Treatment of Arterial Thrombosis
The treatment of arterial thrombosis requires urgent revascularization with anticoagulation, with thrombolytic therapy being the primary treatment for occlusive arterial thrombosis. 1
Initial Management
Immediate Interventions
- Anticoagulation: Initiate immediately upon diagnosis 1, 2
- IV unfractionated heparin: 70-100 IU/kg bolus followed by continuous infusion
- OR subcutaneous low molecular weight heparin (e.g., enoxaparin 1 mg/kg twice daily)
- Pain management: Provide adequate analgesia
- IV fluids: Maintain hydration
- Address metabolic abnormalities: Correct acidosis and hyperkalaemia if present
Assessment of Severity
Evaluate neurological function to determine urgency of intervention:
- No sensory loss, normal motor function → Urgent revascularization
- Sensory loss with mild-to-moderate muscle weakness → Emergency revascularization
- Complete sensory loss and loss of motor function → Consider primary amputation or palliative care
Revascularization Options
Thrombolytic Therapy
- Primary treatment for occlusive arterial thrombosis 1
- Alteplase (tPA) regimens:
- 0.5 mg/kg/h IV for 6 hours (common dosing) 1
- OR 0.2 mg/kg IV (max 15 mg), then 0.75 mg/kg over 30 min (max 50 mg), followed by 0.5 mg/kg over 60 min (max 35 mg)
- For coronary thrombosis: Consider low-dose tPA combined with abciximab
Monitoring During Thrombolysis
- Maintain fibrinogen >100 mg/dL and platelets >50,000 1, 3
- Continue low-dose heparin during alteplase administration (10 μg/kg/h)
- Monitor for bleeding complications (occurs in 30-40% of cases) 1
Surgical Options
- Thrombectomy: For cases where thrombolysis is contraindicated or unsuccessful
- Hybrid approaches: Ideally performed in a hybrid room allowing for completion angiography and local thrombolysis if needed 1
Special Considerations
Coronary Artery Thrombosis
- For coronary thrombosis (e.g., in Kawasaki disease): Thrombolytic therapy with tPA plus aspirin and heparin 1
- Alternative for patients of sufficient size: Mechanical restoration of coronary blood flow via catheterization
Post-Catheterization Arterial Thrombosis
- Initial management with heparin for 24-48 hours 1
- If pulse remains absent or reduced, proceed to thrombolytic therapy
- Success rates of 65-88% for complete clot resolution with thrombolytic therapy 1
Follow-up Management
- After revascularization, establish hemodynamic success
- Investigate etiology of thrombosis (cardiac sources, prothrombotic conditions)
- Consider imaging: Holter-ECG, echocardiogram, and aortic imaging 1
- Initiate optimal medical therapy including statins 1
- For male patients, consider extended anticoagulation (at least 3 months) due to higher recurrence risk (1.8 times higher than women) 3
Pitfalls and Caveats
- Delay in treatment: Urgent intervention is critical; diagnostic imaging should not delay treatment 1
- Bleeding risk: Major complications occur in up to 40% of patients receiving thrombolytic therapy 1
- Systemic thrombolysis: Has no role in the treatment of acute limb ischemia; catheter-directed thrombolysis is preferred 1
- Monitoring requirements: Close monitoring of hemostasis during thrombolytic treatment is essential to prevent hemorrhagic complications 3
- Recurrence risk: Male sex is a risk factor for recurrence, requiring consideration of extended anticoagulation 3