For obstruction of long-term indwelling central venous catheters by fibrin sheath or intraluminal clot, which of the following is not correct?
A. Haire et al showed that a 2 mg dose of alteplase was more effective than urokinase (5000 IU) for the treatment of radiographically proven thrombotic occlusion of a CVC after a dwell time of 120 min.
B. In the COOL trial (Cardiovascular Thrombolytic used to Open Occluded Lines), catheter occlusion was cleared after 120 min in 74% of 69 patients who were given one 2 mg dose of alteplase compared with only 17% of 70 patients given placebo.
C. Current recommendations include delivery of a thrombolytic agent into the catheter lumen with a dwell time of at least 30 min and a repeated dose if needed. If catheter patency is not restored, a low dose of alteplase can be infused over 6—8 h.
D. If treatment with a thrombolytic agent does not clear the catheter, a guide wire should not be inserted through the catheter lumen to dislodge a thrombus at the tip of the CVC.
Answer: D
If treatment with a thrombolytic agent does not clear the catheter, a guide wire can be inserted through the catheter lumen to dislodge a thrombus at the tip of the CVC. Fibrin sheath stripping by a vascular snare device to dislodge and remove the fibrin sheath can also be done. Although effective, these procedures are more invasive and are only used when necessary.
Reference
Jacquelyn L Baskin MD, Prof Ching-Hon Pui MD, Ulrike Reiss MD, et al. Review: Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. The Lancet, Volume 374, Issue 9684, Pages 159 – 169, 11 July 2009