Thrombolytic therapy (thrombolysis). Thrombolysis: essence, applications, drugs, indications, complications Thrombolytic therapy drugs

The mysterious word thrombolysis sounds when choosing a treatment for thromboembolism pulmonary artery(PE), heart attack, stroke, or some other type of thrombosis. But what is the procedure behind this name? In order to understand the importance and necessity of such an intervention, consider: what is thrombolytic therapy and who needs it.

What is the procedure

To understand what it is - thrombolysis treatment, let's pay attention to the constituent words. The name stands for thrombus lysis.

In a healthy person, special blood enzymes are involved in the destruction of a blood clot, but in a number of diseases, the protective forces fail and artificial or artificial thrombolysis is required.

The need for lysis or dissolution of thrombus formation occurs in the following cases:

  • a detached blood clot completely blocks the lumen of the vessel, preventing the blood supply to the tissues;
  • the accumulation of blood clots impedes vascular blood flow.

Thrombolytic therapy is aimed at eliminating blood clots with the help of medications. Means that eliminate platelet aggregation are administered intravenously or inside a thrombosed vessel.

Varieties of thrombolysis

Depending on the injection site of the drugs necessary for thrombolysis, doctors distinguish between systemic and local methods. Each of the methods has disadvantages and advantages.

Systemic

Thrombolytic drugs are administered to the patient in a vein at the elbow.

The advantages of the method are as follows:

  • general blood thinning;
  • the ability to dissolve a blood clot in a hard-to-reach area;
  • ease of manipulation (can be performed both in a hospital setting and as first aid for acute thrombosis).

The disadvantages include the need to administer drugs for thrombolysis at maximum therapeutic doses. Such a medicinal effect negatively affects the general condition of the blood.

Local (selective)

Drugs that eliminate thrombosis are injected into the vessel where the blood clot is located.

Advantages of introduction:

  • therapeutic effect is achieved in a short time;
  • there is no need to administer large doses of drugs;
  • drugs have less effect on overall blood clotting;
  • effective 6 hours after the cessation of blood flow to the tissues.

Selective thrombolysis has one drawback - a specially trained specialist is required to carry out the intervention. The procedure is performed by a doctor, introducing a catheter under the control of an ultrasound machine.

Also, thrombolytic treatment is divided into types according to the properties of the administered medications:

  • generalized (drugs with a wide spectrum of action are used);
  • selective (use medicines of a narrowly directed influence).

Which method will be used is selected individually. The choice is influenced by the time elapsed since thrombosis, the nature of vascular disorders and many other factors.

Indications for thrombolysis

Any pronounced disturbance of blood flow caused by the formation of a blood clot inside the vessel.

Thrombolysis is indicated in the following cases:

  • Myocardial infarction (AMI). Thrombolytic therapy for myocardial infarction is carried out in order to prevent the re-formation of blood clots and increase blood fluidity. Indications for thrombolysis in myocardial infarction - the first hours after an attack. If AMI occurred 6 or more hours ago, then thrombolytics are not administered, but medications with a blood-thinning effect from other groups are prescribed.
  • Stroke. Thrombolysis at ischemic stroke used relatively often. But with a stroke caused by a rupture of the vessel (hemorrhagic), the procedure is not used because of the risk of increased bleeding.
  • TELA. Pulmonary thrombosis is a life-threatening condition. With PE, blood circulation in the small circle stops and the person dies from lack of oxygen. Indications for thrombolysis in PE are blockage of a pulmonary artery by a thrombus.
  • Spicy coronary syndrome(OKS). Most mistakenly consider this term to be synonymous with heart muscle infarction. But with ACS, not only the myocardium suffers: the rhythm and hemodynamics are disturbed. The cause of the coronary syndrome can be acute myocardial ischemia, an attack of unstable angina pectoris, and some other cardiac disorders. Indications for thrombolysis in patients with ACS are associated with the presence of a thrombus in the coronary arteries. A heart attack is considered one of the forms of ACS.
  • Acute forms of thrombophlebitis. In patients with acute venous thrombosis, thrombolysis can reduce the severity of the condition and improve blood flow in the extremities.

For thrombolytic therapy, indications are associated with obstruction of the veins or arteries due to the formation of blood clots. In addition to these conditions, it is possible to use thrombolytics in other diseases accompanied by the appearance of intravascular thrombi.

Contraindications for thrombolysis

When prescribing thrombolysis, the doctor takes into account the indications and contraindications. Thrombolytic therapy is prohibited in the following cases:

  • hypertensive crisis;
  • recent surgery (risk of internal bleeding at the surgical site);
  • blood diseases;
  • age over 70 years (vessels become fragile and hemorrhages may develop);
  • the presence of benign or malignant neoplasms;
  • tendency to bleeding (low blood clotting);
  • diabetes;
  • recent TBI (up to 2 weeks from the date of receipt);
  • pregnancy;
  • breast-feeding;
  • ulcerative lesions of the mucosa of the digestive tract;
  • aneurysm of any localization;
  • insufficiency of liver or kidney function;
  • individual intolerance to medicines.

Even if the above contraindications are not identified, then there are the following prohibitions for the procedure in acute conditions:

  • With AMI. Conditional contraindications to thrombolysis in myocardial infarction - the patient has atherosclerosis or more than 6 hours have passed since the attack. Thrombolysis with a heart attack in these cases will be poorly effective.
  • With OKS. Acute coronary syndrome occurs for various reasons and a contraindication to thrombolytic therapy in patients with ACS is the absence of thrombosis.
  • With a stroke. Thrombolysis therapy is not always needed in patients with stroke. If it is undesirable to do the procedure in ischemic stroke, if a lot of time has passed since the attack, then thrombolysis in hemorrhagic stroke is dangerous by increasing intracranial hemorrhages.
  • With TELA. There are no contraindications. With this pathology, there is a pronounced violation or complete cessation of pulmonary blood flow, and without medical assistance, pulmonary thromboembolism ends in death. Thrombolysis helps save lives.

But all contraindications are relative. Often, in severe cases, doctors use thrombolysis for PE or extensive heart attacks without clarifying the list of prohibitions. This is due to the fact that the patient's vital signs deteriorate sharply, and the introduction of thrombolytics helps to avoid death.

Therapeutic techniques

As mentioned earlier, there are systemic and selective methods of administering drugs. Let's get acquainted which method is better, taking into account the nature of the pathology that has arisen and how it is carried out.

Systemic

They are considered universal. Systemic thrombolysis is done by injecting lysing agents through a vein. Shown in the following cases:

  • with a stroke;
  • with a heart attack;
  • with TELA.

The convenience lies in the fact that assistance can be provided both in the hospital and at the pre-hospital stage. Clinical guidelines during therapy - monitoring of ECG and blood clotting.

Selective

Other name - catheter thrombolysis. In this case, the catheter is placed by the doctor in a vein or artery affected by thrombosis.

How the procedure is performed depends on the location of the thrombus:

  • Local thrombolysis with a heart attack, they do it in cardiological resuscitation with an intravenous catheter. The method serves as an alternative to coronary bypass surgery.
  • Selective thrombolysis in stroke is rarely performed due to the fact that it is difficult to access the cerebral arteries. Thrombolytic therapy for ischemic stroke using catheterization is possible only in clinics specializing in helping stroke patients.
  • vein thrombosis. With this pathology, lysis of blood clots is considered one of the simplest. The doctor injects the selected medication into the vein of the limb.

Which of the methods to use is decided individually.

Catheterization of a thrombosed vessel makes it possible to more effectively eliminate the problem, and intravenous infusion of thrombolytics makes it possible to provide assistance faster and prevent complications.

Thrombolysis drugs

Thrombolytic therapy for myocardial infarction, stroke or PE is carried out with various medications. Thrombolytic agents are selected taking into account the nature of the pathology, but sometimes it is possible to use those drugs that are in the first aid kit (the list of drugs in the ambulance is limited). Consider the popular drugs for thrombolysis:

  • Streptokinase. A classic drug for dissolving blood clots, used for myocardial infarction or PE, less often as thrombolytic therapy for ischemic stroke. With thrombosis, the drug has a powerful lytic effect, but greatly thins the blood and increases the permeability of the vascular wall. Streptokinase is considered a thrombolytic agent with many side effects. Most often used in myocardial infarction and PE.
  • Actilyse. Mechanism of action: thrombolytics and fibrinolytics. The components of the drug, having reacted with fibrinogen, provoke the lysis of a blood clot. Despite the fact that Actilyse belongs to the second generation thrombolytic drugs, the drug gives few side effects and is often used in hospitals. Actilyse and other new generation drugs are considered the most popular drugs.
  • Urokinase. In the 4th generation classification, it is considered a convenient drug for lysing blood clots. When used, it gives few side effects, but is expensive.
  • Fortelizin. Like Actilyse, it belongs to the second generation (this list of drugs is the most popular for the treatment of thrombosis). Fortelizin is considered one of the best drugs for thrombolysis with a small number of adverse reactions.

The names of drugs from the group of 5th generation thrombolytics are not worth listing. These modern drugs have a minimum of contraindications, are well tolerated, but are expensive and are used only in large clinics.

There are no oral agents for thrombolysis - drugs are used only in injectable solutions. But some patients mistakenly confuse thrombolytics and anticoagulants (Warfarin), which are available in tablets and are indicated for long-term use.

Ambulance with thrombolysis in emergencies

In the system of urgent measures for persons working in an ambulance, the following clinical recommendations are indicated:

  • TELA. When this condition occurs, therapy with thrombolytic agents is indicated, regardless of possible contraindications.
  • Stroke. If there is no certainty about the nature of stroke lesions, then the introduction of thrombolytics is undesirable. Recommendations to doctors and paramedics of the ambulance indicate that it is better to carry out maintenance therapy in order to eliminate the risk of intracranial bleeding in hemorrhagic stroke.
  • AMI. Thrombolysis for myocardial infarction at the prehospital stage will help in the first hours. If more than 6 hours have passed since the attack, then only the introduction of narcotic analgesics and the delivery of the patient to the hospital are recommended.

All appointments are made by a doctor, and, in some cases, a paramedic. Before the use of thrombolysis in the prehospital stage, the possible benefits and harms to the patient are taken into account.

What are the complications

Thrombolytics are considered "heavy" means for the human body. Consider the most common complications of thrombolytic therapy:

  • fever up to 38 ° and above;
  • acute failure of cardiac function;
  • cerebral hemorrhagic hemorrhages (with ischemic stroke);
  • heart rhythm disturbances;
  • drug hypotension;
  • internal and external bleeding.

To avoid unwanted reactions, thrombolysis is carried out under the control of electrocardiography and blood clotting.

How is efficiency assessed?

How much the procedure helps is assessed using MRI or Doppler ultrasound. Consider the main criteria for the effectiveness of thrombolysis:

  • Zero. Means do not affect the blood clot.
  • First. There is a slight lysis of the thrombus structure.
  • Second. There is a blood flow, but the bloodstream is partially released.
  • Third. The maximum therapeutic effect - the bloodstream is fully functional.

Whether thrombolysis is needed or not is decided individually. But if the procedure is necessary, then one should not refuse - resorption (lysis) of the thrombus will improve blood circulation and prevent complications of the disease.

Video: the use of thrombolytic therapy by emergency doctors


The vessels of the human body are subject to aging in the same way as other tissues. Metabolism slows down, due to age-related changes, blood clotting increases. The presence of somatic diseases exacerbates the situation. As a result, an elderly person develops thrombosis - the formation of blood clots in the vessels, completely or partially blocking the blood flow.

A blood clot can provoke a myocardial infarction, stroke or cerebral infarction, and other equally serious problems. To give such a patient effective help, developed a method of thrombolysis, or thrombolytic therapy (TLT). The essence of the technique with which you can save a life and carry out a complete recovery is to remove a blood clot in the most radical way.

Thrombolytic drugs are used in the treatment of myocardial infarction, ischemic stroke, deep vein thrombosis, pulmonary embolism.

Types of thrombolytic therapy:

    Selective thrombolysis. A drug that dissolves blood clots is injected into the pool of the damaged artery. The method can be applied no later than 6 hours from the moment of blockage of the vessel by a thrombus.

    Non-selective (intravenous) thrombolysis. The method is applied no later than 3 hours after the vascular accident.



Stroke, or acute cerebrovascular accident, which causes major neurological complications, sounds like a death sentence for many patients. Until recently, in Russia during the first month, at least 50% of patients died, most of the survivors lost their ability to work and became disabled.

In countries where thrombolytic therapy is used, mortality from ischemic stroke does not reach 20%. The remaining patients restore the functioning of the central nervous system.

The thrombolysis procedure is not very difficult. It consists in introducing special enzymes into the vessel that dissolve the clot.

Contraindications for TLT:

    Available at the time of thrombolysis, bleeding of any localization, since not only thrombi of a pathological nature are subject to dissolution, but also those that have formed to protect against blood loss during bleeding.

    Aortic dissection.

    Tumors of brain tissue of any etiology.

    Arterial hypertension.

    History of brain surgery.

Thrombolytic therapy is carried out in patients of any age. Some contraindications are relative, the most important among them is bleeding. If there is bleeding, thrombolysis is not performed.

To carry out this major event it is important to meet the time allotted for TLT - 3-6 hours from the onset of a stroke. It is important to pay attention to its signs in a timely manner:

    Numbness of a limb on one side of the body;

    Articulation disorders;

    The inability to make the simplest facial movements with the muscles of one half of the face.

The simplest test for determining the onset of a stroke is to ask the patient to stretch their arms and say something. If he is unable to do so, urgent action is required. health care because there is not much time left to save a person!



As a result of blockage of a coronary vessel by a thrombus, a patient develops a myocardial infarction.

This process does not occur spontaneously, it is preceded by general disturbances:

    Slowing down of blood flow;

    Reduction in the blood content of heparin and fibrinolysin, which have an anticoagulant effect;

    Increase in the content of blood coagulation components;

    Ulceration of atherosclerotic plaques;

    Roughness of the inner wall of the vessel;

    Slowing down the flow of blood, thickening it.

In case of myocardial infarction, to restore the blood supply to the heart muscle, it is necessary to remove the blood clot that clogged the coronary vessel in a timely manner. If you do not first conduct a thorough examination of the patient, the procedure is fraught with complications.

Necessary studies to determine the localization of the thrombus and clarify the site for drug administration:

    duplex scanning;

    Angiography;

    CT ( CT scan);

    Doppler ultrasound.

A comprehensive study helps to reduce the risk of complications many times over.

For urgent indications, the cardiology ambulance team can perform thrombolysis on an emergency basis to save the patient's life. The duration of the procedure takes from 10 minutes to 2 hours. Just as with relief of consequences, bleeding is the most important contraindication.

The cost of a complex of drugs for thrombolytic therapy can reach up to 50-60 thousand rubles, but these costs are included in the health insurance rates.




There are two main ways to carry out thrombolytic therapy:

    System method- drugs are injected into a vein without taking into account the localization of the thrombus, they reach the blood clot and begin to dissolve it. To increase the effectiveness of the systemic method, a high concentration of the drug is required, which negatively affects the circulatory system.

    local method- drugs are injected much more accurately than in the previous method, directly into the area of ​​​​blockage of the vessel. For this, a catheter is used that moves through the vein, so the method is called catheter thrombolysis. This minimally invasive procedure is controlled by x-rays. It is used even with relative contraindications.


Drugs of choice for thrombolytic therapy:

    Streptokinase. One of the cheap thrombolytics, not very compatible with human body often causes allergic reactions. For effective action slow administration of Streptokinase is required, the drug can cause hemorrhagic complications.

    Urokinase. A protein found in small amounts in urine, tissues and organs of the human body. It has a higher cost compared to Streptokinase. When using Urokniase, simultaneous intravenous administration Heparin.

    Anistreplaza. It has a high cost, it is injected in a stream, intravenous administration of Heparin is not required.

    Alteplaza. It has a high cost, provokes cerebral hemorrhages. The use of Alteplase improves patient survival.

Complications after thrombolytic therapy


The most common complication of thrombolysis is the occurrence of bleeding of varying intensity, from minor to massive and voluminous. May cause a sharp drop in blood pressure.

Other complications:

    Decreased vision, cognitive functions;

These symptoms are a sign of the onset of the disease, especially if they occur in older people. In order not to miss fatal changes, you need to conduct the following studies:

    Duplex scanning of the carotid arteries;

    Ultrasound of the vessels of the brain;

    Examination of coronary vessels;

    MRI of the brain (indicated for patients arterial hypertension, heart failure).

When the first signs of thrombosis appear, it is important to start thrombolysis in a timely manner, without waiting for the onset of a heart attack or stroke. This measure reduces in-hospital mortality by 17-19%, because "disease is easier to prevent than to cure."


If thrombolytic therapy is available prior to hospitalization, it should be used. This requires qualified health workers, the ability to immediately conduct and decipher the cardiogram. Thrombolysis can be fully carried out within half an hour after examining the patient.

It is important to apply the method of thrombolytic therapy no later than 3-6 hours from the onset of the first symptoms. Delay in the use of TLT will lead to necrosis of myocardial cells and the cessation of the functioning of the cells of the medulla.


Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma from the educational and scientific medical center for the administration of the President of the Russian Federation.

Thrombolytic therapy- highly effective help in ischemic stroke, which allows you to restore blood flow in the affected vessel and prevent irreversible changes in brain tissue.

Currently, for thrombolysis in ischemic stroke, preference is given to alteplase (Actilyse) - the drug has passed clinical researches has performed well in randomized trials. Principle of action: recombinant tissue plasminogen activator (Actilyse) directly activates the conversion of plasminogen into plasmin. After intravenous administration, alteplase remains relatively inactive in the circulation. It is activated by binding to fibrin, which causes the conversion of plasminogen to plasmin and leads to the dissolution of the fibrin clot (the main component of a thrombus).

Thrombolysis is carried out in patients with stroke in the first 3-4.5 hours from the onset of the development of neurological symptoms. Only in a hospital, after determining the criteria for indications / contraindications, conducting a number of necessary studies.

Today, VTT is the standard method of treating patients in the most acute period of IS in the absence of contraindications. The method is applicable in most neurological hospitals, does not require long or complex preparation. A relatively small amount of clinical, instrumental and laboratory research. At the same time, due to a significant number of contraindications, only about 5-10% of patients with acute violation cerebrovascular accident (CVA) according to the ischemic type can potentially be selected for this type of treatment, and a narrow "therapeutic window" (4.5 hours) places high demands on the speed of transportation and examination of the patient. The effectiveness of the drug of choice - recombinant tissue plasminogen activator - depends on the level of serum plasminogen, the volume and age of the thrombus.

However, there are contraindications:

  1. Bleeding of various localization. With TLT, all blood clots dissolve in the vessels, and those that form as a result of bleeding are not excluded.
  2. Possible aortic dissection.
  3. Arterial hypertension.
  4. Intracranial tumors.
  5. Hemorrhagic stroke (hemorrhage, which is caused by rupture of the walls of cerebral vessels).
  6. Liver diseases.
  7. Pregnancy.
  8. Operations on the brain.

Thrombolytic therapy for ischemic stroke should be carried out in an intensive care unit and resuscitation.
According to international recommendations the time from the patient's admission to the hospital to the start of thrombolytic therapy should not exceed 60 minutes (door-to-needle time). During this time, it is necessary to determine the indications and exclude contraindications for thrombolytic therapy.
Necessary:
1. Examination by a neurologist and taking an anamnesis, assessment of vital functions and neurological status. It is necessary to conduct a survey using a scale stroke NIHSS. Thrombolytic therapy is indicated for a score of NIHSS scale from 5 to 25.
2. Immediate conduct of computed tomography of the brain.
3. Change in the level of blood pressure on both hands.
4. Installation of a cubital peripheral venous catheter.
5. Measurement of glucose level in blood serum.
6. Taking blood and performing the following laboratory tests:
a) the number of platelets;
b) APTT;
c) INR.
7. Provide monitoring for at least 24 hours:
1) blood pressure level;
2) heart rate;
3) frequency of respiratory movements;
4) body temperature;
5) oxygen saturation.

Thrombolysis can be:

  1. system;
  2. Local.

Methods for conducting thrombolytic therapy

The first method is beneficial in that the drug can be injected into a vein without having an idea where the blood clot is hiding. With the blood flow, the drug is carried throughout the entire circulation, where on its way it encounters an obstacle in the form of a blood clot and dissolves it. But systemic thrombolysis has a significant drawback: an increased dose of the drug is required, and this is an additional burden on the entire circulatory system.

INDICATIONS FOR THROMBOLYSIS IN ACUTE ISCHEMIC STROKE:

Severe neurological deficit associated with acute ischemic stroke and, apparently, caused by occlusion of a large artery (basilar, vertebral, internal carotid): in the form of movement disorders, speech, facial paresis, disorders of the level of consciousness. Using special scales (NIHS-scale), a neurologist assesses the level of neurological deficit.
. no hemorrhage according to computed tomography
. terms of development from the beginning of the clinic up to 3 hours (up to 6 hours with selective thrombolysis, up to 12 hours with a heart attack in the basin of the main artery)

THROMBOLYSIS CONTRAINDICATIONS:

ABSOLUTE CONTRAINDICATIONS:

1) minor and rapidly regressing neurological deficit
2) hemorrhage, well-defined extensive acute infarction brain or other CT data that are contraindications (tumor, abscess, etc.)
3) convincing evidence that the patient has a vascular malformation or a tumor of the central nervous system
4) bacterial endocarditis

RELATIVE CONTRAINDICATIONS:

1) severe injury or stroke within the last 3 months
2) history of intracranial bleeding or suspected diagnosis of subarachnoid hemorrhage
3) major operation in the last 2 weeks
4) minor surgery in the last 14 days, including liver or kidney biopsy, thoracocentesis, and lumbar puncture
5) arterial puncture in the last 2 weeks
6) pregnancy (ten days after birth) and breastfeeding
7) acute gastrointestinal bleeding, urological or pulmonary bleeding in the last three weeks
8) hemorrhagic diathesis in history (including renal and hepatic insufficiency)
9) peritoneal or hemodialysis
10) changes in the coagulogram (PTT more than 40 seconds, prothrombin time more than 15 (INR more than 1.7), platelets less than 100,000)
11) seizure as the debut of a stroke (careful differential diagnosis is required)
12) changes in blood glucose levels (hypo or hyperglycemia)

DRUG INTRODUCTION:

Nonselective thrombolysis is more common. For its implementation after a minimal examination of the patient (examination by a neurologist, computed tomography to exclude hemorrhage), general analysis blood with platelet levels, blood biochemistry (glucose level, coagulogram if possible) 100 mg of Akilize is administered intravenously: 10 mg is administered as a bolus, the remaining 90 mg is intravenously dripped to the physical. solution 0.9% 400.0 for 1 hour.

COMPLICATIONS OF THROMBOLYSIS:

The main complications are the risk of bleeding (nasal, gastrointestinal, renal) and the risk of transformation of the ischemic focus into a cerebral hemorrhage.

Thrombolytic therapy makes it possible to witness a truly dramatic improvement in the patient's condition, when the grossest neurological disorders literally "on the needle" disappear, and he not only survives, but also recovers, which was almost impossible before.

Local thrombolysis: When performing local thrombolysis, the drug is injected directly into the site of the thrombus. The drug is delivered through a catheter, so the method is called catheter thrombolysis. However, this method is more complicated than the first one and is associated with a certain danger. During the procedure, the doctor observes the movement of the catheter using an x-ray. The advantage of this method is its low invasiveness. It is used even in the presence of a large number chronic diseases at the patient.

Thrombosis of the coronary vessels can cause a violation of the blood supply to the heart and brain, which can lead to a heart attack or stroke.

A full-fledged rehabilitation and a return to a healthy lifestyle is impossible without the restoration of impaired blood circulation, which, in turn, will not be able to recover while the clot is in the vessel, so it becomes extremely important to remove the clot as soon as possible. Read more about that here.

What is thrombolysis?

- these are methods of dissolving a blood clot, allowing you to remove it from the vessel and restore blood flow. There are several methods that allow you to carry out the procedure without harm to the body, and contribute to the most complete restoration of the functionality of the affected areas.

The time factor plays a decisive role, since the faster thrombolysis is carried out, the more effective it is. Thrombolysis can save lives in patients with myocardial infarction, stroke, pulmonary embolism, vein thrombosis lower extremities and mesenteric vessels.

You are looking for the best in this article.

How is thrombolysis performed?

is an intravenous injection medicines(thrombolytics). These drugs include streptokinase, urokinase, alteplase and anestreplase in combination with heparin.

The drug is injected either into the cubital vein (systemic thrombolysis, used in the prehospital stage) or as an endovascular operation, which allows the drug to be injected directly into the affected area (catheter thrombolysis). This type of thrombolysis is performed in a hospital.

Both of these types of thrombolysis can be performed sequentially if there are indications for this - systemic at the prehospital stage (ambulance team), catheter - in the hospital. The need for such double thrombolysis is rare.

When is thrombolysis performed?

The decision on the need for thrombolysis is made by the doctor. He can prescribe this procedure for myocardial infarction, ischemic stroke (not hemorrhagic!), thromboembolism, including the pulmonary artery.

The procedure can be carried out both at home, during the provision of assistance by the ambulance team, and in the hospital. Immediate thrombolysis has an undeniable time advantage- it allows not only to save a life, but also to enable the maximum possible rehabilitation of the patient.

Hospital thrombolysis is performed in a hospital after diagnostic procedures. It is not as operative as prehospital, but it avoids systemic complications and thrombolysis if it is contraindicated.

Indications for prehospital thrombolysis:

  • Signs of myocardial infarction on EGC;
  • Signs of damage to large branches of the pulmonary artery are shortness of breath, turning into suffocation, swelling of the jugular veins, crepitus and pleural friction noise.

Thrombolysis for suspected stroke is usually not performed by the ambulance team, because without an MRI machine or angiography, it is difficult to distinguish between ischemic stroke, which requires thrombolysis, and hemorrhagic, in which it only aggravates the condition.

Indications for in-hospital thrombolysis:

  • Myocardial infarction (less than six hours after symptom onset unless prehospital thrombolysis was performed);
  • Ischemic stroke (less than six hours after the onset of the disease);
  • TELA;
  • Thrombosis of the veins of the lower extremities;
  • Thrombosis of veins of internal organs.

It is important to carry out thrombolysis no later than six hours after the onset of the first symptoms, since it will not bring results at a later date.

Thrombolysis drugs

To carry out the dissolution of the thrombus, enzyme preparations are used. One of the earliest drugs of its kind streptokinase. It quickly and reliably splits a blood clot, besides, it is cheaper than its more modern counterparts. It is quickly excreted from the body without causing long-term complications.

But it also has significant drawbacks - streptokinase often causes allergic reactions, disrupts the blood coagulation process and can cause bleeding. The rapid decomposition of streptokinase requires that it be administered in a large dose, which increases the risk of allergic reactions.

Urokinase It got its name from the fact that it was first isolated from human urine. More effective than streptokinase, splits blood clots, acts faster, but causes the same side effects, therefore, its advantage over streptokinase is not considered proven. Additionally requires the introduction of heparin.

Alteplaza is a more modern analogue of streptokinase. The risk of allergic reactions is much lower, it acts already in small doses, it is quickly excreted from the body. After the introduction, treatment with heparin is required for a week, which significantly increases the risk of bleeding and hemorrhage.

Anistreplaza. The most expensive and modern of the listed. Its advantage is that this drug can be administered by bolus, and it does not require heparin. The disadvantage is the very high price, which makes its use in an ambulance almost impossible.

Contraindications

Thrombolysis should not be performed if:

  • The patient has bleeding of any localization, including suspicion of hemorrhagic stroke;
  • There is evidence of a bleeding disorder or DIC;
  • In the postoperative period;
  • With arterial hypertension;
  • With increased intracranial pressure;
  • If you suspect an aortic dissection or cerebral aneurysm;
  • With a history of severe allergic diseases;
  • With liver diseases;
  • During pregnancy.

All these conditions are absolute contraindications to thrombolysis; injecting thrombolytic drugs in such cases is dangerous for the patient's life.

Methods for performing thrombolysis

There are two methods for performing thrombolysis - systemic and local. Systemic thrombolysis involves the introduction of the drug into the cubital vein. This allows the dissolution of the thrombus, regardless of its location.

It can be carried out at the prehospital stage. Disadvantages - a high risk of allergic manifestations, a large dose of the drug necessary to achieve the effect.

Local or catheter thrombolysis It is performed only in a hospital and is essentially an endovascular operation. Online access is through femoral vein- a catheter is inserted that directly reaches the thrombus and the introduction of drugs occurs directly in the affected area.

The advantages of the method are that it does not require large concentrations of the drug, and the disadvantage is the great complexity of the method, as well as the fact that before performing endovascular thrombolysis, angiography or MRI is necessary to establish the exact location of the thrombus, which takes a lot of time, and after all diagnostic procedures, thrombolysis may lose its effectiveness.

Use of thrombolysis in acute emergencies

At emergency conditions the ambulance team can apply systemic thrombolysis if there are indications for its use. In myocardial infarction, indications for thrombolysis are signs of thrombosis. coronary arteries on the ECG. In stroke, it is not always possible to distinguish ischemic from hemorrhagic stroke.

Most often, with ischemic stroke, pallor of the face is observed, and with hemorrhagic - redness and swelling, as well as high arterial pressure, but these are not absolute figures. Reliable differential diagnosis can only give an MRI, so in case of a stroke, thrombolysis is performed only in a hospital.

In case of pulmonary embolism (PE), it is also difficult to make a diagnosis without an MRI machine or X-ray of the lungs, therefore, in this case, treatment is also carried out in a hospital

Possible complications and signs of successful therapy

Thrombolytic therapy may be complicated by bleeding, especially when heparin is required, or by an allergic reaction (the patient may not be aware that he is allergic to thrombolytic drugs).

Signs of successful treatment - this is an improvement in the patient's condition, which occurs within a few hours, the dissolution of the thrombus, which is confirmed by angiography, and the successful rehabilitation of the patient in the future. Thrombolysis is most successful in the first three hours of the disease, in extreme cases - six, in a later period, irreversible changes develop in the tissues exposed to hypoxia.

With age, certain processes occur in the human body that adversely affect health. In particular, the vessels lose their elasticity, cholesterol plaques form on their walls, and the blood can become viscous.

The consequence of such processes may be the formation, which can partially or completely block the lumen of the vessel, thereby preventing normal blood circulation. This can lead to the development of life-threatening complications. In such cases, specialists can prescribe thrombolysis, what it is and how it is performed, we will talk further.

thrombolysis- a procedure for the administration of drugs that can dissolve formed in the blood

reference. The natural process of thrombolysis is carried out by special enzymes in the blood, however, they can only deal with small single blood clots.

Larger blood clots can partially or completely block the lumen of the vessel, resulting in impaired blood circulation. This, in turn, leads to disruption of the process of supplying tissues with nutrients and oxygen.

Dysfunction of the affected areas of the brain, heart muscle and other organs can lead to disability or even death.

Thrombolysis is used to dissolve a blood clot that interferes with the process of blood supply to organ tissues.

Timely treatment is extremely important here, therefore, in such cases, thrombolysis therapy is often resorted to, as one of the effective methods elimination of dangerous clots in the circulatory system.

This technique began to be developed in the twentieth century, and was first put into practice for the treatment of a patient in 1995 in the United States. Having found out what thrombolysis is, let's move on to considering the procedure itself and the features of its appointments.

Thrombolysis

Today in medicine, thrombolytic therapy is performed by 2 methods:

  • systemic;
  • local.

With a systemic method, the drug is injected into a vein in the elbow bend

System way carried out in situations where there is no exact information about the location of the thrombus.

The drug is administered intravenously, distributed throughout the circulation and dissolves the clot anywhere.

The method is technically simple to perform, however, it requires the use of an increased dosage of the drug, which creates an additional load on the circulatory system.

Reference. The disadvantages of this method include an increased risk of bleeding.

Local technique is more complex because medicine is injected as close as possible to the area of ​​localization of the blood clot.

The substance is delivered through a catheter, and a contrast agent is additionally introduced into the vessel. In parallel, transluminal catheter angiography is performed.

With local thrombolysis, complications are less likely to develop.

The doctor monitors the progress of the procedure using X-ray equipment.

Reference. The advantage of the method is the low probability of bleeding and the possibility of application even with serious chronic ailments.

After the procedure, the patient's well-being is monitored throughout the day. The following parameters are measured in the patient:

  • Body temperature.

The effect is expressed in the restoration of blood flow and the elimination of pain already 1 hour after the procedure.

Medications for thrombolysis

Thrombolytic agents used in medicine are constantly being improved.

To date, drugs for thrombolysis are classified into 4 groups based on the nature of the effect on the human body:

Thrombolytic drugs are divided into 4 types, each of which has its own application.

  • natural enzymes("Fibrinolysin", "Streptokinase", "Streptodekaza", "Urokinase") - are used in the systemic method. Act aimed at restoring the process of fibrinolysis. They affect not only the clot, so bleeding may occur. Allergic reactions are also observed. Such features limit their use;
  • genetic engineering drugs("Actilise", "Alteplase", "Prourokinase") - selectively restore fibrinogen in a blood clot. Not able to have a general impact;
  • advanced tool group("Reteplaza", "Tenecteplaza", "Lanoteleplaza") - are characterized by selective and long-term effects;
  • combined medicines("Urokinase - Plasminogen") - combine several medications.

The second group is the most studied. Although they have the highest dissolution rate, they are used with caution because often cause various complications.

The remaining groups are distinguished by a narrowly focused impact, and their application is considered in each specific case.

Contraindications

Contraindications for thrombolysis are all those situations in which there is a threat of unexpected bleeding:

The procedure cannot be performed in some cases

  1. — increased rates blood pressure.
  2. Diabetes.
  3. Allergic reaction to medications.
  4. Diabetic retinopathy.
  5. Oncology.
  6. Blood clotting disorders.
  7. Pregnancy period.
  8. Insufficiency of the kidneys and liver.
  9. Stomach ulcer.
  10. Recent surgery.
  11. Taking anticoagulants.
  12. Chronic pathologies affecting the occurrence of bleeding ( acute pancreatitis, aortic aneurysm, pericarditis).
  13. Traumatic brain injury up to 2 weeks old.

The procedure has no age restrictions. But along with this the maximum age limit is set at 75 years.

Complications

Thrombolysis therapy may experience some complications, among which the most common are the following:

  • bleeding- intense (with a decrease in hemoglobin, platelets) or insignificant (bleeding gums, at the injection site);
  • increase in body temperature, chills;
  • - lowering blood pressure;
  • skin rash- if the case is severe, but corticosteroids are prescribed.

Complication rate