Thrombolytic treatment of acute thrombotic obstruction with disk valve prostheses: experience with 26 cases

Twenty-eight episodes of prosthetic valve thrombosis occurred in 26 patients, and all were treated by thrombolytic drugs. The treatment consisted of UK (4500 IU/kg/hr for 12 hours) or SK (2,000,000 IU over 10 hours). The results were followed clinically and in the laboratory and by the same methods that are used for the diagnosis (echocardiography, fluoroscopy) of these problems. Immediate complete regression was seen in 23 cases. These cases did not undergo cardiac surgery. In three cases, in which clear clinical improvement was obtained while both the echocardiography and cinefluoroscopy showed persistent valve dysfunction, the patients were treated medically in two cases (second thrombolysis) and by surgery in one case. In two other cases thrombolysis was ineffective and the patients underwent emergency valve replacement. There were no significant hemorrhagic complications, but emboli from the thrombolysis occurred in five patients. Laboratory data illustrated changes in the success and improvement groups. There were no changes in the failure group.

Local infusion of urokinase for the lysis of thrombosis associated with permanent central venous catheters in cancer patients

We assessed the efficacy of local fibrinolytic therapy in 35 axillary-subclavian vein thromboses (SVT) that occurred in cancer patients with percutaneous central venous catheters (CVC). These catheters were indwelling for a median of 1 month (range, one day to 10 months) before thrombosis developed. Urokinase was administered at a dose of 500 to 2,000 U/kg/h. Complete lysis occurred in 25 of 30 thrombi that were directly infused, after a median of four days. Complete lysis occurred in one of 12 thrombi that could not be directly infused with urokinase and in two of six with associated phlebitis. Eighty-one percent of the thrombi that were symptomatic for less than 1 week before treatment resolved, compared with 56% present for longer than 1 week. Sixteen patients who had complete (12) or partial (four) thrombolysis did not have their CVCs removed. All four patients with partial thrombolysis had recurrent thrombosis at a median of eight days (range, one to 90). Only two patients who had complete thrombolysis had recurrent thrombosis, at 8 and 16 months. Only minor hemorrhagic toxicity was seen.

The UKEP study: multicentre clinical trial on two local regimens of urokinase in massive pulmonary embolism. The UKEP Study Research Group

A multicentre trial (10 centres) of urokinase (UK) was performed in patients with acute severe pulmonary embolism (PE). The aim of this trial was, to compare the efficacy of two doses of UK administered via a catheter in the pulmonary artery: 2000 IU kg-1 h-1 for 24 hours (UK 2000) in conjunction with heparin versus 4400 IU kg-1 h-1 UK alone for 12 hours (UK 4400) followed by heparin. PE was less than 5 days old and the clinical diagnosis was confirmed by pulmonary angiograms demonstrating a vascular obstruction of more than 30% (Miller's index greater than 11). The efficacy of treatment was evaluated by the degree of early revascularization (pulmonary angiograms were performed 30 to 48 hours after initiation of thrombolytic treatment and analysed blindly by four independent vascular radiologists). 133 patients were included in this trial: two patients died before treatment and two were excluded retrospectively, leaving 129 patients for final analysis (67: UK 2000 + heparin; 62: UK 4400). The two groups had similar pretreatment clinical, haemodynamic and angiographic characteristics: the Miller angiographic index of severity averaged 22.6 +/- 3.7 for patients in the UK 2000 group, and 22.6 +/- 3.4 for patients in the UK 4400 group (average filling defect of 66% on pulmonary angiograms). There was a similar and significant degree of resolution in the two groups: 26% and 20%, respectively. Minor and major bleeding problems were observed with equal frequency in the two groups (24% and 29%, respectively). These bleeding complications were severe in only 4.5% and 3%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Clot lysis for thrombosed central venous catheters in pediatric patients

Central venous catheters (CVC) in pediatric patients provide a reliable method for administration of total parenteral nutrition and chemotherapy. Catheter thrombotic occlusion is a major complication and, until recently, the only therapeutic option was removal and surgical replacement of the catheter. Two fibrinolytic agents, streptokinase and urokinase, have been used successfully in adults to dissolve the clots. Few side effects have been reported when these agents were administered for this purpose. The Physician's Desk Reference advises against the use of such agents in the pediatric population. However, several reports of successful use of these agents in pediatric patients have been reported. They have also been infused systemically to relieve both arterial and venous thrombi. We prospectively evaluated the safety and efficacy of thrombolytic drugs in infants and children with CVCs who were receiving parenteral nutrition and/or hemodialysis. Abbokinase was used on 14 occasions to unclot silastic catheters in 10 pediatric patients. All catheters restored to patency were cleared within 50 minutes with an average clearance time of 19.3 minutes. Only one catheter could not be salvaged. Protime levels were obtained whenever possible before and after administration of the abbokinase. No significant elevations were noted after abbokinase administration. No allergic reactions or other complications occurred. Abbokinase was found to clear clotted central lines in a shorter time frame than has previously been reported in this patient population.

Massive pulmonary embolism: short-term effects of thrombolytic treatment

This study assessed the short-term effects of thrombolytic treatment in 38 patients with massive pulmonary embolism. Thirty-two were treated with streptokinase and six with urokinase. Intrapulmonary artery instillation of fibrinolytic agents was utilized except in 3 patients. There was a marked hemodynamic and arteriographic improvement (p less than 0.0005) in 33 patients (86.8%). Four patients (10.5%) died because of treatment failure. In these cases the fibrinogen concentration remained above 1 gr/liter during therapy. Bleeding was detected in 22 patients (57.8%) but was most often related to puncture or cut-down sites, and only 2 patients (5.2%) had major bleeding. One patient (2.6%) had cerebral hemorrhage. It is concluded that "classic" thrombolytic treatment is to be chosen in life-threatening pulmonary embolism. However, the difficulties sometimes encountered in producing an intense lytic effect and its low fibrinolytic specificity for the thrombus do not permit the obtainment of better results.

Coronary thrombolysis with recombinant single-chain urokinase-type plasminogen activator in patients with acute myocardial infarction

Seventeen patients with acute transmural myocardial infarction and angiographically confirmed complete coronary occlusion were treated with heparin combined with intravenous single-chain urokinase-type plasminogen activator (scu-PA), obtained by expression of the cDNA encoding mature human scu-PA in Escherichia coli. In eight patients, recombinant scu-PA (rscu-PA) was given as a 10 mg bolus followed by 30 mg over 1 hr. Recanalization was obtained in six patients, but with persistent delayed opacification of the vessel in four of these patients. During infusion, a plateau level of rscu-PA antigen in plasma of 3.4 micrograms/ml (median value, range 1.4 to 5.5) was reached. At the end of the infusion the alpha 2-antiplasmin level had decreased to 54% (median, range 22% to 82%) of the preinfusion level, the fibrinogen level to 89% (median, range 26% to 101%), and fibrinogen degradation products (FDPs) to 20 micrograms/ml (median, range 8 to 387). In nine patients, rscu-PA was administered as a 10 mg bolus followed by 60 mg over 1 hr. This resulted in recanalization with normal distal filling of the vessel in seven patients, within 46 +/- 17 min (mean +/- SD). During infusion the concentration of rscu-PA in plasma increased to a median value of 7.4 micrograms/ml (range 4.0 to 13.3). At the end of the infusion the alpha 2-antiplasmin level was 22% of baseline (range 5% to 47%), the fibrinogen level 45% (range 4% to 94%), and the concentration of FDPs 87 micrograms/ml (range 6 to 1034). No significant bleeding or short-term side effects were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Thrombolysis of occluded femoropopliteal grafts

In a series of 44 occluded femoropopliteal grafts, streptokinase was used for thrombolytic therapy in 22 cases and urokinase in 22 cases. In most cases, thrombolytic agents were administered via an indwelling arterial catheter directly into the proximal thrombus. The catheter tip was advanced as thrombolysis occurred. Compared with streptokinase infusions, urokinase bolus injection followed by infusion had better results (77% vs 41%) and fewer complications (23% vs 50%). During thrombolytic infusion, concomitant heparin infusion was usually used to reduce the frequency of thrombus formation on the infusion catheter or recurrent thrombosis of the graft, once the tip of the infusion catheter was advanced distally. Follow-up in 23 of 26 successful cases showed that 11 of the grafts remained open at an average follow-up of 12 months or until the patient died. The 12 grafts that reoccluded remained open an average of 3 months. In none of the 18 failures was simple surgical thrombectomy or thrombectomy with graft revision effective in revascularizing the distal limb. The advantages of thrombolysis compared with thrombectomy are less trauma to the graft, which is especially important in vein grafts, and improved distal runoff due to lysis of infrapopliteal thrombus. Even among cases considered failures in this series, the surgical approach was often simplified because of partial thrombolysis. Thrombolysis requires a considerable amount of time, effort, and expense, but in certain patients where thrombectomy is indicated for the treatment of occluded femoropopliteal grafts this technique offers important advantages.

Intra-arterial fibrinolytic therapy. Efficacy of streptokinase vs urokinase

This study is a retrospective comparison of the results in 25 low-dose, intra-arterial streptokinase and 12 low-dose intra-arterial urokinase infusions for thromboembolic disease. Intra-arterial streptokinase was successful in 50% of infusions and was marked by significant abnormalities in the coagulation criteria. There was a high incidence of major and minor bleeding (48% overall), which could be attributed to systemic effects of the drug. Urokinase was successful in 100% of infusions, and showed no significant effects on systemic coagulation criteria. There were also fewer complications during urokinase infusion. The average pharmacy cost for a course of intra-arterial streptokinase was $165, while urokinase cost $1142. Despite the significant difference in expense, the increased efficacy and safety of urokinase make it the preferred agent for intra-arterial infusion. Theoretical reasons for the increased effectiveness of urokinase are discussed.

Controlled trial of combined urokinase and dextran sulfate therapy in patients with acute cerebral infarction

In this multiinstitute cooperative study, 143 patients were treated with either urokinase (UK) or combination of urokinase and dextran sulfate (UK-DS) within one to seven days following acute onset of cerebral thrombotic infarction. Of these, 81 randomized cases received a single dose of UK (2.83 X 10(5) units) by six-hour intravenous drip infusion and the remaining 62 received a combined dose of UK (2.84 X 10(5) units) and DS (3000 mg) for only one day. Moderate to marked clinical improvements assessed during the seven-day study period were observed in 30.9% of the patients treated with UK and in 61.3% of those with UK-DS, the latter being significantly higher. Hemorrhagic phenomena appeared in 3.2% of the cases treated with UK-DS and in none of those with UK alone, but mortality was 1.6% in the former and 2.5% in the latter. UK-DS produced a prompt and sustained increase in plasma fibrinolytic activity with transient and relatively minor disturbance of the blood coagulation system. The results indicate that combined therapy with UK and DS is more effective than UK alone for acute cerebral thrombotic infarction.

Transgraft hemorrhage: a serious complication of low-dose thrombolytic therapy

A 71-year-old woman came to the hospital with a 24-hour-old occlusion of the left limb of an aortoiliac knitted Dacron graft and was treated with an intra-arterial infusion of urokinase, 40,000 U/hr. Although the graft limb was successfully recanalized in 16 hours, the patient suffered a massive retroperitoneal hemorrhage through the wall of the graft. Clinicians must be aware of this potentially serious complication of thrombolytic therapy in patients with thrombosed, knitted Dacron grafts.

Acute peripheral arterial and graft occlusion: treatment with selective infusion of urokinase and lysyl plasminogen

Thirty-five patients hospitalized for recent angiographically documented arterial occlusion in the legs (27 femoropopliteal arteries and eight grafts) benefited from local fibrinolytic therapy delivered at the site of the occlusion with a 4- or 5-F catheter. This therapy combined a continuous urokinase (UK) infusion of 1,000 U/kg/hour and a lysyl plasminogen (LYS-PLG) infusion of 15 microkatals every 30 minutes. Angiographically confirmed lysis was obtained in 85% of the cases. Only 3% of the patients had major and 6% had minor groin hematomas. Only two patients had concentrations of fibrinogen as low as 100 mg/dl. Intravascular infusion of UK-LYS-PLG is as effective as streptokinase. Its excellent tolerance makes it a good alternative in the treatment of acute ischemia in the lower limbs.

Complications of intraarterial urokinase-lys-plasminogen infusion therapy in arterial ischemia of lower limbs

Thirty-five patients with peripheral arterial occlusions were treated by intraarterial infusion of low-dose urokinase associated with bolus of lys-plasminogen. Thrombolysis was achieved in 26 cases (74%), but only 10 patients (28.5%) experienced sustained improvement. Complications of thrombolysis occurred in 11 patients: Five patients developed groin hematoma, five had distal emboli, and one experienced macroscopic hematuria. Catheter-related thrombosis was observed in 14 patients (40%) despite intravenous heparin. Nine patients suffered from recurrent thrombosis and three from proximal emboli. A patient died from catheter-related infection. Limited fibrinolysis could increase pericatheter thrombosis, and further work will be necessary to assess the local risk of intraarterial thrombolysis.

Intravenous and intracoronary fibrinolytic therapy in acute myocardial infarction: overview of results on mortality, reinfarction and side-effects from 33 randomized controlled trials

During the past 25 years, 24 randomized trials of intravenous (IV) fibrinolytic treatment have been reported, involving a total of some 6000 patients in the acute phase of myocardial infarction. Most tested IV streptokinase (SK), but a few tested IV urokinase (UK). In the past 2 or 3 years numerous small randomized trials of intracoronary (IC) SK have been started, 9 of which, involving a total of about 1000 such patients, have been reported. Because all of these IV and IC trials were small (the largest including only 747 patients), their separate results appear contradictory and unreliable. But, an overview of the data from these trials indicates that IV treatment produces a highly significant (22% +/- 5%, P less than 0.001) reduction in the odds of death, an even larger reduction in the odds of reinfarction, and an absolute frequency of serious adverse effects to set against this that is much smaller than the absolute mortality reduction. The apparent size of the mortality reduction in the IV trials was similar whether anticoagulants were compulsory or optional, whether treatment was in a coronary care unit or an ordinary ward and, surprisingly, whether treatment began early (less than 6 h from onset of symptoms) or late (generally 12-24 h). In addition, there was no evidence that UK was more effective than the less expensive SK, or that, despite their technical complexity, the new IC regimes were more effective than the old IV regimes. Even the IV schedules that have been studied in randomized trials were, however, quite complex, and the IC schedules were far more so. Perhaps partly because of this, none of them is widely used. If so, then some much simpler, and hence more widely practicable, IV SK regimes should be developed and tested. For example, a simple one hour high-dose IV SK infusion, without anticoagulation, will successfully convert virtually all of the available plasminogen into plasmin. But, it may be several years before the net effects on mortality of any more widely practicable IV SK regimes can be agreed unless many of the hospitals that do not wish routinely to use IC regimes or the complex previous IV regimes will collaborate in multicentre randomized trials that can, if necessary, continue rapid intake until some tens of thousands of patients have been randomized, and some thousands of deaths have been observed among the control and treated patients. The same, of course, may be true for any other fibrinolytic regimes (e.g. infusion of tissue plasminogen activator) if their net effects on mortality are comparable to those of IV SK.

Intravenous urokinase in acute myocardial infarction

To achieve reperfusion early, an intravenous bolus of 2 million units of urokinase was administered in 50 patients with transmural acute myocardial infarction (AMI) 1.8 +/- 2.5 hours after the onset of symptoms. Coronary angiography performed 1.1 +/- 0.6 hours after urokinase therapy revealed patent coronary arteries in 30 patients (60%), with no significant difference between those with anterior and those with inferior AMI. Reocclusion occurred in only 1 of 24 patients restudied. Failure to achieve reperfusion was not related to the degree of systemic fibrinolytic activity, which was equally high in patients who did and those who did not achieve reperfusion, as evident from serially obtained fibrinogen measurements (77 +/- 52 vs 84 +/- 24 mg/dl, difference not significant). Plasmin activity, measured serially from 15 minutes to 24 hours after urokinase in 7 patients, was maximal at 15 minutes and undetectable after 3 hours. Wall motion at the infarct site measured from contrast ventriculograms was significantly better at follow-up only in patients in whom reperfusion was achieved and who received urokinase within 2 hours after the onset of symptoms as compared with patients in whom reperfusion was not achieved (-1.2 +/- 1.4 vs -2.4 +/- 0.9 standard deviations from normal, p less than 0.05). Peak serum creatine kinase level was significantly lower in patients in whom reperfusion was achieved than in those in whom it was not or those who had rethrombosis (802 +/- 763 vs 1,973 +/- 1,071 U/liter, p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Current status of thrombolytic therapy

The optimal role of thrombolytic therapy in clinical practice has not been defined precisely. A review of available information indicates that such therapy may be useful in a small number of carefully selected patients with deep vein thrombosis and/or pulmonary emboli. The superiority of thrombolytic therapy over conventional surgery for arterial thrombi has not been convincingly demonstrated. Available evidence suggests such therapy should be reserved for those conditions in which surgery may be expected to have a poor outcome or be associated with a high incidence of complications. Preliminary information suggests thrombolytic therapy may be of benefit in selected patients with acute myocardial infarction.

Coronary thrombolysis with urokinase infusion in acute myocardial infarction: multicenter study in Japan

The efficacy of intracoronary administration of urokinase was evaluated in 514 patients with acute myocardial infarction (anterior, 296 patients; inferior, 195; lateral or posterior, 18; and anterior and inferior, five). The time between onset of chest pain and coronary arteriography was 0.5 to 81.0 hr with an average of 5.0 hr. Initial administration of nitrates resulted in recanalization of the coronaries in 9.3%. Subsequently, urokinase was infused into the coronary arteries, and coronary thrombolysis was successfully achieved in 66.8%. The success rate was low in a group with average infusion speed of more than 30,000 units/min or with a total dose of urokinase of 480,000 units or less. Complications, mainly arrhythmias, were present in 111 patients (33.2%) of the 334 who had successful thrombolysis and in 18 patients (10.8%) of the 166 with unsuccessful thrombolysis, but serious hemorrhage was rare and no fatal case was reported. Patients who had successful thrombolysis had less in-hospital mortality than those who did not (6.3 vs 13.3%). Thus, coronary thrombolysis can be achieved effectively and relatively safely with a sufficient amount of intracoronary urokinase administration in acute myocardial infarction.

Sustained improvement of pulmonary hemodynamics in patients at rest and during exercise after thrombolytic treatment of massive pulmonary embolism

This study assessed the long-term effects of thrombolytic treatment in patients with acute massive pulmonary embolism (PE). Seven patients with PE that followed deep-vein thrombosis underwent pulmonary angiography and pressure measurements before and 6 +/- 3 days (mean +/- SD) and 15 +/- 4 months after treatment with intrapulmonary infusions of urokinase (average dose 1724 U/kg X hr) and heparin (average dose 17 U/kg X hr). Treatment was guided by daily measurements of pulmonary arterial (PA) pressure and was continued until PA pressure had normalized (average of 6 days). Late after treatment patients returned for pulmonary angiographic examination, right heart catheterization at rest and during bicycle exercise, and phlebography of the deep veins of both legs. Pulmonary angiograms showed massive obstruction before therapy (Walsh index 15 +/- 2 points of a maximum of 18 points), which was improved 6 days (3 +/- 3 points) and 15 months (1 +/- 2 points) after therapy. Mean PA pressure declined from 37 +/- 9 to 13 +/- 3 mm Hg after 6 days and to 15 +/- 3 mm Hg after 15 months. No recurrence of PE was observed. In six of seven patients at rest and during bicycle exercise (up to 100 W) in the supine position mean PA pressure and total pulmonary resistance remained within normal limits. Over the short term all patients showed clinical signs of deep-vein thrombosis; 15 months later four patients had normal deep veins, but three patients had still phlebographic signs of old thrombosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Thrombolytic therapy for acute arterial occlusion

To evaluate the role of selective intra-arterial low-dose thrombolytic therapy (SILDT) as an alternative to the surgical management of acute arterial occlusion, the hospital records of 40 patients who underwent 43 SILDT treatments with either streptokinase (36) or urokinase (7) between December 1979 and March 1984 were reviewed. Twenty-eight patients underwent 30 treatments (group 1) for native arterial occlusion and 12 patients underwent 13 treatments (group 2) for prosthetic or autogenous graft occlusions. Therapy was deemed successful if subsequent surgical therapy was obviated. In group 1, SILDT was successful in 13 of 28 (45%) patients with 12 of 25 lower extremity occlusions and one of three upper extremity occlusions. Successful lysis in the native artery occlusion group fell into three categories: five patients were successfully treated for arterial thrombosis complicating percutaneous transluminal angioplasty (PTA); four patients required PTA after complete lysis revealed an underlying arterial stenosis; and only three required no further therapy after SILDT. SILDT failed in all three patients with the aortoiliac occlusions. Eleven patients with femoral artery occlusions and unsuccessful SILDT required six bypass procedures, three amputations, one embolectomy, and one PTA. In group 2 only 3 of 14 treatments (21%) were successful. Bypass revision was not possible in 11 patients and all required amputation. Systemic fibrinolysis was seen in 20 (59%) of 34 patients with available data. Neither fibrinogen levels nor fibrin degradation products predicted the occurrence of complications. Minor complications occurred in 18 of 43 (43%) treatments; small hematomas at the catheter entry site were most common. Minor complications occurred in 20 of 43 treatments (44%) and included severe local hemorrhage (four), distant bleeding (three), pulmonary embolism (four), myocardial infarction (three), unmasking of an aortoduodenal fistula (one), and clot migration requiring emergency thrombectomy (four). SILDT is most effective in acute arterial thrombosis complicating arteriography or percutaneous angioplasty. It may play a role in the patient in whom thrombolysis can reveal an underlying stenosis amenable to percutaneous angioplasty. This experience shows SILDT to be of limited value in the management of prosthetic autogenous graft occlusions. Finally, thrombolytic therapy is associated with significant morbidity and mortality rates and requires cautious monitoring to detect arterial thrombus migration, worsening tissue ischemia, venous thromboembolism, intracerebral hemorrhage, and local or systemic bleeding.

Angiographic and pathologic evidence of hemorrhage into the myocardium after coronary reperfusion

Severe myocardial hemorrhage can occur as a potential adverse effect of reperfusion therapy in evolving myocardial infarction. This report describes a 83-year-old man, who showed angiographic evidence of extravasation of contrast medium from the reperfused right coronary artery into the inferoposterior left ventricular wall. At autopsy, severe hemorrhage was transmurally observed in the inferoposterior wall of the left ventricle. The finding of extravasation is a useful angiographic sign of the production of hemorrhage during coronary reperfusion therapy, and great attention should be focused to the existence of this sign to prevent further hemorrhage.

Efficacy of intracoronary and intravenous urokinase in acute myocardial infarction

The efficacy of intracoronary and intravenous urokinase was studied in 83 patients with acute evolving myocardial infarction. Urokinase was administered intracoronary in 48 patients with a success rate of 89% obtained after 47 +/- 32 minutes of infusion of a dose of 255.000 +/- 224.000 IU. In-hospital mortality in this group of patients was 10%. Severe arrhythmias were observed in 33% of the patients and the reocclusion rate at the re-study was 16%. Intravenous urokinase was administered as 200.000 IU bolus followed by 1.220.000 IU infusion in 21 patients. Angiography performed in this group of patients 48 hours after therapy showed a patency rate of 66%. A single intravenous bolus of 500.000 IU of urokinase was administered to 14 patients. At angiography all patients but one were found reperfused. The value of intravenous low-dose bolus injection of urokinase in acute myocardial infarction needs hower to be assessed with a properly designed clinical trial.

Effects of a single bolus of urokinase in patients with life-threatening pulmonary emboli: a descriptive trial

To evaluate hemodynamic, angiographic, and biological effects of a single bolus of urokinase, an open descriptive trial was conducted in a homogeneous group of 14 patients with acute life-threatening pulmonary emboli and without prior cardiopulmonary disease. For every patient the efficacy of the treatment was evaluated by comparing control and posttherapeutic values after the bolus injection of 15,000 IU/kg body weight urokinase (urinary source) administered in 10 min in the right atrium, followed by continuous intravenous full-dose heparin therapy. In two patients clinical status, hemodynamics, vascular obstruction, and biological (fibrinogen and plasminogen levels) parameters remained unchanged. One of these two patients died, making the mortality rate for the whole group 7%. Twelve of 14 patients showed rapid clinical improvement. Evaluation at 12 hr demonstrated significant decreases in pulmonary vascular obstruction (Miller index, 34%), total pulmonary vascular resistances (37%), and fibrinogen and plasminogen levels (41% and 40%, respectively), without any significant change in cardiac index. The hemodynamic sequential measurements performed (1,3, 6, and 12 hr) in seven of the 12 improved patients showed that the greatest percentage of the total hemodynamic improvement occurred within the first 3 hr after bolus administration of urokinase. No severe hemorrhagic complications were observed. Because of its rapid efficacy and its low cost, the bolus technique appeared particularly useful in the treatment of patients with acute life-threatening pulmonary emboli.

Discrepancy in the thrombolytic effect of UK between angiographic and circulatory evaluations

A clinical case in which angiographic and circulatory evaluations of the thrombolytic effect of urokinase (UK) were not correlated, is described. Circulatory improvement distal to the thrombosis was recognized on the basis of a rise in skin temperature and increased palpability of the pulse at the distal artery. However, angiography revealed the development of thrombosis. This discrepancy may have arisen from the hypotensive action of UK preparations due to increased flow in the collateral circulation. The significance of angiography in providing direct evidence for assessing the thrombolytic effect of UK is emphasized.

[Multicenter study of 2 urokinase protocols in severe pulmonary embolism. Research Group on Urokinase and Pulmonary Embolism]

The results of a multicentre trial (10 centres) of urokinase (UK) extracted from human urine in patients with recent massive pulmonary embolism (PE) are reported. The aim of this trial was to compare the efficacy of two protocols of UK therapy: low dose UK: 2 000 IU/kg/hour (UKl) associated with heparin, against high dose UK: 4 400 IU/kg/hour for 12 hours (UKh) followed by heparin. This randomised single blind trial included patients under 80 years of age. The clinical diagnosis of recent PE (less than 5 days) was confirmed by pulmonary angiography showing over 30% vascular obstruction (Miller index greater than 11). The efficacy of treatment was assessed by the degree of early revascularisation on pulmonary angiography 30 to 48 hours after the start of thrombolytic therapy, as analysed by 4 independent vascular radiologists. A total of 133 patients entered the trial between November 1978 and October 1981: 2 died before receiving treatment, 2 were excluded, 129 patients were retained (67 UKl and 62 UKh). The initial clinical, haemodynamic and angiographic parameters were comparable in the two groups: Miller index; 22.6 +/- 3.7 (UKl) and 22.6 +/- 3.4 (UKh), an average vascularisation defect of 66%. The efficacy of treatment was the same: 26% and 20% respectively. The incidence of haemorrhagic complications was the same in both groups: 24% and 29% respectively, but only 2% of patients had spontaneous severe bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)

Outcome of treatment of deep-vein thrombosis with urokinase: relationship to dosage, duration of therapy, age of the thrombus and laboratory changes

Forty-one patients with phlebographically proven DVT of the popliteal, femoral or iliac veins were treated with different regimens of urokinase (UK) given by continuous intravenous infusion. The four groups were comparable with respect to localization, extension and estimated age of the thrombi. Another phlebographic picture was taken within 48 hr after the end of UK infusion. Substantial lysis had occurred in 2 of 10 patients treated with 1500 U/kg/h for 2 days, in 4 of 11 treated with 2500/U/kg/h for 3 days, in 2 of 10 treated with 2500 U/kg/h for 7 days and in 4 of 10 treated with 4000 U/kg/h for 4 days. Only thrombi younger than 8 days could be lysed, with 61% (8/13) rate of lysis for thrombi less than 5 days old. Bleeding complications were observed more frequently with the higher doses and longer durations of therapy. The four treatment regimens all induced dose-dependent changes in fibrinogen, fibrin(ogen) degradation products, plasminogen and antiplasmin. Neither pre- nor post-infusion values of these parameters could differentiate patients with lysis from those without lysis. It is concluded that UK can provoke a high rate of thrombolysis of DVT treated early after the appearance of symptoms but that there is no relationship between UK-induced modifications of fibrinolysis and the outcome of therapy.

[Treatment of childhood hemolytic-uremic syndrome with urokinase. Cooperative controlled trial]

The results of a controlled therapeutic trial comparing 2 groups of patients presenting with hemolytic-uremic syndrome (HUS) are reported. Group A (15 children) was given urokinase (UK) and heparin; group B (18 children) received no treatment. Ages of patients, the delay before admission, the severity of anemia, thrombocytopenia and initial renal failure were similar in both groups. UK was responsible for bleedings in 12 children, minimal in 8, severe in 4. No child died in group A, 3 children died in group B (n.s.). Durations of hemolysis, thrombocytopenia and anuria were similar in both groups. Long-term evolutions of renal function and arterial pressure were comparable in both groups. Needle kidney biopsy (26 cases) showed cortical necrosis in 3 children of group A and in 2 of group B, and glomerular thrombotic microangiopathy in 10 children of group A and in 11 of group B. The average ratio of injured glomeruli was 40 (19 to 80) in group A, and 38 (21 to 75) in group B. Two children in group A and 3 children in group B presented with 50 to 80% of glomerular lesions. This trial suggests that UK is of no significant value in the treatment of HUS.

Unusual nodular pulmonary lesions associated with thrombolytic therapy

The occurrence of solitary nodular pulmonary lesions associated with thrombolytic therapy is reported in two patients. Resolution was spontaneous in each patient. Multiple thin needle aspiration biopsies in one case revealed only red blood cells. This unusual entity should be included as one of the potential complications associated with the use of thrombolytic agents.

Intravesical therapy of noninvasive bladder tumors (stage Ta) with doxorubicin and urokinase

A double-blind investigation was done on 44 patients with noninvasive bladder tumors (stage Ta) given randomized intravesical treatment with doxorubicin with or without urokinase. The bladder tumors were not removed before treatment in any patient. No significant difference in response was detected between the 2 types of treatment. Of the patients 86 per cent responded to treatment, including 52 per cent who achieved complete remission. At 12 and 42 months after termination of treatment 42 and 35 per cent of the patients, respectively, remained free of recurrent tumor.

Controlled multicenter pilot study of urokinase- heparin and streptokinase in deep vein thrombosis

Thirty-three patients with acute iliofemoral thrombosis were randomly assigned to three treatment groups in a pilot dose-ranging study of thrombolytic therapy in deep vein thrombosis. One group received tissue culture urokinase in a dose of 2,200 I.U./kg/hr, and a second group in a dose of 1,100 I.U./kg/hr following a loading dose of 4,400 I.U./kg given in ten min. Urokinase was administered for 12 hr periods, alternating with 12 hr periods of heparin. A third group received an initial dose of 250,000 I.U. of streptokinase in 20 min, followed by 100,000 I.U./hr. Treatment of all patients continued for three days. At the end of this period little improvement, evaluated by "blinded" interpretation of pre- and post-treatment phlebograms, was found in five out of ten of the higher-dose urokinase patients, seven out of eleven of lower-dosage urokinase patients, and six out of ten of streptokinase patients. Optional treatment for another three days showed little further improvement of urokinase-patients and moderate further improvement in the streptokinase-patients. Neither of the 2 dosage schemes at intermittent application of urokinase appeared to be advantageous. Urokinase treated patients experienced fewer adverse reactions.

[Thrombosis of a valve prosthesis: fatal cerebral embolism during thrombolytic treatment]

The authors report the first case of lethal cerebral embolism complicating thrombolytic therapy administered for thrombosis of a mitral valve prosthesis. The incidence of systemic embolism during this form of therapy appears to be at least one in five cases. It may be underestimated and should lead to further discussion as to the indications of thrombolytic therapy and surgery for thrombosis of a left heart valve prosthesis.

Intraarterial infusion of urokinase in the treatment of acute pulmonary thromboembolism: preliminary observations

Eleven patients were treated for acute pulmonary thromboembolism by perfusion of urokinase in the main pulmonary artery for a period of 12 hr with angiographic control. Clinical and radiologic improvement was achieved in all patients except for one in whom an embolectomy was later performed. The complications were similar to those for intravenous urokinase treatment, the most frequent being hemorrhage.

Urokinase-treatment of fresh laser irradiation-induced vitreous hemorrhage

Using a ruby laser, we induced vitreous hemorrhage in each eye of 12 rabbits. On the following day either 25,000 Ploug units of urokinase or saline were injected into the eyes of each rabbit. Urokinase did not accelerate the absorption of blood from the vitreous but prevented the development of severe vitreous fibrosis which replaced the hemorrhage in seven of the control eyes.

Fibrinolytic guidelines in diabetes

Urokinase and streptokinase are the two fibrinolytics approved for clinical use. Streptokinase has the broader application, being used to treat deep vein thrombosis (DVT), pulmonary embolism (PE), arterial thromboembolism, and occluded arteriovenous shunts in renal dialysis. Bleeding, the most significant complication of fibrinolytic therapy, arises mostly from invaded sites and can be significantly reduced by minimizing venipuncture and other invasive procedures.

[Medical treatment of ilio-caval venous thrombosis]

120 patients with ilio-caval thrombosis were managed medically. 55 patients were given heparin (5 mg/Kg/day for 15 days), 50 patients received streptokinase (loading dose 250,000 u; maintenance dose 100,000 m/h for 48 hours) and 15 patients had urokinase (112,500 u/h for 44 hours). Thrombolytic therapy was prescribed, in the absence of contraindications, for patients below 70 year of age: other patients were treated with heparin. The results were assessed by venography performed before and after treatment: success was defined as the complete disappearance of the thrombus of disobliteration of the ilio-caval axis. The overall success rate was 32%, with 68% failures. Success was higher with streptokinase (50%) than with heparin (20%) or urokinase (13%). The site, extension ans aetiology of the thrombosis did not affect the results. On the other hand, two other factors seemed to play an important role: - the duration of thrombosis: this only affected the streptokinase group; 23 of the 25 successes were obtained in patients treated before the tenth day. The results were unaffected by the duration of the thrombosis in the heparin group; - the biological effectiveness of therapy: 7 out of the 11 successes in the heparin group had been constantly well anticoagulated; there were only 4 successes out of 38 patients in whom the biological effectiveness had been intermittent. There were 21 successes out of 32 patients treated by streptokinase with serum fibrin levels of less than 1 g. There were only 4 successes in the 18 other cases. The incidence of haemorrhage was identical in the 3 groups. Embolism was slightly commoner in the streptokinase (3) than in the heparin group (2).

[Urokinase treatment of phlegmasia coerulea dolens (author's transl)]

Fibrinolysis treatment with urokinase was successfully undertaken in two patients, aged 71 and 76 years, with phlegmasia coerulea dolens. In the first case, with necrosis in the fore-foot, there was significant regression of the necrotic area, but a later limited amputation was still necessary. In the second, with severe heart failure, recurrent pulmonary emboli and hyperosmolar uncontrolled diabetes mellitus, complete healing was achieved. Venous thrombectomy was not possible in these two patients because of the duration of the thrombosis in the veins of the pelvic region, necrosis had already occurred, and the patients' general condition was so serious. The advanced age and arteriosclerotic changes argued against streptokinase treatment. Mean urokinase maintenance dosage of 1000-1500 IU/kg X h, with simultaneous administration of heparin at about 20 U/kg X h, produced no significant side-effects. Minor gastro-intestinal bleeding did not require stoppage of urokinase administration.