Fibrinolytic therapy for upper-extremity arterial occlusions.

Acute upper-extremity arterial occlusion may be due to embolic phenomena or de novo thrombosis. If the occlusion is left untreated, claudication or ischemia necessitating amputation can occur. Operative Fogarty-balloon embolectomy has been the treatment of choice for this entity. In a 6-year period the authors used fibrinolysis on nine occasions in eight patients to treat acute upper-extremity arterial occlusions. Concomitant balloon angioplasty was helpful in four cases. Success, defined as a normal hand with at least one artery that was continuously patent to the wrist, was achieved in all patients. A single significant groin hematoma was seen. Neither stroke nor death occurred in any case, and no amputations were necessary. Local transcatheter intraarterial administration of urokinase can be considered a first-line treatment for brachial artery embolus and other causes of acute upper-extremity arterial occlusion.

Noninfectious complications of long-term central venous catheters: radiologic evaluation and management.

During a 5-year period, 416 long-term double-lumen central venous catheters were inserted into 288 patients. In these patients, 106 catheter venograms and nine upper extremity venograms were performed. All studies were reviewed retrospectively to determine the nature and prevalence of noninfectious catheter-related complications, to evaluate the efficacy and safety of streptokinase therapy, and to determine if catheter venography should be performed before streptokinase therapy is started. Noninfectious complications occurred in 66 (23%) patients. Complications that resulted in catheter malfunction included deposition of fibrin around the catheter tip (formation of a fibrin sheath) in 44 (57%) instances, a constricting suture in six, abutment of the catheter tip against the venous wall in eight, catheter leak in two, and migration of the catheter completely out of the vein in three. Venous thrombosis developed in 11 patients. Treatment with low doses of streptokinase successfully relieved catheter obstruction due to a fibrin sheath in 27 (87%) of 31 instances. No bleeding complications occurred. Five patients had malpositioned catheters in the azygous, axillary, or internal jugular veins. By use of a deflector wire or snare inserted via the femoral vein, all five were relocated successfully into the superior vena cava. Recognition of noninfectious complications associated with use of long-term catheters is important for institution of appropriate therapy, which in many instances obviates removal of the catheter. Formation of a fibrin sheath in only 57% of cases of catheter malfunction provides an argument for performing catheter venography before streptokinase therapy is started. Low-dose streptokinase therapy for long-term central venous catheters occluded by a fibrin sheath is safe and efficacious.