Combination of Thrombolysis and Glycoprotein IIb/IIIa Inhibition in Chronic Peripheral Thrombosis: A Case Report

Currently, many interventionalists employ either tissue plasminogen activator (alteplase, Genentech,San Francisco, CA), or recombinant plasminogen activator (reteplase, Chiesi USA, Inc., Cary, NC), for peripheral thrombolysis. Further, combination therapy utilizing a thrombolytic agent and a glycoprotein IIb/IIIa receptor antagonist has been proposed as a way to overcome the limitations of thrombolytic therapy alone by reducing the duration of infusion, preventing rethrombosis, and improving the efficacy of thrombolysis. The following report discusses a patient with stenoses in the distal right posterior tibial artery. The patient underwent percutaneous transluminal angioplasty along with tissue plasminogen activator infusion therapy. Initially, the tissue plasminogen activator infusion reduced pain. However,an embolic occlusion to the distal right lateral plantar artery led to recurrence of pain. Due to failure of thrombolytic monotherapy using tissue plasminogen activator, a combined treatment of eptifibatide (Integrilin, Cor Therapeutics and Schering-Plough) and tissue plasminogen activator infused intraarterially was initiated. In this report, the successful clinical use of combination therapy has been demonstrated after failed intra-arterial tissue plasminogen activator infusion monotherapy. The use of purely intra-pedal intra-arterial eptifibatide is novel and should be studied in randomized trials to establish efficacy. Furthermore, we have shown that failure of monotherapy to treat occlusions can be recovered through the use of combination therapy.