Thrombolysis for PE after limb surgery

A patient develops shock and dyspnoea on the orthopaedic ward after a total knee replacement and massive pulmonary embolism is confirmed radiologically. Would you give a fibrinolytic or is it contraindicated? Harry Wright and colleagues did, but before giving 50 mg of intravenous rtPA they applied a tourniquet (Cryocuff) to the limb to limit the proportion of the systemic thrombolytic agent that would reach the site of the surgery. The tourniquet was inflated just before the infusion and was left on for one hour. There was some oozing of blood from the postoperative wound, which settled with bandage compression. The authors state that the inflation time of one hour was sufficient for the thrombolytic agent to be largely eliminated from the circulation, since alteplase has a plasma half-life of less than five minutes, although some plasminogen activator activity does persist for up to four hours.

The patient was well at three month follow up. They suggest:

Given the success in this case, we believe that major limb surgery no longer represents a contraindication to thrombolysis.

Thrombolysis for postoperative pulmonary embolism: limiting the risk of haemorrhage
Thorax. 2011 May;66(5):452

3 thoughts on “Thrombolysis for PE after limb surgery”

  1. Interesting case report. Working in the ICU setting I’m seeing increasing numbers of massive PEs in the post operative setting. (Cases which seem always to be complex.) This options would be faster and simpler then alternatives like intra-arterial catheter thrombolysis.

  2. There must be a period of time after which the risk of post-op bleeding is outweighed by the benefit of lysis delivered not only to the PE but also to the DVT – in that without the cuff the circulating tPA is free to lyse some of residual clot burden in the leg too.

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