CDT | PERT Ottawa

CATHETER DIRECTED THROMBOLYSIS

These procedures take under an hour on average

Consists of a PA catheter through a 5F or 6F introducer

Total of 20mg intracatheter Alteplase over 15 hours will be given. (1mg/catheter/hr over 5 hours followed by 0.5mg/catheter/hr for 10 hours

This plan will require reconsideration if the patient does not improve or deteriorates

If patient does not significantly improve you can re-image and/or run these infusion for another 10 hours

Patients may become unstable during the procedure and require a change in plan (systemic thrombolysis) and/or intervention (intubation, Inotropes/Pressors)

These patients may need to be accompanied to the angio suite and/or have experienced hands readily available to intervene

ANTICOAGULATION PRE, during, AND POST CDT

Anticoagulation before CDT

Anticoagulation during and after CDT

Anticoagulation during and after CDT

Unless anticoagulation is contraindicated, do not hold or delay anticoagulation for any catheter directed therapies.

All procedures can be performed while fully anticoagulated with either LMWH or UFH

Anticoagulation during and after CDT

Anticoagulation during and after CDT

Anticoagulation during and after CDT

Don't forget to re-start full dose unfractionated heparin after CDT

Remember CDT will deliver 0.5mg, or as much as only 1mg of Ateplase per catheter, per hour

The patient must still be systemically anticoagulated unless contraindicated

We choose unfractionated heparin during catheter directed infusions due to is reversibility if bleeding occurs

You can resume LMWH 2 hours after catheters are removed if no bleeding at the access sites

LMWH can be started at the same time the unfractionated heparin infusion is turned off

PA CATHETER AND INTRODUCER REMOVAL POST CDT

CDT is delivered through 1 femoral venous sheaths (usually on the same side) with PA catheters through them ie little difference between this and our usual swan ganz set up

Once the alteplase infusion is complete, the venous catheters can simply be removed first by removing the PA catheters followed by the introducer

Introducer is 5F or 6F in size

Do not interrupt anticoagulation for catheter removal

Hold pressure for 15-20 minutes

If you are not comfortable removing these, IR is also willing to come to remove the catheters at the ICU MD's discretion

Transition to LMWH as above (see "Anticoagulation after CDT")

IF PATIENTS become UNSTABLE during or waiting for Procedures

Intermediate High-Risk (submassive) PEs can become High-RIsk (massive) PEs and require systemic thrombolysis (see "systemic TPA/TNK dosing" heading)

It is important to establish whether or not there will be delays for IR procedures (ie if IR is tied up with another case, or if they anticipate the case will be lengthy.

Remember that there are other options for variable dosing of systemic therapy if you don't think the patient will be stable enough to wait for a procedure (see heading "systemic TPA/TNK dosing")