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Thrombolytic — Catheter-Directed Thrombolysis / Peripheral Arterial Occlusion Pregnancy: Contraindicated in first 18 weeks of pregnancy; use only if immediately life/limb threatening thereafter

Alteplase (Peripheral Arterial / DVT Use)

Brand names: Actilyse

Adult dose

Dose: Catheter-directed thrombolysis (CDT) for peripheral arterial occlusion: 0.5–1 mg/hour via intra-arterial catheter; Catheter-directed for DVT (IILI): 0.01 mg/kg/hour (typically 0.5–1 mg/hour); Catheter occlusion: 1–2 mg in 2 mL instilled
Route: Intra-arterial catheter (vascular) or intravenous
Frequency: Continuous infusion (CDT); single instillation (catheter lock)
Max: Individualized per vascular interventionist protocol; CDT typically 24–48 hours max
CDT is performed by interventional radiologists/vascular surgeons under imaging guidance. Systemic thrombolysis for stroke is separate indication (alteplase_stroke in neurology). Monitor fibrinogen — stop if <1 g/L. Antidote: fresh frozen plasma, tranexamic acid for fibrinolysis control.

Paediatric dose

Route:
Seek specialist opinion — paediatric thrombolysis requires specialist haematology and vascular input

Dose adjustments

Renal

No dose adjustment for renal impairment — not renally cleared

Hepatic

Use with caution in severe hepatic impairment — impaired clotting factor synthesis

Clinical pearls

  • CDT for acute limb ischaemia: effective for thrombotic (not embolic) occlusion of <14 days onset — compared to surgical thromboembolectomy in STILE and TOPAS trials
  • Fibrinogen monitoring essential during CDT — falling fibrinogen <1 g/L indicates systemic fibrinolysis; stop infusion
  • Access site haematoma most common complication — manual compression and check ACT regularly
  • Distal embolisation of lysed thrombus fragments can cause 'trash foot' or digital ischaemia — anticipate and discuss with patient
  • ATTRACT trial (2017): CDT for proximal DVT did not reduce post-thrombotic syndrome vs anticoagulation alone — shifted practice away from routine DVT thrombolysis

Contraindications

  • Active internal bleeding (non-target site)
  • Recent surgery/trauma (<10 days)
  • Recent stroke (<3 months)
  • Uncontrolled hypertension
  • Coagulopathy
  • Recent lumbar puncture or arterial puncture at non-compressible site

Side effects

  • Bleeding at catheter site
  • Systemic bleeding
  • Intracranial haemorrhage (rare with CDT)
  • Distal embolisation ('trash foot')
  • Reperfusion injury
  • Compartment syndrome

Interactions

  • Anticoagulants — additive bleeding (often co-administered at low dose in CDT protocols)
  • Antiplatelets — additive bleeding

Monitoring

  • Fibrinogen (2-hourly during CDT — stop if <1 g/L)
  • aPTT (co-administered heparin)
  • Imaging to assess thrombus resolution
  • Limb perfusion (pulses, Doppler, compartment pressures)
  • FBC and coagulation screen

Reference: BNFc; BNF 90; STILE Trial; TOPAS Trial; ATTRACT Trial 2017; ESC/ESVS Peripheral Arterial Disease Guidelines. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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