Alteplase infusion for clot in port

[Cincinatti1978]

A coworker had a pt that has facial swelling caused by a clot in her mediport. The MDs did not want the alteplase to just dwell in her line, instead they ordered an alteplase infusion. We do not do that on our floor and the pt was being upgraded to ICU. I'm confused because later in the night a doctor asked if we were using alteplase to make the line functional or to break up the clot. Would I be incorrect? If Alteplase is used, the clot can then dissolve and help reduce facial swelling, right? The clot wouldn't break off and then travel to other parts of her body, right? Alteplase would hopefully dissolve the clot first? Thank you!

[MunoRN, RN]

What you describe suggests that it's more than just the port that has a clot, the facial swelling would be caused by a thrombus in the vein itself and not just the lumen of the line.

I've never seen a tPA infusion for this purpose, if it was severe enough to require lytic therapy then it usually should be done as catheter guided lytic therapy in IR. One reason for this is that depending on how the catheter is positioned, it may not lyse the thrombus from the center of the lumen outwards but instead might lyse where it's adhered to the vein wall first, allowing it travel to the right heart and then the lungs.

[Asystole RN]

What you describe sounds like SVC syndrome r/t an indwelling port. It is not unheard of to use an Alteplase infusion to break up an extralumenal thrombus like that but it is very rare to not do it in IR for the concerns that you have.

Using the med that way is definitely off label and the whole procedure was definitely odd, sounds like the physician just said to himself, "Meh, lets see what happens."

[calivianya, BSN, RN]

I have never seen anything like that.

The only close thing I've seen is an alteplase infusion through a sheath placed in the leg in a patient with arterial occlusion in the leg. Ran tPA through a sheath in the popliteal artery and heparin through an ankle vein, with q1h neurovascular checks to the leg. I hadn't realized it would be necessary to give them together and I asked about it, but apparently the vessel where the clot's getting broken up can be a bit of a sensitive soul and prone to forming new clots, hence systemically anticoagulating with heparin too.

Thinking about that, I guess my biggest concern with your situation would be the same as yours - that tPA alone would be insufficient to break up the clot, or the clots would break up unevenly without heparin also being present. You weren't running a concurrent heparin drip, were you?