin overnight between bolus urokinase doses. Efficacy was assessed by comparing baseline and prehospital discharge vascular imaging studies, which constituted either venous ultrasound or contrast venography. A vascular-imaging panel of physicians, unaware of the sequence of paired studies, found that 14 patients (52%) had clot lysis (6 slight, 6 moderate and 2 marked), 9 (33%) had no change, and 4 (15%) had more extensive thrombosis after treatment (1 slight, 2 moderate and 1 marked). There were no bleeding complications. At 48 hours after starting urokinase, mean plasma fibrinogen levels had decreased 61% from baseline, and the mean bleeding time had increased 28% from baseline (but remained within the normal range). Because of the promising efficacy and safety that were found in this case series, it is concluded that further testing of bolus urokinase is warranted against anticoagulation alone.

Febrile reaction associated with urokinase

Urokinase is an endogenously produced human proteolytic enzyme used to treat many thrombotic disorders. A 54-year-old man with recurrent myocardial infarction experienced fever during intracoronary urokinase infusion into a saphenous vein graft; the fever resolved after discontinuation of the infusion. After excluding all other possible etiologies of fever, urokinase was determined to be the cause. Several studies indicated that this reaction may be associated with urokinase infusion, but it is actually recognized by few individuals. This is the first published case report of the adverse event to our knowledge.

Safety of thrombolytic therapy in elderly patients with massive pulmonary embolism: a comparison with nonelderly patients

OBJECTIVES

The aim of the study was to prospectively estimate the safety of thrombolytic therapy in elderly patients with massive pulmonary embolism in comparison with that in nonelderly patients.

BACKGROUND

In massive pulmonary embolism, lysis of thrombi can be achieved faster with thrombolytic therapy than with conventional heparin therapy, but it is administered with great caution in elderly patients because the risk of bleeding is thought to be higher than in nonelderly patients. Yet, thrombolytic therapy might be of value in elderly patients also, in allowing potentially more rapid improvement than is achieved with conventional heparin therapy.

METHODS

Eighty-nine patients with massive pulmonary embolism defined as Miller score > or = 17/34 underwent thrombolytic therapy without consideration of age if they had no contraindication for such treatment. Fifty-three patients were < or = 70 years old (mean age +/- SD 54 +/- 15 years; range 18 to 70), and 36 patients were > or = 71 years old (78 +/- 5 years; range 71 to 88). Except for mean age, there were no significant differences between the two treatment groups, particularly in terms of clinical presentation, average Miller score and pulmonary artery pressure regimen. Thrombolytic therapy was administered in the form of streptokinase at a dose of 100,000 IU/h over 12 h, with an initial injection of 250,000 IU over 15 min. Heparin was introduced 12 h after initiation of thrombolytic therapy. Urokinase or tissue-type plasminogen activator was used only in case of contraindication to streptokinase.

RESULTS

The frequency of uncomplicated clinical course was the same in both treatment groups. Surgical embolectomy was necessary in three nonelderly patients (5.6%) and one elderly patient (2.7%). Changes in pulmonary pressure regimen and Miller score were identical in both groups. Three patients died during the in-hospital course: two nonelderly patients (3.7%) and one elderly patient (2.7%). Minor bleeding occurred in five nonelderly (9.4%) and five elderly (13.8%) patients (p = 0.74). Major bleeding was observed in three nonelderly (5.6%) and five elderly (13.8%) patients (p = 0.29). Bleeding subsequent to early invasive procedure accounted for six (75%) of eight patients with major bleeding: two nonelderly patients (one of whom died) and four elderly patients. No intracranial hemorrhage was observed. No predisposing factor for bleeding was identified, except the need for early vascular access for pulmonary angiography through the femoral approach or for percutaneous insertion of an intracaval device for partial interruption of the inferior vena cava.

CONCLUSIONS

Thrombolytic therapy administered for massive pulmonary embolism in patients free of contraindication yields similar results and carries a similar risk for bleeding complications in elderly compared with nonelderly patients. Limiting early invasive procedures may result in less frequent major bleeding complications.

The effect of taprostene in patients with acute myocardial infarction treated with thrombolytic therapy: results of the START study. Saruplase Taprostene Acute Reocclusion Trial

Taprostene is a prostacyclin analogue that inhibits platelet aggregation and thus might be a useful adjuvant to thrombolytic agents in acute myocardial infarction. In a placebo-controlled dose rising study, taprostene or placebo was intravenously infused in 80 patients treated with the thrombolytic agent saruplase (rscu-PA) for acute myocardial infarction. Three doses of taprostene were used: 6.25; 12.5; or 25.0 ng.kg-1 x min-1. Taprostene or placebo was infused for 48 h, followed by a 24 h tapering period. All 80 patients had short symptom-to-treatment delay and marked ST segment elevation. Patency at 90 min was documented in 58/78 patients (two patients had no angiography). Success rate varied from 67-82% in the four treatment arms (P = 0.33). Patency after rescue PTCA was seen in 10 out of 13 patients. Of the 58 patients having a patent artery at 90 min, none of the 43 taprostene patients and one of the 15 placebo patients had a re-occluded artery at the second angiography at 32-48 h (5/58 patients had no recatheterization). Conversely, of nine patients who had successful rescue PTCA, three of four placebo patients had a re-occluded artery at the second angiography compared to one of five taprostene patients (one placebo patient had no recatheterization) (P = 0.33). Safety evaluation revealed no major difference between the placebo plus saruplase and the taprostene plus saruplase groups. Taprostene was well tolerated up to 25 ng.kg-1 x min-1. Although taprostene did not affect 90 min patency, there was a trend to better maintenance of patency after rescue PTCA.

Acute anuric renal failure: a complication of combined thrombolytic and antithrombotic therapy

Thrombolytic agents are routinely given to patients with acute myocardial infarction, often in combination with heparin. Genitourinary hemorrhage is an uncommon adverse effect of systemic thrombolysis, and acute azotemic complications are distinctly rare. We describe a case of genitourinary hemorrhage after combined thrombolytic and antithrombotic therapy leading to acute bilateral ureteral obstruction and then briefly review renal complications of systemic thrombolysis.

[Thrombolytic therapy in pulmonary embolism. Indications and therapeutic strategies]

The absence of significant symptoms and signs makes the diagnosis of pulmonary embolism difficult. Sensitivity and specificity of laboratory tests, chest X-ray, ECG, echocardiography and venous studies is low. Ventilation-perfusion scanning is also often not diagnostic. The combination of several diagnostic techniques, however, and pulmonary angiography confirm the diagnosis. Heparin remains the standard therapy for patients with stable haemodynamics. Thrombolytic therapy is recommended in haemodynamically compromised patients, since it yields accelerated clot lysis and pulmonary reperfusion. In standard dose regimes streptokinase, urokinase and t-PA are equally efficient. t-PA, however, acts more rapidly than the other agents. So far there is no study to prove that thrombolytic therapy significantly reduces mortality in pulmonary embolism.

High-dose urokinase therapy in newborn infants with major vessel thrombosis

The effectiveness of urokinase therapy for thrombosis in children, particularly in newborn infants, has not been established. We report our experience with the local administration of high-dose intrathrombus urokinase in two newborn infants. One infant had aortic thrombosis and the other, thrombosis of the right femoral artery. The known abnormalities in the newborn's fibrinolytic mechanism provide the rational basis for the therapeutic use of high doses of plasminogen activators. No significant abnormalities of our patients' fibrinolytic systems were found, and effective thrombolysis was achieved. A literature review of the use of urokinase therapy for thrombosis in children reveals great disparities in dosage and outcome. We believe that fixed-dose regimens should be replaced by individually adjusted thrombolytic therapy and that the need for higher doses of urokinase in newborns should be studied further.

Combined effects of urokinase and heparin on PTT values during thrombolytic therapy

The local infusion of urokinase may be complicated by hemorrhage. Except for maintaining fibrinogen levels above 100 mg/dL, no other criteria exist for titrating the dose of urokinase to avoid hemorrhagic complications. A retrospective examination of the fibrinolytic and coagulation states was performed on 11 patients receiving local high-dose urokinase (240,000 U/hr) and heparin for thrombolysis of acute occlusions to identify parameters other than fibrinogen levels that may correlate with bleeding complications. Five patients experienced bleeding complications, 3 of whom had partial thromboplastin time (PTT) values greater than 150 seconds. None of the five patients having hemorrhagic complications had fibrinogen levels below 100 mg/dL at any time. Urokinase began to enhance the effect of heparin on PTT values as a result of reducing fibrinogen levels. In 10 of 11 patients this effect caused PTT values to at least double when compared with heparin alone. This substantial rise in PTT occurred only after fibrinogen levels approached 200 mg/dL in 8 of 11 patients. Although the number of patients is small, these data suggest that when heparin is used during thrombolysis, closer PTT monitoring should be carried out as fibrinogen levels begin to decline, especially when they approach 200 mg/dL, to avoid excessive PTT elevations and subsequent bleeding.

Acute myocardial infarction complicating urokinase infusion for total saphenous vein graft occlusion

Saphenous vein graft occlusions have been successfully treated with extended urokinase infusions. We report a case of myocardial infarction complicating this treatment. A review of reported cases suggests that this complication may not be uncommon. The optional drug, dose, and infusion technique for intra-graft lytic therapy has not been determined. The costs, risks, and difficulty of this technique may limit its application.

Safety of intracavitary urokinase with percutaneous abscess drainage

OBJECTIVE

Percutaneous drainage of abscesses is an effective treatment, but the success rate is lower for abscesses that have septa and are multilocular. Several clinical and in vitro studies suggest urokinase may be useful in such cases. Our study was designed to determine the safety of urokinase administered into an abscess cavity during the course of percutaneous drainage.

SUBJECTS AND METHODS

Our study included 26 consecutive patients with 31 abscesses treated with percutaneous drainage. Exclusion criteria included age less than 18 or more than 95 years, CNS disorders (e.g., tumor, vascular problems), coagulation impairments, hepatic failure, pregnancy, and abscesses in the spleen, pancreas, or interloop area. Three doses were used: group 1 (nine patients), 1000 IU of urokinase per centimeter of abscess diameter; group 2 (11 patients), 2500 IU of urokinase per centimeter of abscess diameter; and group 3 (nine patients), 5000 IU of urokinase per centimeter of abscess diameter. These doses were administered every 8 hr for 3 days along with percutaneous drainage. Charts were reviewed to determine success and to detect adverse clinical events. Studies included sequential CT scans; serial serum determinations of hematocrit, prothrombin time, partial thromboplastin time, platelet count, fibrinogen levels, and levels of fibrin degradation products; and serial laboratory analysis of purulent material for fibrinogen and fibrin degradation products. Percutaneous drainage was considered successful if no surgical intervention was required.

RESULTS

Our results showed no significant change in hematologic studies and no bleeding complications. Analysis of purulent material indicated that urokinase remained active in the abscess milieu. Drainage was successful in seven of 11 patients in group 1, all nine patients in group 2, and 10 of 11 patients in group 3. All eight abscesses with septa were successfully drained.

CONCLUSION

Intracavitary urokinase can be given safely during percutaneous drainage of an abscess, with no associated bleeding complications or changes in coagulation parameters.

Combined thrombolytic therapy for prosthetic mitral valve thrombosis

Prosthetic valve thrombosis is associated with high mortality. The treatment of choice remains operation. This is a case report of the successful combination therapy of tissue plasminogen activator and urokinase for an isolated thrombosed prosthetic mitral valve in a postpartum patient in whom operation was thought to carry an unacceptable risk. Combined thrombolytic therapy or therapy with a single agent with a long half-life and a prolonged infusion time is suggested as an emergent treatment option for prosthetic mitral valve thrombosis.

Urokinase combination chemotherapy in small cell lung cancer. A phase II study

BACKGROUND AND METHODS

Fifty-one patients with small cell lung cancer (SCLC) were treated with alternating urokinase (UK)-cyclophosphamide-doxorubicin (Adriamycin, Adria Laboratories, Columbus, OH)-vincristine and cisplatin-etoposide-vincristine. UK was given as a loading dose of 3000 micrograms/kg body weight, followed by 3000 micrograms/kg/h for 6 hours. Thoracic irradiation with split technique (46 Gy) and prophylactic cranial irradiation (25 Gy) were administered to responding patients. A second staging was performed in patients exhibiting a clinical complete response (CR) after 1 year.

RESULTS

In 27 patients with limited disease, there were 23 CR and 8 partial responses (PR) (CR, 85.1%; 66.2-95.8% at 95% confidence intervals); in 24 patients with extensive disease, there were 17 CR, 4 PR, and 3 cases with progression. Pathologically proven CR were observed in 59.2% patients with limited disease and 33.3% patients with extensive disease. Survival rates were as follows: in patients with limited disease, 1 year, 85.1%; 2 years, 55.5%; and 3 years, 25.9%; in patients with extensive disease, 1 year, 54.1; and 2 years, 16.9%. Median survival times were 26.3 months (patients with limited disease) and 13.3 months (patients with extensive disease). UK-related toxic effects included four episodes of mild to moderate bleeding, one allergic reaction, and one cerebrovascular accident. Myelotoxicity was severe, with a median of two episodes of Grade III-IV (World Health Organization classification) aplasia per patient.

CONCLUSIONS

These results are consistent with a potential benefit of fibrinolytic therapy in combination with chemotherapy in patients with SCLC with limited disease. Additional trials are indicated.

Rate of fibrinogen breakdown related to coronary patency and bleeding complications in patients with thrombolysis in acute myocardial infarction--results from the PRIMI trial

Four hundred and one patients with acute myocardial infarction of less than 4 h duration were randomized to receive intravenous thrombolytic treatment with either 80 mg of full length unglycosylated single-chain-urokinase plasminogen activator (INN saruplase) or 1.5 million IU of streptokinase delivered over a 60 min period. Angiographic patency rates were higher at 60 min in saruplase treated patients (71.8% vs 48%; P less than 0.001), but did not differ significantly at 90 min (71.2% vs 63.9%; P = 0.15). Fibrinogen levels dropped markedly in both groups, the decrease being delayed and less pronounced with saruplase. Total fibrin and fibrinogen degradation products and D-dimer values rose earlier and to higher peak values in streptokinase treated patients. In both groups marked plasminogen and alpha 2-antiplasmin consumption was observed. Lower fibrinogen levels, and in particular the faster rate of fibrinogen breakdown, were associated with higher patency rates at 90 min (P less than 0.05). Patients with bleeding complications had lower 'lowest points' and a more rapid decrease in fibrinogen (P less than 0.05). These findings were not related to the drug used. Increased heparin levels at 6 to 12 h were correlated to bleeding complications in streptokinase treated patients. It is concluded that the rate of fibrinogen breakdown during and following thrombolytic treatment for acute myocardial infarction is related to early vessel patency and bleeding complications.

Treatment of massive pulmonary thromboembolism with low intrapulmonary dosages of urokinase. Short-term angiographic and hemodynamic evolution

Sixteen patients who had massive pulmonary thromboembolism and shock had no history of cardiopulmonary disease. We present an evaluation of the short-term effects of fibrinolytic treatment consisting of intrapulmonary administration of a bolus of 500,000 IU of urokinase followed by infusion of 1 x 10(6) IU into the right auricle over 12 h and subsequent intravenous infusion of heparin. For each patient, the effectiveness of treatment was evaluated by comparing pretreatment angiographic and hemodynamic parameters with those measured 48 h after the start of treatment. The Miller index fell from 22.9 +/- 5.9 to 9.8 +/- 3.3 (p less than 0.001), with a mean improvement of 57.2 percent. All the hemodynamic parameters studied (cardiac output and index, total pulmonary vascular resistance, and systolic, diastolic, and mean pulmonary vascular pressure) also exhibited statistically significant differences between pretreatment and posttreatment values (p less than 0.001 for each parameter), with a mean improvement of over 30 percent in each case. All the patients survived, and in no case did treatment fail; only one patient (6.2 percent) suffered severe hemorrhage. We conclude that this form of administration of urokinase is useful for patients with critical massive pulmonary thromboembolism.

Treatment of urokinase-related anaphylactoid reaction with intravenous famotidine

OBJECTIVE

We describe our experience with an anaphylactoid reaction to urokinase and the treatment used. We also discuss the use of histamine H1- and H2-blockers in combination for the treatment of allergic anaphylactoid reactions.

DESIGN

Case report.

SETTING

Hospital.

PARTICIPANTS

Observation of a patient who had a pulmonary embolism.

INTERVENTION

During the use of urokinase, in treatment of a pulmonary embolism, the patient developed an anaphylactoid reaction that did not respond to diphenhydramine or hydrocortisone. Famotidine was administered.

RESULTS

Abatement of urticaria and normalization of vital signs were obtained soon after famotidine was given. Completion of thrombolysis took place.

CONCLUSIONS

Further investigation of the use of H1- and H2-blocking agents in the presence of anaphylactoid reactions to thrombolytic agents should be performed. Consideration of intravenous famotidine for the treatment of anaphylactoid-type reactions to urokinase is suggested.