Introduction. The reason for using thrombolytic therapy is to eliminate vascular thrombosis and promote vascular permeability. Acute limb ischemia is associated with significant morbidity and mortality. ROCHESTER, STILE and TOPAS studies showed that thrombolytic therapy for acute limb ischemia decreases the rate of surgical interventions and significantly increases the rate of limb salvage.
Aim of the Study. The purpose of this study is to assess the efficacy and outcomes of intra-arterial thrombolysis in the treatment of acute occlusions of the lower limb over a four-year period.
Material and Methods. We analysed 103 patients who had been treated in our department. There were acute ischemias of stage IIa and IIb according to the Rutherford classification. The data prior to, and after thrombolysis was analysed. We used Alteplase as a thrombolytic agent (mean dose 62 mg ±23.5). Procedural success was based on angiographic and clinical outcomes. Statistics were calculated by SPSS 16.
Results. The mean duration of symptoms prior to hospitalisation was 2.5 days (IQR 5-96 hours). The mean age at the time of thrombolysis was 63±11 for males 69±10 years for females. The success of intraarterial thrombolysis was defined by angiographic and clinical outcomes (successful in 86.4% and failed in 13.6%). Adjunctive angioplasty was performed on 39 (37.9%) patients, and immediate reconstructive surgery was required on 19 (18.4%) patients. The incidence of complications was 17,4 %, with the most common being-bleeding from the puncture side, the urinary tract or the gastrointestinal tract. Overall mortality was 8.7%. The women who required thrombolysis were older (p=0,034) and with a higher death rate (p=0.047). A CDT (catheter-directed thrombolysis) for an abdominal aorta thrombosis carries a significantly high mortality rate (p=0.00013). There were no statistically significant differences between the duration of symptoms and limb amputation and between other analysed data.
Conclusions. Intraarterial thrombolysis is an effective treatment method in acute limb ischemia for selected patients, as long as accurate procedural monitoring is ensured. Thrombolysis often leads to the discovery of underlying vascular lesions. A CDT for an abdominal aorta thrombosis carries a significantly high mortality rate.
1. Baglin TP. Hepari induced thrombocytopenia thrombosis (HIT/T) syndrome: diagnosis and treatment // J Clin Pathol, 2001;54(4):271-4
2. Becker F, Robert-Ebadi H, Ricco JB et al, Chapter I: Definition, epidemiology, clinical presentation and prognosis // Eur J Vasc Endovasc Surg, 2011;42(2):S4-S12
3. Berridge DC, Kessel DO, Robertson I. Surgery versus thrombolysis for initial management of acute limb ischemia // Cochrane Database Syst Rev, 2013;(6):CD002784
4. Braithwaite BD, Birch PA, Poskitt KR et al. Accelerated thrombolysis with high-dose bolus t-PA extents the role of peripheral thrombolysis but may increase the risks // Clin Radiol, 1995;50:747-750
5. Castaneda F, Swischuk JL, Li R et al. Declining-dose study of reteplase treatment for lower extremity arterial occlusions // J Vasc Interv Radiol, 2002;13:1093-1098
6. Clouse ME, Stokes KR, Perry LJ et al. Percutaneous intraarterial thrombolysis: analysis of factors affecting outcome // J Vasc Interv Radiol, 1994;5: 93-100
7. Comerota AJ, Weaver FA, Hosking JD et al. Results of prospective, randomized trial of surgery versus thrombolysis for occluded lower extremity bypass grafts // Am J Surg, 1996;172:105-112
8. Cragg AH, Smith TP, Corson JD et al. Two urokinase dose regimens in native arterial and graft occlusions: initial results of a prospective, randomized clinical trial // Radiology, 1991;178(3):681-6
9. Dakhil B, Lacal P, Abdesselam AB et al. Evaluation of ballon catheter-guided intra-arterial thrombolysis for acute peripheral arterial occlusion // Ann Vasc Surg, 2013;27(6):781-784
10. Dotter CT, Rosch J, Seaman AJ. Selective clot lysis with low-dose streptokinase // Radiology, 1974;111:249-252
11. Ebben HP, Nederhoed JH, Lely RJ et al. Low-dose thrombolysis for thromboembolic lower extremity arterial occlusion is effective without major hemorrhagic complications // Eur J vasc Endovasc Surg, 2014;5(48):551-558
12. Goodman GR, Tersigni S, Li K, Lawrence PF. Thrombolytic therapy in an isolated limb // Ann Vasc Surg, 1993;7(6):512-520
13. Grip O, Kuoppala M, Acosts S et al. Outcome and complications after intra-arterial thrombolysis for lower limb ischemia with or without continuous heparin infusion // BJS, 2014;101:1105-1112
14. Huang CK, Lee SO, Chang E et al. Androgen receptor (AR) in cardiovascular diseases // J Endocrinol, 2016;14:JOE-15-0518
15. Karnabatidis D, Spiliopoulos S, Tsetis D et al. Quality improvement guidelines for percutaneous catheter-directed intra-arterial thrombolysis and mechanical thrombectomy for acute lower-limb ischemia // Cardiovasc Intervent Radiol, 2011;34(6):1123-36
16. Koraen L, Kuoppala M, Acosta S et al. Thrombolysis for lower extremity bypass graft occlusion // J Vasc Surg, 2011;54(5):1339-44
17. Kuoppala M, Åkeson J, Svensson P et al. Risk factors for haemorrhage during local intra-arterial thrombolysis for lower limb ischemia // J Thromb Thrombolysis 2011;31:226-232
18. Kühn JP, Hoene A, Miertsch M et al. Intraarterial recombinant tissue plasminogen activator thrombolysis of acute and semiacute lower limb arterial occlusion: quality assurance, complication management, and 12-month follow-up reinterventions // Am J Roentgenol, 2011;196(5):1189-93
19. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the management of Peripheral arterial disease (TASC II) // Eur J Vasc Endovasc Surg, 2007;33(1):S1-S75
20. Ouriel K, Shortell CK, Azodo MV et al. Acute peripheral arterial occlusion: predictors of success in catheter-directed thrombolysis therapy // Radiology, 1994;193(2):561-6
21. Ouriel K, Shortell CK, De Weese JA, et al. A comparison of thrombolytic therapy with operative revascularization in the initial treatment of acute peripheral arterial ischemia // J Vasc Surg, 1994;19:1021-1030
22. Ouriel K, Veith FJ, Sasahara AA. A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. Thrombolysis or peripheral arterial surgery (TOPAS) investigators // N Engl J Med, 1998;338(16):1105-11
23. Ouriel K, Veith FJ, Sasahara AA for the TOPAS Investigators. Thrombolysis or peripheral arterial surgery (TOPAS): phase I results // J Vasc Surg, 1996;23:64-75
24. Plate G, Jansson I, Forssell C et al. Thrombolysis for acute lower limb ischaemia – a prospective, randomised, multicentre study comparing two strategies // Eur J Endovas Surg, 2006;31:651-660
25. Razavi MK, Lee DS, Hofmann LV. Catheter-directed thrombolytic therapy for limb ischemia: current status and controversies // J Vasc Interv Radiol, 2004;15:13-23
26. Sebastian AJ, Robinson GJ, Dyet JF et al. Longterm outcomes of low-dose catheter-directed thrombolytic therapy: a 5-year single-center experience // J Vasc Interv Radiol, 2010;21(7):1004-1010
27. Semba CP, Murphy TP, Bakal CW et al. Thrombolytic therapy with use of alteplase (rt-PA) in peripheral arterial occlusive disease: review of the clinical literature // J Vasc Interv Radiol, 2000;11:149-161
28. The Leaflet for Usage of Actilyse®. Boenhringer Ingelheim International GmbH // Binger Strasse 173, D-55216, Ingelheim am Rhein, Germany, December 2013
29. The STILE Investigators: results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity. The STILE trial // Ann Surg, 1994;220:251-268
30. Working Party on Thrombolysis in the Management of Limb Ischaemia. Thrombolysis in the management of limb arterial occlusion. Towards a consensus interim report // J Int Med, 1996; 240:343-355