Thrombolysis to treat arterial thrombotic complications of heparin-induced thrombocytopenia.

An 80-year-old man with diabetes developed acute ischemia of the right leg secondary to heparin-induced thrombocytopenia while being treated for a pulmonary embolism. For fear of recurrent thrombosis at the operative site, he was treated with cessation of heparin, placement of a Greenfield filter, and intra-arterial infusion of urokinase into the popliteal artery for 36 hours. All arterial thrombus resolved with no complications. One week later he underwent a below-knee popliteal to anterior tibial artery translocated cephalic vein bypass and transmetatarsal amputation for progressive gangrene of the right toes. The graft remains patent 2 years later. This patient represents the eighth case reported in the world literature in which thrombolytic therapy was used to treat arterial thrombotic complications of heparin-induced thrombocytopenia. Five patients were successfully treated without complications, two others required major amputations, and one died of adrenal hemorrhage. Although thrombolytic therapy should be used cautiously for treatment of arterial thrombotic complications of heparin-induced thrombocytopenia, this adjunct may prove useful and safe in selected cases.