Plasma Fibrinogen Change As A Predictor Of Bleeding During Catheter-directed Thrombolysis
Trevor F. Dorey, MSc, MD1, Daniel Kong, MD2, Wendy Lobo, CRNP2, Erin Hanlon, PA-C2, Steven Abramowitz, MD2, Justin Turcotte, PhD, MBA1, Geetha Jeyabalan, MD1.
1Luminis Health - Anne Arundel Medical Center, Annapolis, MD, USA, 2MedStar Health, Georgetown/Washington Hospital Center, Washington, DC, USA.
Objective: Data from early literature suggest an association between low plasma fibrinogen level (PFL) (e.g. <150 mg/dl) and hemorrhagic complications during catheter directed thrombolysis (CDT) for acute vascular occlusion. PFL is often used as a proxy for systemic hemostatic function during CDT, and low values may direct duration and dosing of thrombolytic infusion. Newer data suggest that there are other potential predictors of bleeding, including a change in PFL from baseline rather than a fall below a given threshold, lysis duration, and total lytic agent given. The aim of this study is to closely interrogate the association between PFL and bleeding complications during CDT, as well as the importance of lysis duration and total lytic dose.
Methods:In this large, multicenter retrospective cohort study, we reviewed patients undergoing CDT for peripheral arterial and venous thromboses, and for pulmonary embolism, between January 2016 and August 2021. Relationships between PFL, duration and dose of lysis, and major bleeding during CDT were examined, while controlling for patient characteristics and thrombosis location. Results:A total of 438 patients underwent CDT during the study period, with a major bleeding rate of 16%. There was no association between the incidence of major bleeding and duration of lysis (P = 0.726), total tPA dose (P = 0.753), or a nadir PFL of <150 mg/dl (P = 0.194). Those who experienced major bleeding complications had a significantly greater decrease in PFL from baseline to nadir. This was true for both absolute (P = 0.029) and relative (P = 0.034) PFL decrease. In regression analysis, the PFL changes that were the best predictors of major bleeding complications were an absolute decrease of 146 mg/dl, or a relative decrease of 47%. If neither were true, the negative predictive value for major bleeding was 90%, regardless of absolute plasma fibrinogen level.Conclusion: In our evaluation of 438 patients undergoing CDT for acute vascular occlusion there was no association between a nadir PFL <150 mg/dl and risk of major hemorrhage. Patients whose PFL does not drop by 47% or by 146 mg/dl may tolerate CDT without increased bleeding risk, even if absolute PFL drops below the commonly applied threshold of 150 mg/dl. Lysis duration and cumulative tPA dose are not associated with major bleeding.
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