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Thrombolysis: End point or diagnostic step in the treatment of lower limbs ischaemia
Vol. 65, Suppl. 1
ABSTRACTS OF 12TH INTNAT’L CONGRESS
s99
Cl94 THROMBOLYSIS: LOWER LIMBS
END ISCHAEMIA.
POINT
OR C.
DIAGNOSTIC
Pratesi,
R.
Putti,
STEP S.
IN THE
Michelagnoli,
TREATMENT S.
Matticari,
OF A.
Alessi
Innocenti. Department of Vascular Surgery, University of Florence, Italy. The incidence of acute and sub-acute critical lower limb ischaemia must be considered a serious event in vascular pathology. An early diagnosis and the right choice of therapy seem to be important factors in preventing severe consequences. Association of thrombolysis and surgery or PTA seem to be a reliable alternative and it should be attempted prior to performing reconstructive surgery. Authors present their experience with thrombolytic therapy in the treatment of acute and sub-acute lower limbs ischaemia. Their experience is based on 151 treatments (132 men and 19 women, mean age 60 years) of which 60 Were related to late graft occlusions and 91 arterial occlusion, in whom we used urokinase. A clinical resolution of symptomatology was achieved in 69.6% of cases. Angiographyc lytic ratio was influenced by time and site of occlusion, resulting to 100% in case of proximal occlusion treated within 96 hours, and rispectivelly 77.7% and 66.6% in case of distal occlusion of artery and graft treated within the same time. In all cases the lytic drug was administered locally by Seldinger method, directly into the clot. The authors are using this protocol: 100,ODO U. bolus of urokinase and then 35,000 U/hour. Our protocol includes serial controls by means of clinical evaluation, Doppler examination at least every 6 hours, and angiography every 12 hours or every time required. Angiography at the end of the therapy can detect those cases that need adjunctive therapy. In the group of patient with arterial occlusion a complesentar therapy was used in 28% of cases, in graft occlusion 39%. PTA procedure was applied 18 times in 17 patients: 7 prossimal Ciliofemoral level), 9 distal Cpopliteal district) and in one both. In 6 cases of the 8 prossimal dilatation we achieved a good secondary patency, in two cases we performed an adiunctive surgical intervention that was able in one case to obtain a good patency, but in the other achieved only a limb savage. As concern= the group of 10 distal PTA, in 5 cases a good secondary patency was achieved, but in the other 5 surgery was required, and obteined 2 more tertiary patency and in 3 cases at least the limb savage. In conclusion we want to stress that the inability of thrombectomy to achieve uniform success in the restoration of circulation is frequently due to failure to remove distal propagating thrombus end to the inability to recognise the thrombosis cause. In these cases the use of “low dose" catheter directed therapy is the treatment of choice for its best results and its no significant systemic effect. The indications for thrombolytic therapy must be wider also because this kind of treatment didn't preclude, if ineffective, any surgical procedure. In our opinion a close and careful1 patients monitoring is required, and a vascular surgery stand-by is mandatory. The association of thrombolysis and adiunctive procedures was able in our series to achieve a good percentage of secondary patency reducing the reocclusion rate.
Cl95 THE ACTIVITY OF rtcu-PA GENERATED FROR rscu-PA DURING LYSIS OF PLASWA CLOTS IN VITRO IS NOT AFFECTED BY THE HBPARIN-DEPRNDENT u-PA IRRIBITORS. A. MOLINARI, L. PQNCMWI, C. GIORGETII, H. GERNA, J. LANSER. FARMITALIA CARLO ERBA, ERBAMOWI' GROW, VIA GIOVANNI XXIII, NERVIANO (MILANO), ITALY. Scu-PA is the proenzpme form of tcu-PA which initiates fihrinolpsis bY activating plasminogen to plasmin. As opposed to tcu-PA, scu-PA is relativelp fibrin specific and stable in plasma in vitro. Conversion to rtcu-PA at the fibrin surface has been proposed as an explanation for rscu-PA specificity for fibrin and we found, bp using an ELISA assap system which discriminates between rscu-PA and rtcu-PA in plasma, that complete and fibrin specific 1Ysis of clots induced bY 100 IV/ml (7% + rig/nil) rscu-PA was accmed bY 12% (93 + 7 rig/ml) conversion. When &u-PA was added directly to plasma at a concentration (101 + 8 rig/ml) and at a rate similar (P>O.O5) to the rtcn-PA generation curve observed with 100 III/ml rscu-PA, only 5% 1Ysis was obtained. In a purified sYstem the amidolptic (S-2444) activitp of rtcu-PA was unaffected bp 1 IU/ml AT-III. On the contraq, this adivitY was dramaticallY reduced in the presence of the ccmplex AT-III/heparin. The rate and extend of 1Ysi.s of clots induced bY rscu-PA wes unaffected bp up to 5 In/ml heparin. Tbe 1Ysis produced bY rtcu-PA was instead significantlY reduced by heparin alreadY at 1 Ill/ail. When 100 Ill/ml rtcu-PA was pre-incubated at 37OC in plaslpa before addition of the clots, its fibri.nolYtic activitY tot&Y disappeared in 120 + 10 min. With 1 and 5 IV/ml heparin, ccqlete neutralization was obtained in 70 + 10 and 35 + 8 rein (P
ABSTRACTS OF 12TH INTNAT’L CONGRESS
s99
Cl94 THROMBOLYSIS: LOWER LIMBS
END ISCHAEMIA.
POINT
OR C.
DIAGNOSTIC
Pratesi,
R.
Putti,
STEP S.
IN THE
Michelagnoli,
TREATMENT S.
Matticari,
OF A.
Alessi
Innocenti. Department of Vascular Surgery, University of Florence, Italy. The incidence of acute and sub-acute critical lower limb ischaemia must be considered a serious event in vascular pathology. An early diagnosis and the right choice of therapy seem to be important factors in preventing severe consequences. Association of thrombolysis and surgery or PTA seem to be a reliable alternative and it should be attempted prior to performing reconstructive surgery. Authors present their experience with thrombolytic therapy in the treatment of acute and sub-acute lower limbs ischaemia. Their experience is based on 151 treatments (132 men and 19 women, mean age 60 years) of which 60 Were related to late graft occlusions and 91 arterial occlusion, in whom we used urokinase. A clinical resolution of symptomatology was achieved in 69.6% of cases. Angiographyc lytic ratio was influenced by time and site of occlusion, resulting to 100% in case of proximal occlusion treated within 96 hours, and rispectivelly 77.7% and 66.6% in case of distal occlusion of artery and graft treated within the same time. In all cases the lytic drug was administered locally by Seldinger method, directly into the clot. The authors are using this protocol: 100,ODO U. bolus of urokinase and then 35,000 U/hour. Our protocol includes serial controls by means of clinical evaluation, Doppler examination at least every 6 hours, and angiography every 12 hours or every time required. Angiography at the end of the therapy can detect those cases that need adjunctive therapy. In the group of patient with arterial occlusion a complesentar therapy was used in 28% of cases, in graft occlusion 39%. PTA procedure was applied 18 times in 17 patients: 7 prossimal Ciliofemoral level), 9 distal Cpopliteal district) and in one both. In 6 cases of the 8 prossimal dilatation we achieved a good secondary patency, in two cases we performed an adiunctive surgical intervention that was able in one case to obtain a good patency, but in the other achieved only a limb savage. As concern= the group of 10 distal PTA, in 5 cases a good secondary patency was achieved, but in the other 5 surgery was required, and obteined 2 more tertiary patency and in 3 cases at least the limb savage. In conclusion we want to stress that the inability of thrombectomy to achieve uniform success in the restoration of circulation is frequently due to failure to remove distal propagating thrombus end to the inability to recognise the thrombosis cause. In these cases the use of “low dose" catheter directed therapy is the treatment of choice for its best results and its no significant systemic effect. The indications for thrombolytic therapy must be wider also because this kind of treatment didn't preclude, if ineffective, any surgical procedure. In our opinion a close and careful1 patients monitoring is required, and a vascular surgery stand-by is mandatory. The association of thrombolysis and adiunctive procedures was able in our series to achieve a good percentage of secondary patency reducing the reocclusion rate.
Cl95 THE ACTIVITY OF rtcu-PA GENERATED FROR rscu-PA DURING LYSIS OF PLASWA CLOTS IN VITRO IS NOT AFFECTED BY THE HBPARIN-DEPRNDENT u-PA IRRIBITORS. A. MOLINARI, L. PQNCMWI, C. GIORGETII, H. GERNA, J. LANSER. FARMITALIA CARLO ERBA, ERBAMOWI' GROW, VIA GIOVANNI XXIII, NERVIANO (MILANO), ITALY. Scu-PA is the proenzpme form of tcu-PA which initiates fihrinolpsis bY activating plasminogen to plasmin. As opposed to tcu-PA, scu-PA is relativelp fibrin specific and stable in plasma in vitro. Conversion to rtcu-PA at the fibrin surface has been proposed as an explanation for rscu-PA specificity for fibrin and we found, bp using an ELISA assap system which discriminates between rscu-PA and rtcu-PA in plasma, that complete and fibrin specific 1Ysis of clots induced bY 100 IV/ml (7% + rig/nil) rscu-PA was accmed bY 12% (93 + 7 rig/ml) conversion. When &u-PA was added directly to plasma at a concentration (101 + 8 rig/ml) and at a rate similar (P>O.O5) to the rtcn-PA generation curve observed with 100 III/ml rscu-PA, only 5% 1Ysis was obtained. In a purified sYstem the amidolptic (S-2444) activitp of rtcu-PA was unaffected bp 1 IU/ml AT-III. On the contraq, this adivitY was dramaticallY reduced in the presence of the ccmplex AT-III/heparin. The rate and extend of 1Ysi.s of clots induced bY rscu-PA wes unaffected bp up to 5 In/ml heparin. Tbe 1Ysis produced bY rtcu-PA was instead significantlY reduced by heparin alreadY at 1 Ill/ail. When 100 Ill/ml rtcu-PA was pre-incubated at 37OC in plaslpa before addition of the clots, its fibri.nolYtic activitY tot&Y disappeared in 120 + 10 min. With 1 and 5 IV/ml heparin, ccqlete neutralization was obtained in 70 + 10 and 35 + 8 rein (P