In Situ Alteplase for Rescue Recanalization After Glenn Thrombosis

Superior vena cava (SVC) thrombosis after Glenn palliation constitutes acute cavopulmonary circuit failure.

A 6-month-old boy with hypoplastic left heart syndrome developed SVC syndrome on postoperative day 13 after bidirectional Glenn, secondary to catheter-associated SVC-Glenn thrombosis with distal pulmonary embolisms. Alteplase infused in situ through the existing catheter (0.2 mg/kg/h, 72 hours) achieved complete recanalization without bleeding.

Mediastinal hemorrhage and 4-day veno-arterial extracorporeal membrane oxygenation precluded thrombolysis and surgery, and mechanical disruption risked embolization into the compromised pulmonary bed.

When an indwelling catheter traverses the thrombus, catheter-directed alteplase achieves complete recanalization, even after hemorrhage and extracorporeal support.