Intracerebral hemorrhage postpharmacomechanical catheter-directed thrombolysis: can we prevent it?

SESSION TITLE: Pulmonary Procedures: Creativity and ComplicationsSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 10:15 am - 11:10 amINTRODUCTION: Pharmaco-mechanical catheter-directed thrombolysis (PCDT) has revolutionized the treatment of deep venous thrombosis (DVT) in the recent decade. Despite the mixed data on efficacy and procedure risk, PCDT has been linked with a very low risk of intracranial hemorrhage (ICH). We describe a case of fatal intracranial hemorrhage (ICH) occurring post-PCDT for bilateral DVT's.CASE PRESENTATION: A 61-year-old male with post-thrombotic syndrome (PTS), provoked left lower limb DVT with pulmonary embolism following left foot fracture in 2009, presented to our emergency department with complaints of new back pain and right leg swelling for one-day duration. Doppler ultrasound revealed extensive bilateral acute DVT's involving the right external iliac vein, proximal left common iliac vein, and lower inferior vena cava. After a multidisciplinary team discussion, he underwent bilateral lower limb PCDT. He was later transferred to our critical care unit post-operatively for close monitoring. His fibrinogen level post-op was 242 mg/dL; twelve hours later, a repeat fibrinogen level had decreased to 66 mg/dL. tPA was momentarily held; however, six hours later, the decision was made to restart tPA. Twenty-four hours later, the patient developed an acute change in mental status, tPA was discontinued, and an urgent computed tomogram (CT) head revealed multiple bilateral supratentorial and infratentorial intraparenchymal hemorrhages at the gray-white interface (Image). Despite our supportive measures, a repeat CT head the next day showed progressive hemorrhages with early herniation (Image). After discussion with the patient's family, he was transitioned to comfort care and terminally extubated.DISCUSSION: Anticoagulant therapy remains the gold standard for treating DVT, although up to 20% to 50% of patients will develop post-thrombotic syndrome. (1) It has been proposed that early thrombus removal for selected patients with acute DVT, particularly iliofemoral, reduces PTS morbidity and improves long-term quality of life. In contrast to anticoagulation, thrombolytic therapy used in PCDT activates fibrinogen-bound plasminogen, causing fibrinolysis and decreasing circulating fibrinogen. (2) Although low fibrinogen as a predictor of hemorrhagic complications has conflicting data in scientific studies, several large studies have shown that drops in fibrinogen correlate with bleeding complications. According to a recent study by Liu et al, (3), testing D-dimer and fibrinogen as a thrombolysis-monitoring approach every 8 hours resulted in just one bleeding event compared to three bleeding events in the comparison group using venography and fibrinogen testing every 24 hours.CONCLUSIONS: Due to insufficient data, different monitoring methods during PCDT are still debatable, and further research is needed to elucidate the significance of fibrinogen monitoring and replacement in preventing life-threatening ICH.Reference #1: Kahn SR, Comerota AJ, Cushman M, et al. ; American Heart Association Council on Peripheral Vascular Disease, Council on Clinical Cardiology, and Council on Cardiovascular and Stroke Nursing. The postthrombotic syndrome: evidence-based prevention, diagnosis, and treatment strategies: a scientific statement from the American Heart Association. Circulation. 2014;130(18):1636-1661Reference #2: Raabe RD. Ultrasound-accelerated thrombolysis in arterial and venous peripheral occlusions: fibrinogen level effects. J Vasc Interv Radiol. 2010 Aug;21(8):1165-72. doi: 10.1016/j.jvir.2010.03.020. PMID: 20656221Reference #3: Liu Q, Chen W, Wang YL, Wang ZY, Peng ZQ, Xiang JF, Chen L, Pan YC, Sha Y. A new method of monitoring catheter-directed thrombolysis for deep venous thrombosis-application of D-dimer and fibrinogen testing. Phlebology. 2022 Apr;37(3):216-222. doi: 10.1177/02683555211064026. Epub 2022 Mar 2. PMID: 35236191DISCLOSURES: No relevant relationships by Janhavi AthaleNo relevant relationships by Sreeja Biswas RoyNo relevant relationships by John Makram Fanous SESSION TITLE: Pulmonary Procedures: Creativity and Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Pharmaco-mechanical catheter-directed thrombolysis (PCDT) has revolutionized the treatment of deep venous thrombosis (DVT) in the recent decade. Despite the mixed data on efficacy and procedure risk, PCDT has been linked with a very low risk of intracranial hemorrhage (ICH). We describe a case of fatal intracranial hemorrhage (ICH) occurring post-PCDT for bilateral DVT's. CASE PRESENTATION: A 61-year-old male with post-thrombotic syndrome (PTS), provoked left lower limb DVT with pulmonary embolism following left foot fracture in 2009, presented to our emergency department with complaints of new back pain and right leg swelling for one-day duration. Doppler ultrasound revealed extensive bilateral acute DVT's involving the right external iliac vein, proximal left common iliac vein, and lower inferior vena cava. After a multidisciplinary team discussion, he underwent bilateral lower limb PCDT. He was later transferred to our critical care unit post-operatively for close monitoring. His fibrinogen level post-op was 242 mg/dL; twelve hours later, a repeat fibrinogen level had decreased to 66 mg/dL. tPA was momentarily held; however, six hours later, the decision was made to restart tPA. Twenty-four hours later, the patient developed an acute change in mental status, tPA was discontinued, and an urgent computed tomogram (CT) head revealed multiple bilateral supratentorial and infratentorial intraparenchymal hemorrhages at the gray-white interface (Image). Despite our supportive measures, a repeat CT head the next day showed progressive hemorrhages with early herniation (Image). After discussion with the patient's family, he was transitioned to comfort care and terminally extubated. DISCUSSION: Anticoagulant therapy remains the gold standard for treating DVT, although up to 20% to 50% of patients will develop post-thrombotic syndrome. (1) It has been proposed that early thrombus removal for selected patients with acute DVT, particularly iliofemoral, reduces PTS morbidity and improves long-term quality of life. In contrast to anticoagulation, thrombolytic therapy used in PCDT activates fibrinogen-bound plasminogen, causing fibrinolysis and decreasing circulating fibrinogen. (2) Although low fibrinogen as a predictor of hemorrhagic complications has conflicting data in scientific studies, several large studies have shown that drops in fibrinogen correlate with bleeding complications. According to a recent study by Liu et al, (3), testing D-dimer and fibrinogen as a thrombolysis-monitoring approach every 8 hours resulted in just one bleeding event compared to three bleeding events in the comparison group using venography and fibrinogen testing every 24 hours. CONCLUSIONS: Due to insufficient data, different monitoring methods during PCDT are still debatable, and further research is needed to elucidate the significance of fibrinogen monitoring and replacement in preventing life-threatening ICH. Reference #1: Kahn SR, Comerota AJ, Cushman M, et al. ; American Heart Association Council on Peripheral Vascular Disease, Council on Clinical Cardiology, and Council on Cardiovascular and Stroke Nursing. The postthrombotic syndrome: evidence-based prevention, diagnosis, and treatment strategies: a scientific statement from the American Heart Association. Circulation. 2014;130(18):1636-1661 Reference #2: Raabe RD. Ultrasound-accelerated thrombolysis in arterial and venous peripheral occlusions: fibrinogen level effects. J Vasc Interv Radiol. 2010 Aug;21(8):1165-72. doi: 10.1016/j.jvir.2010.03.020. PMID: 20656221 Reference #3: Liu Q, Chen W, Wang YL, Wang ZY, Peng ZQ, Xiang JF, Chen L, Pan YC, Sha Y. A new method of monitoring catheter-directed thrombolysis for deep venous thrombosis-application of D-dimer and fibrinogen testing. Phlebology. 2022 Apr;37(3):216-222. doi: 10.1177/02683555211064026. Epub 2022 Mar 2. PMID: 35236191 DISCLOSURES: No relevant relationships by Janhavi Athale No relevant relationships by Sreeja Biswas Roy No relevant relationships by John Makram Fanous