Selective Catheter-Directed Thrombolysis: Contraindications

Enzymatic thrombolysis is indicated when the anticipated outcome is similar to that of surgical intervention and can be done quickly enough to avoid irreversible ischemic damage. Regarding the latter, only patients with sufficient collateral vessels to maintain limb viability for 12 hours should be considered for thrombolytic therapy.

Absolute contraindications:

• Irreversible ischemia: Due to reperfusion syndrome and the fact that opening a vessel that has no run off is pointless, as it will quickly thrombose again.
• Recent (> 3 hours and <3 months) ischemic stroke: Patients with ischemic stroke < 3 hours may be eligible for thrombolysis.
• Recent (2 months) intracranial surgery
• Recent (3 months) major blunt head or facial trauma
• History of hemorrhagic stroke
• History of spontaneous intracranial hemorrhage
• Intracranial neoplasm (primary or metastatic) or vascular malformation
• Suspected aortic dissection
• Active bleeding
• Bleeding diathesis

Major relative contraindications:

• Remote (> 3 months) ischemic stroke
• Recent (3 weeks) major thoracic or abdominal surgery
• Recent major trauma
• Recent (1 month) internal bleeding
• Recent (3 months) gastrointestinal hemorrhage
• Uncontrolled hypertension: Increased risk of intracranial hemorrhage.
• Prolonged (> 10 minutes) or traumatic CPR
• Current use of anticoagulants

Minor relative contraindications:

• Pregnancy
• Infected thrombus
• Renal or hepatic insufficiency: Due to increased risk of coagulopathy in these states
• Diabetic retinopathy

References

• Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Ornato JP. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004 Aug 4;44(3):E1-E211.
• Kaufman JA and Lee MJ. Chapter 4: Vascular Interventions. in Vascular and interventional radiology: The Requisites. Mosby 20004.
• Schmittling ZC, Hodgson KJ. Thrombolysis and mechanical thrombectomy for arterial disease. Surg Clin North Am. 2004 Oct;84(5):1237-66, v-vi.
• Valji K. Chapter 2: Standard angiographic and interventional techniques. in Vascular and interventional radiology. Saunders, 1999.