Catheter-Directed Tenecteplase (TNK) Thrombolysis of Acute Unilateral Thrombosed Left Hand

Abstract

Acute hand ischemia is an infrequent clinical entity. We describe a unique case of acute unilateral hand ischemia occurring while being treated for septic shock initially caused by a Recluse spider bite on the opposite forearm.

VASCULAR DISEASE MANAGEMENT 2011;8(10):E169–E171

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Introduction

Unilateral hand ischemia from generalized septic shock has not been described in the literature. This is the first case describing this entity following spider bite with subsequent septic shock. Among the vascular events occurring during septic shock, systemic thromboembolic complications occur in the peripheral vascular system with the highest morbidity in the lower extremities.¹ Recluse spider (Loxosceles reclusa) venom can cause a severe systemic reaction resulting in hemolysis with renal failure and rarely, septic shock.² The interaction between the venom and tissues causes release of proteolytic enzymes, platelet aggregation, and blood flow alterations that result in edema and ischemia with development of necrosis.² Typically, hand, plastic, and vascular surgeons are consulted when presented with a thrombosed upper extremity. Treatment modalities span a spectrum from local wound care and fasciotomy to microvascular transplantation and amputation.¹ Interventional radiological procedures have become the mainstay for the treatment of many peripheral vascular diagnoses. Arterial thrombolysis of acute arterial occlusion is one of many common procedures performed in interventional radiology.^3,4 However, intra-arterial thrombolytic treatment in the setting of septic shock has not been described before due to its high risk for potential bleeding complications. Endovascular techniques are commonly performed in various vascular territories far less common in the upper extremities than in the lower extremities. In this case, we used catheter-directed intra-arterial TNKase^® (Genentech, San Francisco, California) thrombolysis in a patient with septic shock and recent attempted radial artery cannulation with a favorable result and no bleeding complications. Currently, TPA (Activase, Genentech) and TNK are the most common thombolytic agents used in vascular interventions. Even with unilateral global ischemia to the hand and recent attempted arterial puncture of the radial artery, there was excellent reperfusion to the hand upon completion of the procedure. Subselective catheter-directed TNK thrombolysis treated the thrombosed branches of the hand with no residual deficits. Interventionalists as well as the treating hand surgeon should be aware of the various options available to them in treating upper extremity vascular diseases. We feel the utilization of these image-guided, catheter-directed procedures in the upper extremities is a safe and effective alternative to dissolving thrombus and restoring arterial flow even in difficult clinical scenarios like septic shock.

Case Report

A 37-year-old male with no past medical history presented to the emergency room following a Recluse spider bite to the left forearm and was otherwise healthy. His left forearm and hand were swollen and painful and he felt ill. Clinically, an abscess was noted at the spider bite site and a non-contrast MRI confirmed the findings. His platelet count was 136,000(th/ul) at admission and his International Normalized Ratio value was 1.17.

He underwent surgical excision of the left forearm abscess and a thrombosed vein at the center of the wound. Subsequently, he developed full-blown septic shock resulting in cardiovascular collapse requiring multiple pressor agents, fluid resuscitation, and intravenous broad-spectrum antibiotics. He was treated in the intensive care unit for 7 days. During that time, an arterial line was attempted in the right radial artery for hemodynamic monitoring. No Allen’s test was documented in the chart prior to arterial puncture. Despite multiple attempts, no radial artery access could be obtained. A small hematoma was documented in the chart at the puncture site.

The patient’s right hand became dusky, bluish, cold, and pulseless. At the wrist, there were no Doppler signals in the distal ulna artery, distal radial artery, or the palmar arch. Interventional radiology was consulted for angiographic evaluation of the hand. Using standard interventional technique, a selective catheter was placed in the right subclavian artery  from the right common femoral artery approach. An angiogram was performed demonstrating patent right subclavian and brachial arteries. There was no anomalous arterial anatomy of the radial, ulna, or median arteries. Focused images of the wrist and hand demonstrated distal occlusion of the radial and ulna artery with no flow into the deep or superficial palmar arch (Figure 1). First, a microcatheter was placed in the distal radial artery and intra-arterial TNK was delivered at .25 mg/H (2.5 mL/H) for an overnight infusion (approximately 12 H). Fibrinogen levels were monitored during the drug infusion. The next morning, the distal radial artery and deep palmar arch were patent. Subsequently, the microcatheter was then placed in the ulna artery and repeat overnight infusion (approximately 12 H) was performed at the same dose. The next morning, the distal ulna artery was patent with good flow into the superficial palmar arch. There were no bleeding complications during the two 12-hour thrombolytic infusions. Clinically, the hand was warm with brisk capillary refill to the digits suggesting widely patent vessels. A final right hand angiogram demonstrated patency of the ulna and radius to the hand (Figure 2). Overall, the patient improved clinically and was discharged in a few days following the procedure.

Discussion

Acute arterial occlusion to the hand is an infrequent clinical presentation. A unilateral ischemic hand from generalized sepsis has not been described in the literature. This is the first known case of this finding and the first treated with TNK thrombolytic therapy directly into the ischemic hand. The etiologies of unilateral upper extremity ischemia are similar to lower extremity arterial ischemia. Atherosclerosis, trauma, arterial embolism, arterial entrapment, vasculitis, iatrogenic injury and Churg Strauss Syndrome (CSS)⁵ are causes of peripheral arterial ischemia. However, intravenous drug abuse, Raynaud’s vasospasm, Takyasu’s arteritis, topical injuries, and iatrogenic radial artery catheterization are particularly unique to the upper extremities. Case reports of iatrogenic arterial occlusion of the hand have been described with intravenous drug abusers inadvertently injecting drugs into the arterial system.^6,7 Using iatrogenic intra-arterial drug injection instead of venous access route causes an acute arterial thrombosis resulting in a vascular emergency.^6,7 Radial artery occlusion following attempted or successful cannulation is uncommon with approximately 2–10% of patients developing this complication.⁸ As in any arterial procedure, distal emboli, pseudoaneurysms, and dissections can occur during vessel access. Global ischemia from a radial artery puncture is extremely rare and would only be seen in a minority of patients who lack dual blood supply to the hand. Generally, an Allen’s test or Doppler study is performed at the bedside and can identify adequate blood supply to the hand in both the ulna and radial arteries. A recent article by Barone et al concluded that an Allen’s test before radial artery cannulation should not be considered a standard of care.⁹

In the setting of sepsis, peripheral ischemia is the result of profound vascular constriction and microvascular thromboses resulting in critical reduction in tissue perfusion. Surgical debridement is the treatment of choice for removal of the source of infection. As in our case, surgical debridement of the forearm abscess and thrombosed vein in the wound bed was performed at the site of the spider bite but the vascular supply to this hand remained patent with no signs of vascular malperfusion.

As in all of our endovascular treatments, a baseline arteriogram was obtained, evaluating the entire vascular circulation. Hand arteriography is a routine vascular radiology procedure but has not been commonly thought of when considering thrombolytic therapy.¹⁰ In our case, the consulting physicians suspected an iatrogenic radial artery injury from attempted arterial line access but no radial artery injury was noted on the angiogram. There were no pseudoaneurysms, vasospasm, dissections, or large-vessel thromboses at the access site. In light of the patient’s profound septic shock, severe unilateral peripheral vascular constriction as a consequence of preserving central vascular perfusion for vital organs was the working diagnosis. We believe this combination of microvascular events secondary to septic shock resulted in the distal ulna and distal radial thromboses as seen on our images. The attempted radial artery cannulation did not disrupt the integrity of the vessel and therefore in our opinion was not the root cause of this patient’s unilateral ischemia. As the distal vasculature constricted within the digital arteries of the hand, the occlusive process propagated proximally resulting in worsening clinical symptomatology.

Gilani et al described unilateral reperfusion of the hand in the operating room with TPA following failed embolectomy from an ipsilateral left brachial artery catheter placement.¹¹ In contrast, our case was performed entirely percutaneously in the endovascular suite with conscious sedation and no post procedure complications. With the two 12-hour TNK infusions, there were no bleeding complications even in the setting of septic shock. We have used TNK extensively and do not see any bleeding complications with TNK infusion at these dosages even in the most critical patients. TNK has a high fibrin specificity with far less depletion of systemic fibrinogen and thus less bleeding complications. TNK allows the interventionalist the opportunity to perform these atypical scenarios in thrombolytic therapy due to its exquisite clot affinity and extremely low bleeding risks if monitored carefully during the thrombolysis. In order to reduce lysis times, simultaneous catheter-directed thrombolytic infusions of both ulna and radial arteries were discussed but were not used based on the devices available at the time of the procedure. In theory, this technique would have opened the vessels up in one 12-hour infusion as compared to 2 days limiting the drug dose and diminishing overall ICU stay. Placement of a catheter in the brachial artery proximal to the radial and ulna arteries was also discussed but the closer the catheter is placed to the clot, the less wash out of the drug into collateral vessels. However, due to the long distance to the distal radial and ulna arteries from the groin approach, only microcatheter and wire systems are currently available to treat these distal tiny peripheral vascular structures. In addition, these systems can be used through smaller guiding catheter systems resulting in less chance of access site bleeding complications. These technological advances have allowed vascular specialists to reach these previously difficult vascular locations. Overall, distal thrombolytic therapy can be safely performed for upper extremity thrombosis resulting from various clinical entities.

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From the St. Joseph's Hospital and Medical Center, Tampa, Florida.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted May 10, 2011, provisional acceptance given June 6, 2011, final version accepted June 28, 2011.
Address for correspondence: Dr. Glenn W. Stambo, MD, SDI Radiologists/St. Joseph's Hospital snd Medical Center, 4516 N. Armenia Ave, Tampa, FL 33603 E-mail: xraydoc2@yahoo.com