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Aortic aneurysm leak after streptokinase treatment for myocardial infarction
Eur J VascSurg 7, 738-739 (1993)
CASE REPORT Aortic Aneurysm Leak After Streptokinase Treatment for Myocardial Infarction P. C. Hale, S. M. E. Smith and P. R. Taylor Department of Surgery, Guy's Hospital, St Thomas Street, London SE1 9RT, U.K. A leakfrom an abdominal aortic aneurysm following the administration of streptokinase treatment for myocardial infarction is reported. It is important to assess candidatesfor cardiac thrombolytic therapyfor aortic pathology and give such treatment with extreme caution in those patients with abdominal aortic aneurysms. K ~ Words: Abdominal aortic aneurysm; Myocardial infarction; Streptokinase.
We present a case of a contained leak from an infrarenal abdominal aortic aneurysm related to the administration of a thrombolytic dose of streptokinase during an acute myocardial infarction.
Case Report A 59-year-old woman was admitted to h e r local hospital with severe crushing central chest pain and the ECG changes of an acute myocardial infarct. She had suffered a previous myocardial infarction 10 years earlier and had undergone coronary artery vein bypass grafting. During recent investigation for hypertension she was noted to have an infrarenal abdominal aortic aneurysm on a digital subtraction angiogram and ultrasound determined its diameter to be 7cm. She was in the process of being assessed with regard to repair of her aneurysm when she was admitted with chest pain. She was given a bolus dose (1.2 million units) of streptokinase as thrombolytic therapy for her coronary artery occlusion. A few minutes later she developed severe epigastric pain radiating through to her back. Both this and her chest pain were treated with opiate analgesia and subsequently settled. She made a good recovery from her illness. 0950-821X/93/060738+02 $08.00/0© 1993Grune & StrattonLtd.
Fig. 1. AbdominalCT scan showingcontainedleak fromabdominal aortic aneurysm and surroundinginflammatoryreaction. Increasing concern about the size of her aneurysm resulted in a repeat CT scan of the abdomen being performed about 4 weeks later. This revealed a contained leak (Fig. 1) with an associated inflammatory reaction. This necessitated urgent surgical repair of the aneurysm with a prosthetic tube graft. She made a satisfactory recovery after a stormy postoperative course.
Aortic Aneurysm Leak
Discussion
There is little doubt that thrombolytic therapy with streptokinase reduces the mortality associated with acute myocardial infarction. 1-3 It acts by binding to plasminogen attached to thrombi but also may activate circulating plasminogen leading to severe derangement of the whole haemostatic mechanism. There is, therefore, an incidence of haemorrhagic complications associated with the systemic administration of streptokinase in thrombolytic doses. The benefits of reduction of mortality and infarct size must be weighed against such complications.4' 5 Most bleeding occurs at puncture sites but some patients do develop spontaneous oozing. 6 There is also an approximate 0.5% risk of intracerebral haemorrhage.7 Other isolated reports of specific bleeding complications have also been published. Streptokinase has caused haemarthroses, s hypheama, 9 iliopsoas haemorrhage 1° and spontaneous rupture of the spleen. 11 There have also been embolic complications after thrombolytic therapy, probably due to the disintegration of pre-existing clot. 12 There is clear evidence that the use of streptokinase in conditions mimicking myocardial infarction can be catastrophic, particularly if the chest pain is caused by aortic dissection, when thrombolysis frequently results in cardiac tamponade.13-15 We know of no other case where the administration of thrombolytic streptokinase has led to leakage from an infrarenal aortic aneurysm. We presume that the combination of dissolution of mural thrombus and increased bleeding tendency initiated a small but containable leak which caused the patient's symptoms, but happily was not catastrophic. The risk factors associated with the development of an abdominal aortic aneurysm are similar to those predisposing to coronary atherosclerosis and thrombosis. 16 All patients who are candidates for thrombolytic therapy should therefore be assessed, at least clinically, for aortic pathology. We also feel that thrombolytic agents should be given with extreme caution to those
739
patients who suffer a myocardial infarct in the presence of such an aneurysm. References 1 ISIS-2 (Second International of Infarct Survival) Collaborative Group; randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988; ii: 349-360. 2 GISSI (Gruppo Italiano per lo Studio della Streptochinasi Nell'Infarcto Miocardioi); effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986; i: 397-401. 3 Intravenous Streptokinase in Myocardial Infarction Study Group. A prospective trial of intravenous streptokinase in acute myocardial infarction. (ISAM). Mortality, morbidity and infarct size at 21 days. New EngI J Med 1986; 314: 349-360. 4 ERLEMEIERHH. Bleeding after thrombolysis in acute myocardial infarction. Eur Heart J 1989; 10: 16-23. 5 PETCHMC. Dangers of thrombolysis. BMJ 1990; 300: 483-484. 6 RAo AK. Thrombolysis in myocardial infarction (TIMI) trial, phase 1: haemorrhagic manifestations and changes in plasma fibrinogen and the fibrinolytic system in patients treated with recombinant tissue plasminogen activator and streptokinase. J Am Coil Cardiol 1988; 11: 1-11. 7 TOPOLEJ. Selection of thrombolytic agents for clinical use. In: E. HABER, E. BRAUNWALD,eds, Thrombolysis. St Louis: Mosby Year Book Inc., 1991: 301-314. 80LDROYD KG, HORNUNGRS, JONESAM, et al. Spontaneous haemartrosis following thrombolytic therapy for myocardial infarction. Postgrad Med ] 1990; 66: 387-388. 9 CAHANEM, ASHKENAZII, AVNI I, et al. Total hyphaema following streptokinase administration eight days after cataract extraction (Letter). B J Opthal 1990; 74: 447. 10 GILLANDERSIA, NAKIENLYR, CHANNERKS. Spontaneous iliopsoas haemorrhage--an unusual complication of streptokinase therapy. Postgrad Med J 1990; 66: 862-863. 11 GARDNER-MEDWINJ/ SAYERJ, MAHIDAYR, et al. Spontaneous rupture of the spleen following streptokinase therapy. (Letter). Lancet 1989; ii: 1398. 12 STAffORDPJ, STRACHANCJL, VINCENTR, et al. Multiple microemboli after disintegration of clot during thrombolysis for acute myocardial infarction. BMJ 1989; 299: 1301-1312. 13 BUTLERJ, DAVIESAH, WESTABYS. Streptokinase in acute aortic dissection. BMJ 1990; 300: 517-519. 14 CURZENNP, CLARKEB, GRAYH. Intravenous thrombolysis for suspected myocardial infarction: a cautionary note. BMJ 1990; 300: 513. 15 YIN ACN, MING TT. Misuse of streptokinase in dissecting aortic aneurysm. N Z Med J 1991; 104: 257-258. 16 TAYLORPR, WOLFEJHN. Treating aortic aneurysms. BM] 1991; 303: 1127-1129. Accepted 23 January 1992
Eur J Vasc Surg Vol 7, November 1993
CASE REPORT Aortic Aneurysm Leak After Streptokinase Treatment for Myocardial Infarction P. C. Hale, S. M. E. Smith and P. R. Taylor Department of Surgery, Guy's Hospital, St Thomas Street, London SE1 9RT, U.K. A leakfrom an abdominal aortic aneurysm following the administration of streptokinase treatment for myocardial infarction is reported. It is important to assess candidatesfor cardiac thrombolytic therapyfor aortic pathology and give such treatment with extreme caution in those patients with abdominal aortic aneurysms. K ~ Words: Abdominal aortic aneurysm; Myocardial infarction; Streptokinase.
We present a case of a contained leak from an infrarenal abdominal aortic aneurysm related to the administration of a thrombolytic dose of streptokinase during an acute myocardial infarction.
Case Report A 59-year-old woman was admitted to h e r local hospital with severe crushing central chest pain and the ECG changes of an acute myocardial infarct. She had suffered a previous myocardial infarction 10 years earlier and had undergone coronary artery vein bypass grafting. During recent investigation for hypertension she was noted to have an infrarenal abdominal aortic aneurysm on a digital subtraction angiogram and ultrasound determined its diameter to be 7cm. She was in the process of being assessed with regard to repair of her aneurysm when she was admitted with chest pain. She was given a bolus dose (1.2 million units) of streptokinase as thrombolytic therapy for her coronary artery occlusion. A few minutes later she developed severe epigastric pain radiating through to her back. Both this and her chest pain were treated with opiate analgesia and subsequently settled. She made a good recovery from her illness. 0950-821X/93/060738+02 $08.00/0© 1993Grune & StrattonLtd.
Fig. 1. AbdominalCT scan showingcontainedleak fromabdominal aortic aneurysm and surroundinginflammatoryreaction. Increasing concern about the size of her aneurysm resulted in a repeat CT scan of the abdomen being performed about 4 weeks later. This revealed a contained leak (Fig. 1) with an associated inflammatory reaction. This necessitated urgent surgical repair of the aneurysm with a prosthetic tube graft. She made a satisfactory recovery after a stormy postoperative course.
Aortic Aneurysm Leak
Discussion
There is little doubt that thrombolytic therapy with streptokinase reduces the mortality associated with acute myocardial infarction. 1-3 It acts by binding to plasminogen attached to thrombi but also may activate circulating plasminogen leading to severe derangement of the whole haemostatic mechanism. There is, therefore, an incidence of haemorrhagic complications associated with the systemic administration of streptokinase in thrombolytic doses. The benefits of reduction of mortality and infarct size must be weighed against such complications.4' 5 Most bleeding occurs at puncture sites but some patients do develop spontaneous oozing. 6 There is also an approximate 0.5% risk of intracerebral haemorrhage.7 Other isolated reports of specific bleeding complications have also been published. Streptokinase has caused haemarthroses, s hypheama, 9 iliopsoas haemorrhage 1° and spontaneous rupture of the spleen. 11 There have also been embolic complications after thrombolytic therapy, probably due to the disintegration of pre-existing clot. 12 There is clear evidence that the use of streptokinase in conditions mimicking myocardial infarction can be catastrophic, particularly if the chest pain is caused by aortic dissection, when thrombolysis frequently results in cardiac tamponade.13-15 We know of no other case where the administration of thrombolytic streptokinase has led to leakage from an infrarenal aortic aneurysm. We presume that the combination of dissolution of mural thrombus and increased bleeding tendency initiated a small but containable leak which caused the patient's symptoms, but happily was not catastrophic. The risk factors associated with the development of an abdominal aortic aneurysm are similar to those predisposing to coronary atherosclerosis and thrombosis. 16 All patients who are candidates for thrombolytic therapy should therefore be assessed, at least clinically, for aortic pathology. We also feel that thrombolytic agents should be given with extreme caution to those
739
patients who suffer a myocardial infarct in the presence of such an aneurysm. References 1 ISIS-2 (Second International of Infarct Survival) Collaborative Group; randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988; ii: 349-360. 2 GISSI (Gruppo Italiano per lo Studio della Streptochinasi Nell'Infarcto Miocardioi); effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986; i: 397-401. 3 Intravenous Streptokinase in Myocardial Infarction Study Group. A prospective trial of intravenous streptokinase in acute myocardial infarction. (ISAM). Mortality, morbidity and infarct size at 21 days. New EngI J Med 1986; 314: 349-360. 4 ERLEMEIERHH. Bleeding after thrombolysis in acute myocardial infarction. Eur Heart J 1989; 10: 16-23. 5 PETCHMC. Dangers of thrombolysis. BMJ 1990; 300: 483-484. 6 RAo AK. Thrombolysis in myocardial infarction (TIMI) trial, phase 1: haemorrhagic manifestations and changes in plasma fibrinogen and the fibrinolytic system in patients treated with recombinant tissue plasminogen activator and streptokinase. J Am Coil Cardiol 1988; 11: 1-11. 7 TOPOLEJ. Selection of thrombolytic agents for clinical use. In: E. HABER, E. BRAUNWALD,eds, Thrombolysis. St Louis: Mosby Year Book Inc., 1991: 301-314. 80LDROYD KG, HORNUNGRS, JONESAM, et al. Spontaneous haemartrosis following thrombolytic therapy for myocardial infarction. Postgrad Med ] 1990; 66: 387-388. 9 CAHANEM, ASHKENAZII, AVNI I, et al. Total hyphaema following streptokinase administration eight days after cataract extraction (Letter). B J Opthal 1990; 74: 447. 10 GILLANDERSIA, NAKIENLYR, CHANNERKS. Spontaneous iliopsoas haemorrhage--an unusual complication of streptokinase therapy. Postgrad Med J 1990; 66: 862-863. 11 GARDNER-MEDWINJ/ SAYERJ, MAHIDAYR, et al. Spontaneous rupture of the spleen following streptokinase therapy. (Letter). Lancet 1989; ii: 1398. 12 STAffORDPJ, STRACHANCJL, VINCENTR, et al. Multiple microemboli after disintegration of clot during thrombolysis for acute myocardial infarction. BMJ 1989; 299: 1301-1312. 13 BUTLERJ, DAVIESAH, WESTABYS. Streptokinase in acute aortic dissection. BMJ 1990; 300: 517-519. 14 CURZENNP, CLARKEB, GRAYH. Intravenous thrombolysis for suspected myocardial infarction: a cautionary note. BMJ 1990; 300: 513. 15 YIN ACN, MING TT. Misuse of streptokinase in dissecting aortic aneurysm. N Z Med J 1991; 104: 257-258. 16 TAYLORPR, WOLFEJHN. Treating aortic aneurysms. BM] 1991; 303: 1127-1129. Accepted 23 January 1992
Eur J Vasc Surg Vol 7, November 1993