Alteplase Administration for Clogged PICC Lines
For a thrombotically occluded PICC line, instill alteplase 2 mg in 2 mL into the catheter lumen with a dwell time of 30-120 minutes, and administer a second dose if patency is not restored after the first attempt. 1, 2
Dosing Protocol
Standard Adult Dosing
- Instill 2 mg alteplase in 2 mL volume into the occluded catheter lumen 1, 2
- For patients weighing less than 30 kg, use 110% of the internal lumen volume (not to exceed 2 mg in 2 mL) 1, 2
- The KDOQI guidelines suggest 2 mg is preferable to 1 mg for restoring catheter function, though intraluminal volume dosing (1 mg/1 mL) has shown equivalent efficacy with significant cost savings 1, 3
Dwell Time and Assessment
- Initial dwell time: 30 minutes, then assess for restoration of function 1, 2
- If unsuccessful at 30 minutes, extend dwell time to 120 minutes before reassessing 1, 2
- Restoration of function is defined as ability to withdraw at least 3 mL of blood and infuse 5 mL of saline through the catheter 2
Repeat Dosing
- If patency is not restored after the first dose with maximum dwell time, administer a second identical dose 1, 2
- Repeated doses are recommended by both the manufacturer and American College of Chest Physicians 1
- Overall success rate: 75% after one dose, 85-88% after two doses 1, 2, 4
Administration Methods
Both dwell and push methods are acceptable for administering alteplase, though the evidence does not strongly favor one over the other 1. The 30-minute push protocol has demonstrated efficacy in hemodialysis catheters, with 92% success in partially occluded and 85% in completely occluded lines 5.
Expected Efficacy by Clinical Scenario
Duration of Occlusion
- Occlusions present <14 days: 68% success after one dose, 88% after two doses 1
- Occlusions present >14 days: 57% success after one dose, 72% after two doses 1
- Larger doses and longer dwell times generally correlate with greater efficacy (50-90% range) 1
Catheter Type
- Success rates are similar across all catheter types (single-, double-, triple-lumen, and implanted ports) 2, 4
- No gender or age differences in restoration rates 2
Safety Profile
Alteplase for catheter clearance has an excellent safety profile with minimal serious adverse events. 1, 2
Documented Safety Data
- Intracranial hemorrhage: 0% in large trials 1, 2, 4
- No major bleeding or thromboembolic events in pediatric studies of 310 children 1
- Serious adverse events within 30 days: embolic events (0%), GI bleeding (0.3%), thrombosis (0.3%), sepsis (0.4%) 4
- No adverse events noted within 24 hours in pediatric case series 6
Critical Pitfalls to Avoid
Exclude Non-Thrombotic Causes First
- Attempt forceful saline irrigation first before using alteplase 1
- Rule out mechanical occlusion (catheter malposition, kinking) through bedside maneuvers including patient repositioning 1
- Non-thrombotic occlusions require different treatments: lipid occlusion (70% ethanol), mineral precipitates (0.1 N HCl), not alteplase 1
Contraindications
- Do not use in patients with known mechanical occlusion 2, 4
- Exclude patients at high risk for bleeding or embolization 2, 4
- Patients on hemodialysis catheters were excluded from pivotal trials, though alteplase has been used successfully in this population 4, 5
Dosing Errors
- Do not confuse stroke dosing (0.9 mg/kg IV) with catheter clearance dosing (2 mg intraluminal) 1
- For pediatric patients <30 kg, calculate 110% of internal lumen volume to avoid underdosing 1, 2
Alternative Agents
While alteplase is the recommended first-line agent 1, alternatives exist:
- Urokinase plus citrate 4% is also recommended by KDOQI as equivalent to alteplase 1
- The American College of Chest Physicians designates tPA as the agent of choice in pediatric patients due to FDA warnings regarding urokinase, superior in vitro clot lysis, fibrin specificity, and low immunogenicity 1
- Newer agents (reteplase, tenecteplase) may offer shorter dwell times but lack robust comparative data 1