Pulse-spray catheter-directed thrombolysis with urokinase and argatroban for thrombo-occlusion of an inferior vena cava filter due to heparin-induced thrombocytopenia with thrombosis

A 50-year-old man developed acute sub-massive pulmonary thromboembolism and proximal deep venous thrombosis. A continuous intravenous infusion of unfractionated heparin (UFH) was started, and an inferior vena cava (IVC) filter was implanted. He developed symptomatic complete obstruction of the filter 6 days after the initiation of UFH, and he was transferred to our hospital. We started pulse-spray catheter-directed thrombolysis (CDT) with urokinase. However, thrombocytopenia occurred 11 days after the initiation of heparin. We suspected heparin-induced thrombocytopenia (HIT) with thrombosis (HITT), and switched from UFH to argatroban. In addition, we continued pulse-spray CDT. As a result, thrombocytopenia improved and thrombolysis was successful without complications of recurrent thromboembolism or bleeding, leading to retrieval of the IVC filter. The antigen assay for HIT was strongly positive, supporting our diagnosis. In patients with suspected HIT it is important to switch from heparin to an alternative anticoagulant as soon as possible, and pulse-spray CDT with urokinase and argatroban as anticoagulant therapy may be effective treatment for thrombo-occlusions of IVC filters in patients with HITT.