Alteplase for the Treatment of Catheter Occlusion in Pediatric Patients

Abstract

OBJECTIVE To review the literature pertaining to the efficacy of alteplase for restoration of patency of occluded venous and dialysis catheters in pediatric patients. DATA SOURCES A MEDLINE search was conducted and cross-referenced with an EMBASE search through November 2012. Search terms included alteplase, tissue plasminogen activator, and catheter. STUDY SELECTION AND DATA EXTRACTION Search results were limited to humans, English language, and ages from neonates to 18 years. Pertinent studies discussing efficacy of alteplase for restoration of occluded venous or dialysis catheter function were included. Case reports, review articles, and studies that specified inclusion of hemophilia patients or more than 75% of children with malignancy were excluded. DATA SYNTHESIS Fibrinolytics are the drug class of choice for restoration of patency (defined as the ability to withdraw a blood sample) of thrombus-occluded catheters. The trials used to support Food and Drug Administration approval of alteplase for central venous catheter (CVC) occlusions generally had low pediatric enrollment; however, additional small studies are available that support use of alteplase for this indication in children. Alteplase doses of 0.5–2 mg instilled into the lumen of a CVC with dwell times ranging from 30 to more than 240 minutes plus the potential for repeat dosing were reported. Overall efficacy ranged from approximately 50% to 90%, with greater efficacy generally reported with larger doses and longer dwell times. Alteplase doses of 2–2.5 mg with dwell times of 60–120 minutes were observed in 2 studies of occluded peritoneal or hemodialysis catheters, in which efficacy was reported in 57–100% of cases. Limitations of current studies of alteplase for catheter occlusion in children include small study populations and relative lack of pediatric-specific prospective trials. CONCLUSIONS Alteplase appears to show efficacy for treatment of thrombus-related venous catheter occlusion in pediatric patients; however, data regarding its use in occluded dialysis catheters are limited.