PORTSMOUTH HOSPITALS NHS TRUST
NURSING GUIDELINES
Peripheral Arterial Thrombolysis Guidelines. Issue 2. 04.01.2010
TITLE
Peripheral Arterial Thrombolysis Guidelines
Manager /
committee
responsible
DEPARTMENT OF VASCULAR SURGERY, QAH
Date issued
04.01.2010
Version
2
Review date
December 2010
Equality impact
assessment has
been applied to
this guideline
C.M BOWNASS (Vascular Nurse Specialist)
Author
C.M. BOWNASS (Vascular Nurse Specialist)
Ratified by
Professional Advisory Committee – September 2007
Amendments record:
January 2010: This guideline has had its review date extended from June 2008 to December
2010. No other changes other than issue number and issue date.
Contents:
1. Introduction
2. Status
3. Purpose
4. Scope/Audience
5a) Definitions and Indications
5b) Contra-Indications to using alteplase (rt-PA)
6.1 Clinical Practice Guideline
6.2 Process
7. Supporting Evidence
8. Duties and Responsibilities
9. Training: Competency Statement: Peripheral Arterial Thrombolysis
Appendices:
APPENDIX 1: Information for Patients undergoing Peripheral Arterial Thrombolysis
Control Date: 05/02/16
Page 1 of 14
PORTSMOUTH HOSPITALS NHS TRUST
NURSING GUIDELINES
Peripheral Arterial Thrombolysis Guidelines. Issue 2. 04.01.2010
1. Introduction
Guideline for management of peripheral arterial thrombolysis within the Vascular Unit, QAH
2. Status
Clinical guideline
3. Purpose
The purpose of this guideline is to assist nursing and medical staff, in the use of intra-arterial
thrombolysis to obtain safe and effective care for patients.
It is not designed to restrict or limit professional judgement and decision-making. This area of
practice will be evaluated and the guideline reviewed whenever there is a change in circumstances
or annually.
4. Scope/Audience
This guideline applies to all PHT staff involved in the administration of arterial thrombolysis
5a) Definitions and Indications
ARTERIAL THROMBOLYSIS
Insertion of a catheter under x-ray vision and usually via the femoral artery to infuse fibrinolytic
agent – e.g. .Alteplase (i.e rt-PA or Actilyse) directly into an arterial clot (thrombus).
RECOMBITANT TISSUE TYPE PLASMINOGEN ACTIVATOR ALTEPLASE (RT-PA),
rt-PA is a synthetic version of this naturally occurring protein and is potentially fibrin specific, that
is, it works only at the site of recent thrombus deposition, rather than having a generalised
systemic effect. Other lysis agents include streptokinase, tenecteplase, reteplase but alteplase is
currently the only drug in use for arterial thrombolysis in P.H.T.
FIBRINOLYSIS (LYSIS)
This is the dissolution of a blood clot’s fibrin network; it occurs naturally when proteins released by
damaged tissues activate the plasma enzyme PLASMINOGEN into the active plasma enzyme
PLASMIN.
INDICATIONS FOR INFUSION
Arterial occlusion of recent onset involving native artery, by-pass graft or dialysis access fistula.
The most suitable lesions for lysis are 10-20 cm in length, are acutely occluded, and have good
run-off vessels distally.
A common site for lysis is the femoral-popliteal artery. The intra-arterial system is generally
comprised of a sheath into e.g. the femoral artery, and a longer arterial catheter inserted via the
sheath.
Consultation between radiologist and vascular surgeon re appropriateness of procedure and
immediate back up from a vascular surgery team is essential because of the potential
complications of lysis. Where possible, lysis is started early in the working day and as a planned
procedure.
5b) Relative contra-indications to using rt-PA (Senior medical clinician to determine patient’s
suitability for peripheral arterial thrombolysis)
 Ischaemic neurological abnormality/stroke
 Severe liver disease, including hepatic failure, oesophageal varices and active hepatitis
 Recent haemoptysis, G.I. bleed, gross haematuria
 Coagulation defects
Control Date: 05/02/16
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PORTSMOUTH HOSPITALS NHS TRUST
NURSING GUIDELINES
Peripheral Arterial Thrombolysis Guidelines. Issue 2. 04.01.2010







Recent surgery/trauma, including dental extractions in past 3 months
Severe uncontrolled arterial hypertension
Open wounds
Recent childbirth
Patients receiving oral anti-coagulants e.g. warfarin sodium
Neoplasm with increased bleeding risk
Bacterial endocarditis
These factors increase the risk of haemorrhage.
Complications of alteplase (rt –PA)
 Haemorrhage – can be minor e.g. from around the catheter site (approx 40%) or major e.g. a
retroperitoneal haematoma (approx. 9% and requiring blood transfusion 1).
 Cerebral Vascular Accident CVA – (1-2% risk of intra-cranial haemorrhage)
 Allergy/anaphylaxis
 Renal Failure
 Distal emboli (approx 4 % - these may break off from the dispersing thrombus and shower down
the limb causing ischaemic pain. Small clots will be dissolved by the continuation of lysis 1)
 Reperfusion injury (2% - restoring blood flow to ischaemic tissues may lead to systemic
inflammatory response and multi-organ dysfunction 1)
Control Date: 05/02/16
Page 3 of 14
PORTSMOUTH HOSPITALS NHS TRUST
NURSING GUIDELINES
Peripheral Arterial Thrombolysis Guidelines. Issue 2. 04.01.2010
6.1 Clinical Practice Guideline
WARD PREPARATION OF PATIENT
Action
Preparation as for Trans Femoral Angiogram - see
check list
Ward visit by X-Ray nurse /Ward nurse who has
completed Peripheral Arterial Thrombolysis
Competency to:
meet and assess the patient
explain preparation and procedure
explain the aftercare
answer any questions
X-ray nurse to supply check list and any specific
instructions – e.g. care of diabetics
Ward staff and X-ray nurse to ensure that
 patient’s details are correct
 clotting studies (I.N.R. and A.P.T.R.) have
been requested, are available and are
satisfactory
 blood has been taken for urea & electrolytes,
group and save
 a consent form has been signed by the patient
 patient has a wide bore IV cannula
When peripheral arterial thrombolysis is performed
out of hours or is unplanned, it is essential that ward
staff are notified as soon as possible.
All peripheral arterial patients should where possible
be nursed on E2 (i.e. the vascular ward).
E2 ward must assess and address ward and nursing
skill mix in order to provide close supervision of the
patient and a safe standard of care.
Rationale
1, 3, 4,
To allay anxiety, assess patient’s ability to
tolerate the procedure and provide
reassurance
To promote patient safety
To ensure all relevant clinical information
is available, that the patient is medically
stable (renal and coagulation function
assessed) and the risk of complications is
minimised.
To ensure that the patient understands the
procedure and gives valid consent
For I.V. access/analgesia
In order that appropriate arrangements are
made for equipment and that transfer to
the ward is a safe and smooth process
This is a high risk procedure and nursing
staff should be familiar with protocols and
potential complications (many other areas
nurse peripheral arterial thrombolysis
patients on ITUs or HDUs).
PROCEDURE
Action
Initially as for T.F.A.
i.e.
 explain procedure and table controls (e.g.
table movement)
 explain and give sedation if appropriate
 insert wide bore peripheral IV cannula, if not
already done
 prepare and drape skin,
 give local anaesthetic- usually a femoral
approach
 incise skin and insert needle
 insert guide wire
 remove needle
 insert introducer sheath
 insert arterial catheter through sheath
 remove guide wire
Control Date: 05/02/16
Rationale
To reduce anxiety and prepare patient for
intensity of procedure and post-procedure
care
For administration of IV fluids, as required
To reduce risk of infection
To provide pain relief during procedure
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NURSING GUIDELINES
Peripheral Arterial Thrombolysis Guidelines. Issue 2. 04.01.2010
FOR PERIPHERAL ARTERIAL THROMBOLYSIS
Action


catheter re-positioned until tip is situated proximal to or
within thrombus
first dose of alteplase (rt-PA) is given in X-ray. Further
doses may be given in succession before the patient
returns to the ward
catheter secured e.g. with suture/opsite


light dressing applied
Ward staff notified patient is to receive alteplase (rt-PA).

1. Refer to Drug Therapy Guideline)
X-ray nurse to prepare Heparinised Saline. (Unless
prescribed otherwise, add heparin 5000 units to 500ml
sodium chloride 0.9%). Run this through a volumetric
infusion pump. A second volumetric pump will also be
required for the alteplase (rt-PA) infusion.
2. If sheath in situ, prepare Heparinised Saline (as above),
connect to side arm of catheter sheath as marked and set
infusion rate (25 ml per hour, unless directed otherwise, refer
to Drug Therapy Guidelines).
3. Prepare alteplase (rt-PA) solution as per prescription and
prime infusion set and volumetric pump (refer to Drug
Therapy Guidelines)
Label lines as either “Arterial catheter” or “Sheath”
Rationale
To achieve optimal results and maximise
concentration of alteplase (rt-PA) in thrombus
To prevent slippage or accidental pulling of the
arterial line
To facilitate inspection of the puncture site
To prevent delays in commencement of rt-PA
and/or possible occlusion of the lines
Volumetric pumps improve accuracy of drug
administration, i.e. rate, dosage
To prevent platelet aggregation/embolus formation
along the length of the sheath 3
For easy identification of lines
Prior to connection, X-ray nurse should draw back on arterial
catheter (via 3-way tap on connecting tube) using a 20 ml
syringe.
Connect alteplase (rt-PA) line to main arterial catheter, as
marked, and set infusion rate (25 ml per hour, unless directed
otherwise and depending on body weight); modify according
to instructions.
Have available 10-20 ml sodium chloride 0.9% in a sterile syringe
4. Ensure patient stays on strict bed rest throughout alteplase
(rt-PA) therapy, is nursed flat with only 2 pillows and that there is
minimal moving of patient.
If arterial catheter tip is positioned in arm artery, elevate arm on
pillow; if lower limb use bed cradle
If patient has difficulty with passing urine whilst flat, insert a urinary
catheter.
5. Cover catheter entry site with a light gauze dressing, but do
not seal the dressing down.
To ensure line is not blocked and is free of clots.
N.B. the arterial catheter may be on the opposite side to the side
being treated).
Access from the ipsilateral side may be restricted
by previous surgery or the site of the occlusion.
Control Date: 05/02/16
To flush catheter if line blocks. A sterile syringe is
used to minimise risk of introducing infection.
To prevent dislodgement of arterial sheath and
catheter
For comfort and to limit range of movement
To reduce necessity for patient to change position.
To enable continued inspection of line and early
recognition of bleeding.
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NURSING GUIDELINES
Peripheral Arterial Thrombolysis Guidelines. Issue 2. 04.01.2010
PATIENT’S TRANSFER TO WARD
Action
On collecting the patient from Xray, the Ward Nurse & Xray Nurse
should check the following:
 Catheter site
 Labelling of the Arterial Catheter and Sheath
 That both Volumetric pumps are working and the drug
administered, solution, rate etc
 All documentation has been completed
 Any specific instructions noted
and then accompanies patient back to the ward.
CARE OF THE PATIENT RECEIVING ALTEPLASE rt-PA
Action
Rationale
To ensure safe hand-over of patient to ward staff
Rationale
1. Patient nursed in OBSERVATION BAY
To allow close observation and monitoring of
patient
2. Assess cardio-vascular function by monitoring patient’s Pulse andTo enable deviations (i.e. tachycardia, hypotension,
Blood Pressure, Respirations ½ hourly for 4 hours, then hourly if bleeding, allergic reaction or shock) to be
stable. Record temperature 4 hourly.
established quickly and complications to be treated
promptly
Complete MEWS score as per protocol
Observe arterial catheter insertion site hourly for peri –
catheter bleeding, haematoma, line disconnection
Monitor patient for abdominal pain, restlessness, back pain.
3. If major bleeding does occur, apply firm, direct pressure to
puncture site, discontinue lysis, summon help and treat for shock
as necessary.
If peri-catheter bleeding occurs, apply light gauze dressing and
direct, digital pressure.
IF BLEEDING CONTINUES:
 Contact medical staff
 Keep patient nil by mouth
4. Monitor patient for other potential bleeding complications, e.g.
intra-cranial (causing strokes), renal tract (causing haematuria)
and GI Tract (causing oral and/or rectal bleeding). If severe
systemic or intra-cranial bleeding occurs, discontinue peripheral
arterial thrombolysis and seek urgent medical assistance
5. Check limb/foot hourly as for Trans Femoral Angiogram i.e
warmth, colour, movement, swelling, function and evidence of
embolic “trash” etc.
Bleeding may be visible or concealed causing
e.g. retro-peritoneal haematoma, and occur at
any time during the period of lysis 1
To control bleeding and prevent formation of
haematoma 3.
Patient may require surgical intervention to
close the puncture site and secure haemostasis
Medical staff will assess need to contact
Interventional Radiologist
Distant haemorrhagic complications may
occur due to altered anti-coagulant status 5.
Haemorrhage may be due to lysis of
pre-existing blood clots acting as “plugs”
To assess effectiveness of rt-PA, level of action,
worsening of ischaemia or compartment syndrome .
Lysis is contra-indicated if there is total limb
anaesthaesia, paralysis, swollen or tense muscles
Mark foot pulses with skin marker and record presence/absence of pulses.
or persistent skin discolouration 3
6. Check infusion pump hourly throughout procedure to
ensure pump is running and there is adequate volume of infusion
fluid
7. Monitor patient’s pain level (see MEWS chart); ensure adequate
analgesia is prescribed and administer as appropriate. Oramorph
or IV morphine may be indicated and should be titrated to pain.
Control Date: 05/02/16
To ensure infusion runs continuously and there is
no back-bleeding
Clot lysis may cause distal embolisation and
transient pain.
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Peripheral Arterial Thrombolysis Guidelines. Issue 2. 04.01.2010
Action
8. Administer I.V. fluids as prescribed and maintain an accurate
fluid balance chart
Rationale
Contrast medium is nephro-toxic, especially in
patients with compromised renal function.
Monitoring diuresis aids with renal assessment 5
9. If patient scheduled for theatre (e.g. for embolectomy) or outcomeTo
of ensure safe pre-operative preparation of patient
treatment is uncertain, keep nil by mouth, otherwise patient can eat and
drink as desired.
10. If any problems occur, nursing staff should refer to the on call doctor
without delay or directly to senior medical staff as necessary
To ensure help is sought immediately and from the most
appropriate staff
11. At pre-arranged interval (e.g. 12-24 hours) and based on clinical
evidence, a repeat angiogram is carried out.
To monitor extent of re-perfusion, to advance the arterial
line further into the remaining thrombus or as a basis for
surgery 3
12. Exercise caution with administering IM Injections during the period of Alteplase (rt –PA) affects clotting mechanism and may
peripheral arterial thrombolysis and give only under specific medical
cause excessive bleeding after venepuncture etc.4
instruction. If venepuncture or intra-arterial punctures are necessary, then
observe the site for potential bleeding.
FOLLOWING ALTEPLASE (rt-PA) INFUSION
-Switch off alteplase (rt-PA) infusion as directed by medical staff. Replace To prevent platelet aggregation/embolus formation along
alteplase (rt-PA) with heparinised saline (see above) at 25ml/hr
the length of the arterial catheter 3
N.B. patient may therefore be having heparinised saline
- If sheath in situ, continue proximal infusion of heparinised saline
via both the sheath and the catheter.
- Do not remove arterial catheter until consultation with Radiologist. If
patient attends X-ray for repeat angiogram, X-Ray staff may remove
arterial catheter but will leave sheath in situ for removal by the ward staff
(or as per instructions).
Patient may require further lysis, angioplasty or surgical
intervention.
-Loosen adhesive dressing over arterial line and withdraw catheter as
instructed through haemostatic valve on the catheter introducer sheath.
Ensure sheath and dressing are still secure
So that sheath is not dislodged until lytic effect is
reduced.
- Do not remove sheath until alteplase rt-PA has been
switched off for one hour
Half life of alteplase (rt-PA) is about 5 minutes 3
- Check direction of sheath insertion (from notes). Remove stitch /
adhesive dressing.
So that line is removed and pressure applied in
appropriate direction
-When removing sheath, apply manual compression for 10 minutes by
the clock, but do not obliterate the pulse
To achieve effective haemostasis whilst ensuring that the
distal circulation is not compromised.
-Continue to observe the surrounding tissue for bleeding or bulging and
if this occurs apply a further 5 minutes of pressure (more if necessary).
-Apply a light pressure dressing
Further compression may be needed to ensure bleeding
has ceased and to reduce risk of false aneurysm
formation.
To enable regular inspection of puncture site
-Following successful haemostasis- wait at least an hour before
commencing heparin therapy
-Do not mobilise the patient for 6 hours following removal of the catheter
and then follow protocol for care of patient following Trans-femoral
arteriogram
To reduce risk of reactionary bleeding from puncture site.
-Commence IV heparin infusion as indicated
To maintain anti-coagulation
Control Date: 05/02/16
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Peripheral Arterial Thrombolysis Guidelines. Issue 2. 04.01.2010
6.2) Process
Prescription and Dose Administration
For preparation and Pharmaceutical Particulars of Alteplase, refer to Drug Therapy
Guidelines on PHT Intranet site
Infusions will be prepared by:
 Radiologist/Doctor
 Registered nurse / practitioner competent in Intravenous (IV) therapy and competent at
Level 3 - 4 of Peripheral Arterial Thrombolysis protocol (see Training and Competency
Levels)
Infusions will be set up by:
 Radiologist/Doctor
 Registered nurse / practitioner competent in Intravenous (IV) therapy and competent at
Level 3 - 4 of protocol
Infusions will be changed by:
 Radiologist/ Doctor
 Registered nurse / practitioner competent in Intravenous (IV) therapy and competent at
Level 3 - 4 of Peripheral Arterial Thrombolysis protocol
Prior to administration of alteplase (rt-PA) the Radiologist will complete the patient’s prescription
chart in relation to the bolus dose and the maintenance dose to be administered on the ward.
The prescription will include: a) drug and concentration
b) rate in ml/hour
NB Prescribed settings MUST NOT be altered by ward staff without discussion with the
prescribing Radiologist or medical doctor
Alteplase may be re-constituted in x-ray for a bolus dose and the remaining solution returned to the
ward, for infusion via volumetric pump
Acute pain can be a common problem with peripheral thrombolysis. Patients should be boarded for
analgesia (e.g. Oramorph) prior to the procedure and its effectiveness titrated against their pain.
Peripheral arterial thrombolysis will be stopped when it is clinically safe and appropriate to do so.
Equipment
2 volumetric pumps infusion pumps and giving sets
Any syringes made up by medical or nursing staff should be discarded every 24 hours.
Observations to include
Refer to the MEWS observation record chart; in addition
* Arterial catheter site
½ hourly – for puncture site bleeding, peri-catheter haematoma,
* Limb observations
½ hourly. – for colour, temperature, calf muscle tenderness,
function
* Dosage information
1 hourly (Recorded from pump)
Patient Information
A patient information sheet is available (local adaptation of Royal College of Radiologists
template). However peripheral arterial thrombolysis is sometimes an emergency procedure with
minimal time for discussion about the care and issues involved. See Appendix.
Control Date: 05/02/16
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Peripheral Arterial Thrombolysis Guidelines. Issue 2. 04.01.2010
7. Supporting Evidence
1 BEARD J. & GAINES P.2006 Vascular and Endovascular Surgery, Elsevier Saunders,
Philadelphia
2 DOUGHERTY Lisa & LISTER Sara (2004) The Royal Marsden Hospital Manual of Clinical
Nursing Practice
Blackwell Publishing Ltd; Oxford
3 EARNSHAW J. & GREGSON R. 1994 Practical Peripheral Arterial Thrombolysis, Butterworth
Heinemann: Oxford
4 KESSEL DO, BERRIDGE DC &ROBERTSON I (2005) Infusion Techniques for peripheral arterial
thrombolysis The Cochrane Collaboration, John Wiley
5 SHEILA MURRAY (Ed.) 2001 Vascular Disease, Nursing and Management, Whurr; London
6 WORKING PARTY ON THROMBOLYSIS IN THE MANAGEMENT OF LIMB ISCHAEMIA (2003)
Thrombolysis in the management of Lower Limb Peripheral Arterial Occlusion
Journal of Vascular and Interventional Radiology
8. Duties and Responsibilities
It is the responsibility of all clinical staff involved in the administration of arterial thrombolysis to
follow the recommendations of this guideline.
It is the responsibility of the Radiologists, Diagnostic Imaging Modern Matron, Vascular
Consultants and Vascular Ward Sister to ensure that systems exist to enable staff to receive the
training they require.
Control Date: 05/02/16
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Peripheral Arterial Thrombolysis Guidelines. Issue 2. 04.01.2010
9. TRAINING COMPETENCY STATEMENT: PERIPHERAL ARTERIAL THROMBOLYSIS
Competency indicators
1st level
Demonstrates the ability to:
1) Assist a competent practitioner in
the care of a patient undergoing
peripheral arterial thrombolysis
2) Prepare patient for procedure,
using Transfemoral Arteriogram
(TFA) Guideline
3)Ensure patient remains on strict
bed-rest and close supervision.
Assist patient with basic personal
care whilst on bed rest ( e.g. hygiene
needs, elimination, nutrition)
4) Record vital signs–
as per MEWS chart.
5) Recognize and report deviations to
a senior nurse
6) Inform senior nurse of alarm
signals on volumetric pump
Competency indicators
2nd level
All of Level 1 plus
demonstrates the ability to
1) Assist a competent (level 3)
practitioner in the administration of
peripheral arterial thrombolysis
2) Explain pre and post- procedure care
to patients
3) Describe the applications and
complications of peripheral arterial
thrombolysis
4) Practise the correct procedures for
drug administration
a) can counter-check preparation and
commencement of arterial infusions
b) administer analgesia
as prescribed and monitor effectiveness
c) completed (PHT) IV drug
administration competency to level 2
5) Critically observe the ischaemic
limb and monitor changes in colour
temperature and presence of pulses
6) Monitor the integrity of the catheter
entry site (usually the groin)
7) On removal of arterial line, apply
manual compression to puncture site
(only under supervision of level 4
practitioner),
Control Date: 05/02/16
Competency indicators–
3rd level
All of Levels 1 & 2 plus
demonstrates the ability to
1) Describe in detail the principles
and complications of peripheral
arterial thrombolysis
2) Prepare, connect and administer
peripheral arterial thrombolysis
according to prescription
3) Flush arterial line using safe,
sterile technique
4) Assess effectiveness of lysis on
patient’s ischaemic limb
5) Recognize and take appropriate
action to avoid complications
6) Report to medical staff on progress
and concerns re lysis
7) Remove arterial line on
completion of lysis
8) Support nursing staff in caring for
patients undergoing lysis and assist
Level 4 practitioner with teaching
and supervision of the protocol
Page 10 of 14
Competency indicators –
4th level
All of levels 1, 2 & 3 plus demonstrates
1) expert knowledge of the principles and
indications for peripheral arterial thrombolysis
2) expert knowledge of the management and
safe administration of peripheral arterial
thrombolysis
3) provision of education to medical and
nursing staff in all aspects of peripheral arterial
thrombolysis
4) provision of patient centred information to
patients and their carers regarding peripheral
arterial thrombolysis
PORTSMOUTH HOSPITALS NHS TRUST
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Peripheral Arterial Thrombolysis Guidelines. Issue 2. 04.01.2010
Education/resources to support achievement of the above competencies
Ward induction
As Level 1, plus
As Level 2, plus
As Level 3, plus
Experience of caring for angiography
patients,
Observation of angiogram procedure
Evidence of reflective practice on
management of peripheral arterial
thrombolysis
Assessment by member of Senior medical
staff
Trust Medication policy.
Peripheral arterial thrombolysis
guideline,
Resource folder
Pharmacy Guidelines on the
administration of Alteplase on the PHT
intranet site
To be assessed by Level 4 competent
practitioner
Competency maintained through Continuous
Professional Development
Training/Competency assessment/ and
updating in use of volumetric pumps
To be assessed by Level 3 or 4
competent practitioner
To verify competence please ensure that you have the appropriate level signed as a record of achievement in the boxes below
Level 1
Level 2
Level 3
Level 4
Date:
Date:
Date:
Date:
Signature of assessor:
Signature of assessor:
Signature of assessor:
Signature of assessor:
Print Name:
Control Date: 05/02/16
Print Name
Print Name
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Print Name:
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Peripheral Arterial Thrombolysis Guidelines. Issue 2. 04.01.2010
APPENDIX 1: Information for Patients undergoing Thrombolysis
CRPLG/12 - Last updated 30th June 2000
Introduction
This leaflet tells you about the procedure known as Thrombolysis, explains what is involved and what
the possible risks are. It is not meant to be a substitute for informed discussion between you and your
doctor, but can act as a starting point for such a discussion.
If you are having thrombolysis done as a pre-planned procedure, then you should have plenty of time
to discuss the situation with your own GP, your consultant and the radiologist who will be doing the
thrombolysis. However, it is more likely that you need the thrombolysis as an emergency, in which
case there may be less time for discussion, but none the less you should have had sufficient
explanation before you sign the consent form.
What is Thrombolysis?
Thrombolysis means breaking up blood clots. Once a clot starts to form in a blood vessel, it may carry
on getting bigger until the whole vessel is blocked. While an operation may be necessary to remove
the clot, it is also possible to dissolve the clot by injecting a special "clot busting" drug into the artery,
directly into the clot. This can lead to a great improvement in blood flow, and make an operation
unnecessary.
Why do I need Thrombolysis?
Your doctors know that there is a problem with part of your circulation. You are likely to have had an
angiogram, a special x-ray examination of the blood vessels, which has shown a blockage in an
artery. If nothing is done about the situation, then severe and permanent damage will result, and
amputation may be necessary. While the blockage could need treatment with surgery, in your case it
has been decided that thrombolysis is the best way of proceeding.
Who has made the decision?
The doctors in charge of your case, and the radiologist doing the thrombolysis, will have discussed
the situation, and feel that this is the best treatment option. However, you will also have the
opportunity for your opinion to be considered, and if, after discussion with your doctors, you do not
want the procedure carried out, then you can decide against it. Who will be doing the Thrombolysis?
A specially trained doctor called a Radiologist. Radiologists have special expertise in using x-ray
equipment, and also in interpreting the images produced. They need to look at these images while
carrying out the procedure. What are the risks and complications? Thrombolysis is a very safe
procedure, but there are some risks and complications that can arise. There may occasionally be a
small bruise or haematoma around the site where the needle has been inserted, and this is quite
normal. If this becomes a large bruise, then there is the risk of it getting infected, and this would then
require treatment with antibiotics. Very rarely, some damage can be caused to the artery by the
catheter and this may need to be treated by surgery or another radiological procedure. Clot busting
drugs have to be very powerful in order to work, and consequently there is a risk that bleeding will
occur elsewhere. For example, if you have a duodenal ulcer, it is possible that this might start
bleeding. If this happened, it would be necessary to treat it in the usual way, perhaps with a blood
transfusion.
However, the risks associated with not treating your blocked artery are felt to be greater than the risks
of bleeding elsewhere. Sometimes the blood clot may be so extensive that the clot-busting drug
simply cannot dissolve it all away. In these cases, it may be that surgery will be required to relieve the
blockage. Despite these possible complications, the procedure is normally very safe, and is carried
out with no significant side effects at all. Where will the procedure take place?
Control Date: 05/02/16
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PORTSMOUTH HOSPITALS NHS TRUST
NURSING GUIDELINES
Peripheral Arterial Thrombolysis Guidelines. Issue 2. 04.01.2010
Generally in the x-ray department, in a special "screening" room, which is adapted for specialised
procedures. How do I prepare for thrombolysis? You need to be an in-patient in the hospital. You will
probably be asked not to eat for four hours beforehand, though you may be allowed to drink some
water. You may receive a sedative to relieve anxiety. You will be asked to put on a hospital gown. As
the procedure is generally carried out using the big artery in the groin, you may be asked to shave
this area. If you have any allergies, you must let your doctor know. If you have previously reacted to
intravenous contrast medium, the dye used for kidney x-rays and CT scanning, then you must also
tell your doctor about this.
What actually happens during thrombolysis?
The procedure starts off in exactly the same way as an angiogram, and if you have already had this
performed, you will know what to expect. You will lie on the x-ray table, generally flat on your back.
You need to have a needle put into a vein in your arm, so that the radiologist can give you a sedative
or painkillers. Once in place, this needle will not cause any pain. You may also have a monitoring
device attached to your chest and finger, and may be given oxygen through small tubes in your nose.
The radiologist needs to keep everything as sterile as possible, and may wear a theatre gown and
operating gloves. The skin near the puncture site, probably the groin, will be swabbed with antiseptic,
and then most of the rest of your body covered with a theatre towel. The skin and deeper tissues over
the artery will be anaesthetised with local anaesthetic, and then a needle will be inserted into the
artery.
Once the radiologist is satisfied that this is correctly positioned, a guide wire is placed
through the needle, and into the artery. Then the needle is withdrawn allowing the small plastic tube,
or catheter, to be placed over the wire and into the artery. The radiologist will use the x-ray
equipment, and small amounts of contrast medium to make sure that the catheter, still on the wire, is
moved into the right position, very close to the blockage in the artery. Then the wire will be withdrawn
and the clot busting, or thrombolytic, drug injected down the catheter and into the blood clot. The
radiologist will check progress by injecting contrast to show how much the clot has dissolved.
Although sometimes all the clot is dissolved at the first attempt, generally the catheter has to be left in
the artery and attached to an infusion pump, so that injection of the clot busting drug can be
continued over the next few hours, or days.
Will it hurt?
Some discomfort may be felt in the skin and deeper tissues during injection of the local anaesthetic.
After this, the procedure should not be painful. The radiologist and other staff looking after you can
give you additional painkillers through the needle in your arm, if necessary. You will be awake during
the procedure, and able to tell the radiologist if you feel any pain, or become uncomfortable in any
other way. As the dye, or contrast medium, passes around your body, you may get a warm feeling,
which some people can find a little unpleasant. However, this soon passes off and should not concern
you.
How long will it take?
Every patient's situation is different, and it is not always easy to predict how complex or how
straightforward the procedure will be.
Sometimes thrombolysis does not take very long, perhaps half an hour. On other occasions the
procedure may be more involved, and take rather longer, perhaps over an hour. As a guide, expect to
be in the x-ray department for about an hour and a half.
What happens afterwards?
You will be taken back to your ward on a trolley. Nurses on the ward will carry out routine
observations, such as taking your pulse and blood pressure, to make sure that there are no untoward
effects. They will also look at the puncture site to make sure there is no bleeding from it. You need to
stay in bed for as long as the catheter stays in the artery.
Control Date: 05/02/16
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PORTSMOUTH HOSPITALS NHS TRUST
NURSING GUIDELINES
Peripheral Arterial Thrombolysis Guidelines. Issue 2. 04.01.2010
The radiologist needs to check on progress, and will arrange for you to come back to the x-ray
department the next day, or the day after. By injecting a small amount of contrast medium, or dye,
down the catheter it is possible to tell how much of the clot has dissolved. The radiologist may also
use a special balloon, on a different catheter, to try and open up a narrowed artery, and improve
blood flow even more.
What happens next?
This all depends on where the blockage was, and how successful the thrombolysis has been. In many
cases, no further procedure is necessary. In some cases the artery may be so narrowed that an
operation is required to permanently improve the blood supply.
Most patients will be started on Aspirin, or blood thinning drugs, anticoagulants, to improve blood flow
in their arteries, and to try and limit the chance of a similar condition occurring again.
Finally...
Some of your questions should have been answered by this leaflet, but remember this is only a
starting point for discussion about your treatment with the doctors looking after you. Do satisfy
yourself that you have received enough information about the procedure, before you sign the
consent form.
Thrombolysis is considered a very safe procedure, designed to improve your medical condition and
save you having a larger operation. There are some slight risks and possible complications involved,
and although it is difficult to say exactly how often these occur, they are generally minor and do not
happen very often.
© The Royal College of Radiologists, July 2000.
Permission is granted to modify and/or re-produce this leaflet for purposes relating to the
improvement of health care provided that the source is acknowledged and that none of the material is
used for commercial gain. The material may not be used for any other purpose without prior consent
from the College.
Legal Notice
Please remember that this leaflet is intended as general information only. It is not definitive, and the
RCR and the BSIR cannot accept any legal liability arising from its use. We aim to make the
information as up to date and accurate as possible, but please be warned that it is always subject to
change. Please therefore always check specific advice on the procedure or any concerns you may
have with your doctor.
This leaflet has been prepared by the British Society of Interventional Radiology (BSIR) and the
Clinical Radiology Patients' Liaison Group (CRPLG) of the Royal College of Radiologists.
Board of the Faculty of Clinical Radiology
The Royal College of Radiologists. July 2000
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