Safety and efficacy of fibrinolytic therapy in restoring function of an obstructed tunneled pleural catheter

Rationale: Tunneled pleural catheters have been established to be safe and effective in the management of recurrent symptomatic pleural effusions. Obstruction of the tunneled pleural catheter is rare; however, when obstructed the catheter fails to achieve its primary goal of symptom palliation. The management of pleural catheter obstruction has not been studied. Objectives:We aimed to determine if the use of intracatheter fibrinolytic therapy is safe and effective in restoring catheter function. Methods: One hundred seventy-two patients with tunneled pleural catheters placed from 2009 to 2014 were reviewed to identify patients who received fibrinolysis for catheter obstruction, defined by a sudden reduction to less than 10 ml in pleural fluid drainage with fluid visualized in the thorax on ultrasound/radiography. The technique involved intracatheter instillation of 2 to 5 mg of alteplase, which was allowed to remain in the catheter for 60 to 120 minutes, after which drainage was performed. Measurements and Main Results: Obstruction occurred in 37 pleural catheters at a median of 2 months from insertion. One hundred percent (37/37) of obstructed catheters resumed drainage after fibrinolytic instillation, from a median of 4 ml before to 300 ml after fibrinolysis (P <0.001). Twenty-four (65%) were performed in an outpatient setting, and no complications were encountered during or after fibrinolytic therapy. There were 18 episodes of reobstruction, all of which were successfully treated with intracatheter fibrinolytic therapy without complication. Conclusions: Fibrinolytic instillation through a tunneled pleural catheter is safe and effective in restoring function of an obstructed catheter, as evidenced by the lack of complications and success in achieving catheterpatency.The procedure can also be performedsafely in an outpatient setting. Patients who experience catheter obstruction may be prone to reobstruction; however, fibrinolysis was safe and effective in reestablishing patency of the reobstructed catheter.