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Thrombolytic Therapy for Lower Extremity Arterial Occlusion
Basic Data Underlying Clinical Decision Making SECTION EDITOR: Lloyd M. Taylor, Jr.
Thrombolytic Therapy for Lower Extremity Arterial Occlusion Gian Luca Faggioli, MD, and John J. Ricotta, MD, Buffalo, New York
Over the past decade extensive data have been collected on the efficacy of thrombolytic infusion for relief of peripheral arterial insufficiency. The optimal route of administration is intra-arterial, and when possible, directly into the thrombus itself (Table I). Although most thrombolytics are similarly effective in the coronary circulation, streptokinase appears slightly inferior in peripheral arteries, with a lower initial success rate and a higher incidence of complications (Table II). It is generally accepted that intra-arterial lytic infusion should be combined with a heparin infusion to reduce the frequency of catheter-induced thrombosis; however, the dosage of heparin infusion remains controversial. Some authors advocate full heparinization, whereas others report increased bleeding with this approach and suggest extending the partial thromboplastin time to only about 1.5 times normal. The most commonly reported complications are local bleeding requiring transfusion or surgery and catheter-related thrombosis (Table V). Serious complications include renal failure from reperfusion injury and/or dye load and death, usually from intracranial hemorrhage. The occurrence of this latter devastating complication is rare but unpredictable. Factors that influence initial success include age of thrombus, severity of ischemia, and status of From the Division of Vascular Surgery, Department of Surgery, Millard Fillmore Hospital and The State University of New York at Buffalo, N.Y. Reprint requests: John J. Ricotta, MD, Department of Surgery, MilIard Fillmore Hospital, 3 Gates Circle, Buffalo, NY 14029.
runoff. In two studies on graft thrombosis the age of the graft did not predict success, but its position (i.e., suprainguinal vs. infrainguinal) did. Generally prosthetic grafts are easier to open since they are not subject to intrinsic graft problems such as diffuse narrowing. However, their long-term patency is inferior to that of the saphenous vein if the vein graft is not diffusely diseased after completion of the lytic infusion. Infusions have been used for both native vessels and grafts with variable results. Success is usually greatest if an underlying lesion is identified and then corrected. Patients in w h o m an underlying lesion is not corrected have a poor long- term prognosis. The role of thrombolytic therapy in dealing with peripheral ischemia remains controversial. This modality is rarely successful without accompanying treatment such as angioplasty or surgery. Consequently, it has not reduced treatment costs but may in fact have increased them. Data on the long-term patency after thrombolytic infusion are sparse and in general disappointing. The assertion that thrombolytic infusion allows simpler and more successful definitive therapy is supported by anecdotal experience but remains to be proved prospectively. Several clinical studies are currently testing this concept. Recently intra-arterial thrombolysis has been used intraoperatively to clear distal thrombi, facilitate thromboembolectomy, and potentially decrease the incidence of "no reflow" after revascularization for acute ischemia. Doses of up to 500,000 units of urokinase can be used safely. However, as with percutaneous use, the ultimate benefit of this modality remains to be defined.
297
298
Annals of Vascular Surgery
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T a b l e I. Effect of route of administration on initial results Success rate NV (%) IV IA IT
Grafts (%) 35* (30-40)
71.5 (61-82.6) 61.8 (33.3-88)
49.1 (0-75) 67.3 (26-88)
Complications (%)
Ref.
26.6
1,2
31.9 (6.8-53.8) 21.9 (9-44)
3-9 10-25
NV = native vessels; IV = intravenous; IA = intra-arterial; IT = intrathrombus. *Reports did not specify type.
T a b l e II. Thrombolytic agent vs. initial results All series
SK UK tPA
Success rate (%)
Complications (%)
Ref.
63.5 (26-85) 72 (0-100) 88
31.8 (9-70) 22 (8.7-60) 36
3-7, 14-16, 1822, 26-31 8, 10, 1, 21-23, 25, 28, 32 33
Single series comparing UK and SK success rates Success rate (%) SK UK
p Value
Ref.
<0.05
22, 28
T a b l e III. Doses of intrathrombotic urokinase vs. initial results Success rate (%) Native vessels > 75,000
Complications (%)
73.7
23
84.8
20.9
Ref. 8, 9, 19, 22, 32 10, 21, 24, 25, 28
U/hr -< 60,000
U/hr Grafts 125,000
70 83 )
U/hr 50,000
65 85
37.1 p = NS 16.2
p <0.05
32
U/hr
41-50 77-100 i
SK = streptokinase; UK = urokinase; tPA = tissue-type plasminogen activator.
T a b l e IV. Administration of heparin vs. initial results
Streptokinase w i t h heparin Streptokinase w i t h o u t heparin Urokinase w i t h heparin
Success rate (%)
Complications (%)
72.9 (67.6-80) 56.4 (38-69.8) 76.9 ( 54.2-88)
t6.6 (6.8-22.9) 12.3 (6.8-14) 17.8 (2.7-26.1)
Refl 4, 14, 20 4, 16, 18, 24 9, 10, 19, 21, 22, 25, 32
Vol. 7, No. 3 1993
Thrombolytic therapy for lower extremity occlusion 299
Table V. Major complications Streptokinase (%)
Urokinase (%)
Ref.
3.9-60
2.8-25
1, 5, 9, 16, 18, 22, 23, 28, 34-41
0,5-8 2.9-12 4-9 1.9-16 0.6-10 0.6-2.6 4.5-5.2 5.7-10.4 5.2 1.4 4.5 1.0-2.8 7.6-8.5
3.7 16.7 4.5 2-15 1.8 2.8 4.5 1.8 -1.2 1.8 ---
Bleeding requiring transfusion or surgical evacuation CV accident Catheter thrombosis Renal failure Distal embolization Amputation Death Myocardial infarction Arterial/graft thrombosis Brachial plexus palsy Pseudoaneurysm Arterial aneurysm/graft rupture Gastrointestinal bleeding Retroperitoneal h e m a t o m a
1, 5, 9, 27, 30, 34 4, 28, 34 9, 21, 22, 28 4, 9, 10, 15, 21, 22, 28, 34 5, 16, 23, 25 4, 16, 25 22, 25 18, 25 25 10, 16, 34 9, 22 4, 18 7, 18
T a b l e VII. Influence of type of occlusion on initial result
T a b l e VI. Potential factors influencing initial outcome
All series
SUCCESS
rate (%) Thrombus age < 30 days > 30 days 0-2 days 3-12 days > 12 days Grade of ischemia ABI < 0.25 ABI > 0.25 Limb paralysis/ sensation loss Rest pain alone Run off Poor Good Graft age < 6 mo >6 mo < 12 m o > 12 m o Graft position Suprainguinal Infrainguinal ABI = ankle-brachial index.
p Value
Ref.
78 37 77.1 68.4 41
0.0071
6
0.01
9
22 89 33.3
0.0009
13
0.001
27
Native vessels Graft s eopliteal aneurysms
0.001
57.7 71 44.4 70.8
NS
88 59
0.003
NS
40 9
22 9
ReL
68.3 (45-88) 61.6 (0-88) 90 (70-100)
3-5, 10-16, 18-20 3-6, 9, 11-13, 1825, 29-34 4, 5 , 4 2
Series comparing results in native vessels vs. grafts Success
90 0 72.7
Initial success (%)
Native vessels Grafts Native vessels Suprainguinal Infrainguinal Grafts Suprainguinal Infrainguinal Grafts Femoropopliteal vessels Tibial vessels PTFE grafts Vein grafts
rate (%)
p Value
52 ~ 11 !
< 0.05
20
89 ~ 70 /
NS
25
< 0.04
13
NS
16 9, 22
91 68 75 ] 80 20 53-72 64.5-83
ReL
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Table
VIII. Cost of thrombolytic
M e a n a c t u a l cost C o m p l e t e success M e a n effective cost corrected for success Partial success
Table
IX, Series with long-term
t h e r a p y ~2
Thrombolytic therapy
Surgery
p Value
$8232 $39,200
$8859 $9424
NS < 0.01
$16,424
-
follow-up
Ref.
No. of cases
Native vessels or grafts
25 34
48 29 22
Native vessels Grafts Grafts (veins)
37
50
Grafts
33
22
Grafts
41
18 9
Native vessels Grafts
Follow-up interval 6 mo 6 mo 6 mo 12 m o 36 anao 6 mo 12 m o 24 m o 36 m o 6 mo 12 m o 18 m o 18 m o
Patency (%) 71" 41" 42.3 36.6 22.9 70 60 49.6 43.4 64 20 50 22
*Infrainguinal and suprainguinal grafts or arteries are considered together.
Table
X. Series reporting
intraoperative
intra-arterial
thrombolytic
therapy
ReL
No. of cases
Agent
Dose (IU/hr)
Success (%)
Complications (%)
43 44 45 46
7 5 13 14 24 19 28
UK SK SK SK UK SK SK UK
75,000 + 35,000 20,000-100,000 110,000 50,000 ! 50,000 50,000-200,000 50,000-150,000 35,000-150,000
29 100 85 35.7 54.1 100 83 91
0 0 38.5 7.1 0 10 28.5 4.7
47 48
Vol. 7, No. 3 1993
REFERENCES 1. Ricotta J J, Green RM, DeWeese JA. Use and limitations of thrombolytic therapy in the treatment of peripheral arterial ischemia: Result of a multi-institutional questionnaire. J Vasc Surg 1987;6:45-50. 2. Sussman BC, Dardik H, Ibrahim IM, et al. Improved patient selection for enzymatic lysis of peripheral arterial and graft occlusions, Am J Surg 1984;148:244-248. 3. Kolts RL, Kuhener ME, Swanson MK, et al. Local intraarterial streptokinase therapy for acute peripheral arterial occlusions. Should thrombolytic therapy replace embolectomy? Am Surg 1985;51:381-387. 4. Ferguson IA, Faris I, Robertson A, et al. Intra-arterial streptokinase therapy to relive acute limb ischemia. J Vasc Surg 1986;4:205-210. 5. Hamelink JK, Elliott BM. Localized intraarterial streptokinase therapy. Am J Surg 1986;152:252-256. 6. Wolfson RH, Kumpe DA, Rutherford RB. Role of intraarterial streptokinase in treatment of arterial thromboembolism. Arch Surg 1984;119:697-701. 7. Rush DS, Gewerts BL, Lu CT, et al. Selective infusion of streptokinase for arterial thrombosis, Surgery 1983;93:828833. 8. Perler BA, White RI, Ernst CB, et aL Low-dose thrombolytic therapy for infrainguinal graft occlusions: An idea whose time has passed? J Vasc Surg 1985;2:799-805. 9. Durham JD, Geller SC, Abbott WM, et al. Regional infusion of urokinase into occluded lower extremity bypass grafts: Longterm clinical results. Radiology 1989;172:83-87. 10. McNamara TO, Bomberger RA, Merchant RF. Intra-arterial urokinase as the initial therapy for acutely ischemic lower limbs. Circulation 1991;83(Suppl I}:I-106-I-119. 11. Katzen BT, Edwards KC, Albert AS, et al. Low-dose direct fibrinolysis in peripheral vascular disease. J Vasc Surg 1984; 1:718-722. 12. Dacey IA, Dow RW, McDaniel MD, et al. Cost-effectiveness of intra-arterial thrombolytic therapy. Arch Surg 1988;123: 1218-1223. 13. Hallett JW, Greenwood LH, Yrizzary JM, et al. Statistical determinants of success and complications of thrombolytic therapy for arterial occlusion of"lower extremity. Surg Gynecol Obstet 1985;161:431-437. 14. Taylor LM, Porter J i , Baur GM, et al. Intraarterial steptokinase for acute popliteal and tibial artery occlusion. Am J Surg 1984; 147: 583-588. 15. Hess H, Ingrisch H, Mietaschk A, et al. Local low-dose thrombolytic therapy of peripheral arterial occlusions. N Engl J Med 1982;307:1627-1630. 16. Graor RA, Risius 13, Denny KM, et al. Local thrombolysis in the treatment of thrombosed arteries, bypass grafts, and arteriovenous fistulas. J Vasc Surg 1985;2:406-414. 17. Graor RA, Risius 13, Young JR, et al. Peripheral artery and bypass graft thrombolysis with recombinant human tissuetype plasminogen activator. J Vasc Surg 1986;3:115-124.
Thrombolytic therapy for lower extremity occlusion
301
18. Kakkasseril JS, Cranley J J, Arbaugh J J, et al. Efficacy o f low-dose streptokinase in acute arterial occlusion and graft thrombosis. Arch Surg 1985;120:427-429. 19. Italian Cooperative Study Bologna. Endoarterial treatment of acute ischemia of the limbs with urokinase. Int Angiol 1989;8:53-56. 20. Sicard GA, Schier J J, Totty WG, et al. Thrombolytic therapy for acute arterial occlusion. J Vasc Surg 1985;2:65-78. 21. Sullivan KI,, Gardiner GA, Shapiro MJ, et al. Acceleration of thrombolysis with a high-dose transthrombus bolus technique. Radiology 1989;173:805-808. 22. Gardiner GA, Koltun W, Kandarpa K, et al. Thrombolysis of occluded femoropopliteal grafts. AJR 1986;147:621-626. 23. Goldberg L, Ricci MT, Sauvage LR, et aL Thrombolytic therapy for delayed occlusion of knitted Dacron bypass grafts in the axillofemoral, femoropopliteal and femorotibial positions. Surg Gynecol Obstet 1985;160:491-498. 24. van Breda A, Robison JC, Feldman L, et al. Local thrombolysis in the treatment of arterial graft occlusions. J Vasc Surg 1984;1:103-112. 25. McNamara TO, Bomberger RA. Factors affecting initial and 6 month patency rates after intraarterial thrombolysis with high dose urokinase. Am J Surg 1986;152:709-712. 26. Hurley J J, BurreU MJ, Auer AI, et al. Surgical implications of fibrinolytic therapy. Am J Surg 1984;148:830-835. 27. Earnshaw J J, Gregson RHS, Makin GS, et al. Early results of low dose intra-arterial streptokinase therapy in acute and subacute lower limb arterial ischemia. Br J Surg 1987;74:504507. 28. Belkin M, Belkin B, Buckman CA, et al. Intra-arterial fibrinolytic therapy. Efficacy of streptokinase vs urokinase. Arch Surg 1986;121:769-773. 29. Browse DJ, Torrie EPH, Galland RB. Low dose intra-arterial thrombolysis in the treatment of occluded vascular grafts. Br J Surg 1992;79:86-88. 30. Hargrove WC, Berkowitz HD, Freiman DB, et al. Recanalization of totally occluded femoro-popliteal vein grafts with low dose streptokinase infusion. Surgery 1982;92:890-895. 31. Sussmann B, Dardik H, Ibrahim IM, et al. Improved patient selection for enzymatic lysis of peripheral arterial and graft occlusions. Am J Surg 1984; 148:244-248. 32. 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; 178:681-686. 33. Graor RA, Risius B, Young JR, et al. Thrombolysis of peripheral arterial bypass grafts. Surgical thrombectomy compared with thrombolysis. A preliminary report. J Vasc Surg 1988; 7:347-355. 34. Belkin M, Donaldson MC, Whittemore AD, et al. Observations on the use of thrombolytic agents for thrombolytic occlusion of infrainguinal vein grafts. J Vasc S ~ g 1990;11: 289-296.
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Annals of Vascular Surgery
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35. Seabrook GIL Mewissen MW, Schmitt DD, et al. Percutaneous intraarterial thrombolysis in the treatment of thrombosis of lower extremity arterial reconstructions. J Vase Surg 1991;13:646-651. 36. Hirshberg A, Schneiderman J, Garnick A, et al. Errors and pitfalls in intraarterial thrombolytic therapy. J Vase Surg 1989;10:612-616. 37. Gardiner GA, Harrington DP, Koltun W, et al. Salvage of occluded bypass by means of thrombolysis. J Vase Surg 1989;9:426-431. 38. Bemi GA, Bandyk DF, Zierler RE, et al. Streptokinase treatment of acute arterial occlusion. Am Surg 1983;198:185-191. 39. Katzen BT, van Breda A. Low-dose streptokinase in the treatment of arterial occlusions. AJR 1981; 136:1171-1178. 40. Scott DJA, Wyatt MG, Wilson YG, et aL Intraarterial streptokinase infusion in acute lower limb ischaemia. Br J Surg 199 t;78:732-734. 41. Wolfson RH, Kumpe DA, Rutherford RB. Role of intraarterial streptokinase in treatment of arterial thromboembolism. Arch Surg 1984;119:697-702.
BOUND
VOLUMES
42. Porter JM, Taylor LM+ Current status of thrombolytic therapy. J Vasc Surg 1985;2:239-249. 43. Fiessinger JN, Vayssarat M, Jufllet Y, et al. Local urokinase in arterial thromboembolism. Angiology 1980;31:715-720. 44. Quinofies-Baldrich WJ, Zieler E, Hiatt JC+ Intraoperative fibrinolytic therapy: An adjunct to catheter thromboembolectomy. J Vasc Surg 1985;2:319-326. 45. Cohen LH, Kaplan M, Bernhard VM. Intraoperative streptokinase. An adjunct to mechanical thrombectomy in the management of acute ischemia. Arch Surg 1986;121:708-715. 46. Comerota AJ, White JV, Grosh JD. Intraoperative, intraarterial thrombolytic therapy for salvage of limbs in patients with distal arterial thrombosis. Surg Gynecol Obstet 1989;169:283289. 47. Norem RF, Short DH, Kerstein MD. Role of intraoperative fibrinolytic therapy in acute arterial occlusion. Surg Gynecol Obstet 1988;167:87-91. 48. Parent NF, Bernhard VM, Pabst TS, et at. Fibrinolytic treatment of residual thrombus after catheter embolectomy for severe limb ischemia. J Vasc Surg 1989;9:153-160.
OF ANNALS
Bound volumes are available to subscribers only. The hardbound volume of six issues of the 1993 Annals of Vascular Surgery must be ordered by October 1, 1993, from Quality Medical Publishing, Inc., 11970 Borman Dr., Ste. 222, St. Louis, MO 63146. Payment of $60 in U.S. funds must accompany all orders.
Thrombolytic Therapy for Lower Extremity Arterial Occlusion Gian Luca Faggioli, MD, and John J. Ricotta, MD, Buffalo, New York
Over the past decade extensive data have been collected on the efficacy of thrombolytic infusion for relief of peripheral arterial insufficiency. The optimal route of administration is intra-arterial, and when possible, directly into the thrombus itself (Table I). Although most thrombolytics are similarly effective in the coronary circulation, streptokinase appears slightly inferior in peripheral arteries, with a lower initial success rate and a higher incidence of complications (Table II). It is generally accepted that intra-arterial lytic infusion should be combined with a heparin infusion to reduce the frequency of catheter-induced thrombosis; however, the dosage of heparin infusion remains controversial. Some authors advocate full heparinization, whereas others report increased bleeding with this approach and suggest extending the partial thromboplastin time to only about 1.5 times normal. The most commonly reported complications are local bleeding requiring transfusion or surgery and catheter-related thrombosis (Table V). Serious complications include renal failure from reperfusion injury and/or dye load and death, usually from intracranial hemorrhage. The occurrence of this latter devastating complication is rare but unpredictable. Factors that influence initial success include age of thrombus, severity of ischemia, and status of From the Division of Vascular Surgery, Department of Surgery, Millard Fillmore Hospital and The State University of New York at Buffalo, N.Y. Reprint requests: John J. Ricotta, MD, Department of Surgery, MilIard Fillmore Hospital, 3 Gates Circle, Buffalo, NY 14029.
runoff. In two studies on graft thrombosis the age of the graft did not predict success, but its position (i.e., suprainguinal vs. infrainguinal) did. Generally prosthetic grafts are easier to open since they are not subject to intrinsic graft problems such as diffuse narrowing. However, their long-term patency is inferior to that of the saphenous vein if the vein graft is not diffusely diseased after completion of the lytic infusion. Infusions have been used for both native vessels and grafts with variable results. Success is usually greatest if an underlying lesion is identified and then corrected. Patients in w h o m an underlying lesion is not corrected have a poor long- term prognosis. The role of thrombolytic therapy in dealing with peripheral ischemia remains controversial. This modality is rarely successful without accompanying treatment such as angioplasty or surgery. Consequently, it has not reduced treatment costs but may in fact have increased them. Data on the long-term patency after thrombolytic infusion are sparse and in general disappointing. The assertion that thrombolytic infusion allows simpler and more successful definitive therapy is supported by anecdotal experience but remains to be proved prospectively. Several clinical studies are currently testing this concept. Recently intra-arterial thrombolysis has been used intraoperatively to clear distal thrombi, facilitate thromboembolectomy, and potentially decrease the incidence of "no reflow" after revascularization for acute ischemia. Doses of up to 500,000 units of urokinase can be used safely. However, as with percutaneous use, the ultimate benefit of this modality remains to be defined.
297
298
Annals of Vascular Surgery
Faggioli and Ricatta
T a b l e I. Effect of route of administration on initial results Success rate NV (%) IV IA IT
Grafts (%) 35* (30-40)
71.5 (61-82.6) 61.8 (33.3-88)
49.1 (0-75) 67.3 (26-88)
Complications (%)
Ref.
26.6
1,2
31.9 (6.8-53.8) 21.9 (9-44)
3-9 10-25
NV = native vessels; IV = intravenous; IA = intra-arterial; IT = intrathrombus. *Reports did not specify type.
T a b l e II. Thrombolytic agent vs. initial results All series
SK UK tPA
Success rate (%)
Complications (%)
Ref.
63.5 (26-85) 72 (0-100) 88
31.8 (9-70) 22 (8.7-60) 36
3-7, 14-16, 1822, 26-31 8, 10, 1, 21-23, 25, 28, 32 33
Single series comparing UK and SK success rates Success rate (%) SK UK
p Value
Ref.
<0.05
22, 28
T a b l e III. Doses of intrathrombotic urokinase vs. initial results Success rate (%) Native vessels > 75,000
Complications (%)
73.7
23
84.8
20.9
Ref. 8, 9, 19, 22, 32 10, 21, 24, 25, 28
U/hr -< 60,000
U/hr Grafts 125,000
70 83 )
U/hr 50,000
65 85
37.1 p = NS 16.2
p <0.05
32
U/hr
41-50 77-100 i
SK = streptokinase; UK = urokinase; tPA = tissue-type plasminogen activator.
T a b l e IV. Administration of heparin vs. initial results
Streptokinase w i t h heparin Streptokinase w i t h o u t heparin Urokinase w i t h heparin
Success rate (%)
Complications (%)
72.9 (67.6-80) 56.4 (38-69.8) 76.9 ( 54.2-88)
t6.6 (6.8-22.9) 12.3 (6.8-14) 17.8 (2.7-26.1)
Refl 4, 14, 20 4, 16, 18, 24 9, 10, 19, 21, 22, 25, 32
Vol. 7, No. 3 1993
Thrombolytic therapy for lower extremity occlusion 299
Table V. Major complications Streptokinase (%)
Urokinase (%)
Ref.
3.9-60
2.8-25
1, 5, 9, 16, 18, 22, 23, 28, 34-41
0,5-8 2.9-12 4-9 1.9-16 0.6-10 0.6-2.6 4.5-5.2 5.7-10.4 5.2 1.4 4.5 1.0-2.8 7.6-8.5
3.7 16.7 4.5 2-15 1.8 2.8 4.5 1.8 -1.2 1.8 ---
Bleeding requiring transfusion or surgical evacuation CV accident Catheter thrombosis Renal failure Distal embolization Amputation Death Myocardial infarction Arterial/graft thrombosis Brachial plexus palsy Pseudoaneurysm Arterial aneurysm/graft rupture Gastrointestinal bleeding Retroperitoneal h e m a t o m a
1, 5, 9, 27, 30, 34 4, 28, 34 9, 21, 22, 28 4, 9, 10, 15, 21, 22, 28, 34 5, 16, 23, 25 4, 16, 25 22, 25 18, 25 25 10, 16, 34 9, 22 4, 18 7, 18
T a b l e VII. Influence of type of occlusion on initial result
T a b l e VI. Potential factors influencing initial outcome
All series
SUCCESS
rate (%) Thrombus age < 30 days > 30 days 0-2 days 3-12 days > 12 days Grade of ischemia ABI < 0.25 ABI > 0.25 Limb paralysis/ sensation loss Rest pain alone Run off Poor Good Graft age < 6 mo >6 mo < 12 m o > 12 m o Graft position Suprainguinal Infrainguinal ABI = ankle-brachial index.
p Value
Ref.
78 37 77.1 68.4 41
0.0071
6
0.01
9
22 89 33.3
0.0009
13
0.001
27
Native vessels Graft s eopliteal aneurysms
0.001
57.7 71 44.4 70.8
NS
88 59
0.003
NS
40 9
22 9
ReL
68.3 (45-88) 61.6 (0-88) 90 (70-100)
3-5, 10-16, 18-20 3-6, 9, 11-13, 1825, 29-34 4, 5 , 4 2
Series comparing results in native vessels vs. grafts Success
90 0 72.7
Initial success (%)
Native vessels Grafts Native vessels Suprainguinal Infrainguinal Grafts Suprainguinal Infrainguinal Grafts Femoropopliteal vessels Tibial vessels PTFE grafts Vein grafts
rate (%)
p Value
52 ~ 11 !
< 0.05
20
89 ~ 70 /
NS
25
< 0.04
13
NS
16 9, 22
91 68 75 ] 80 20 53-72 64.5-83
ReL
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Annals of Vascular Surgery
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Table
VIII. Cost of thrombolytic
M e a n a c t u a l cost C o m p l e t e success M e a n effective cost corrected for success Partial success
Table
IX, Series with long-term
t h e r a p y ~2
Thrombolytic therapy
Surgery
p Value
$8232 $39,200
$8859 $9424
NS < 0.01
$16,424
-
follow-up
Ref.
No. of cases
Native vessels or grafts
25 34
48 29 22
Native vessels Grafts Grafts (veins)
37
50
Grafts
33
22
Grafts
41
18 9
Native vessels Grafts
Follow-up interval 6 mo 6 mo 6 mo 12 m o 36 anao 6 mo 12 m o 24 m o 36 m o 6 mo 12 m o 18 m o 18 m o
Patency (%) 71" 41" 42.3 36.6 22.9 70 60 49.6 43.4 64 20 50 22
*Infrainguinal and suprainguinal grafts or arteries are considered together.
Table
X. Series reporting
intraoperative
intra-arterial
thrombolytic
therapy
ReL
No. of cases
Agent
Dose (IU/hr)
Success (%)
Complications (%)
43 44 45 46
7 5 13 14 24 19 28
UK SK SK SK UK SK SK UK
75,000 + 35,000 20,000-100,000 110,000 50,000 ! 50,000 50,000-200,000 50,000-150,000 35,000-150,000
29 100 85 35.7 54.1 100 83 91
0 0 38.5 7.1 0 10 28.5 4.7
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35. Seabrook GIL Mewissen MW, Schmitt DD, et al. Percutaneous intraarterial thrombolysis in the treatment of thrombosis of lower extremity arterial reconstructions. J Vase Surg 1991;13:646-651. 36. Hirshberg A, Schneiderman J, Garnick A, et al. Errors and pitfalls in intraarterial thrombolytic therapy. J Vase Surg 1989;10:612-616. 37. Gardiner GA, Harrington DP, Koltun W, et al. Salvage of occluded bypass by means of thrombolysis. J Vase Surg 1989;9:426-431. 38. Bemi GA, Bandyk DF, Zierler RE, et al. Streptokinase treatment of acute arterial occlusion. Am Surg 1983;198:185-191. 39. Katzen BT, van Breda A. Low-dose streptokinase in the treatment of arterial occlusions. AJR 1981; 136:1171-1178. 40. Scott DJA, Wyatt MG, Wilson YG, et aL Intraarterial streptokinase infusion in acute lower limb ischaemia. Br J Surg 199 t;78:732-734. 41. Wolfson RH, Kumpe DA, Rutherford RB. Role of intraarterial streptokinase in treatment of arterial thromboembolism. Arch Surg 1984;119:697-702.
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42. Porter JM, Taylor LM+ Current status of thrombolytic therapy. J Vasc Surg 1985;2:239-249. 43. Fiessinger JN, Vayssarat M, Jufllet Y, et al. Local urokinase in arterial thromboembolism. Angiology 1980;31:715-720. 44. Quinofies-Baldrich WJ, Zieler E, Hiatt JC+ Intraoperative fibrinolytic therapy: An adjunct to catheter thromboembolectomy. J Vasc Surg 1985;2:319-326. 45. Cohen LH, Kaplan M, Bernhard VM. Intraoperative streptokinase. An adjunct to mechanical thrombectomy in the management of acute ischemia. Arch Surg 1986;121:708-715. 46. Comerota AJ, White JV, Grosh JD. Intraoperative, intraarterial thrombolytic therapy for salvage of limbs in patients with distal arterial thrombosis. Surg Gynecol Obstet 1989;169:283289. 47. Norem RF, Short DH, Kerstein MD. Role of intraoperative fibrinolytic therapy in acute arterial occlusion. Surg Gynecol Obstet 1988;167:87-91. 48. Parent NF, Bernhard VM, Pabst TS, et at. Fibrinolytic treatment of residual thrombus after catheter embolectomy for severe limb ischemia. J Vasc Surg 1989;9:153-160.
OF ANNALS
Bound volumes are available to subscribers only. The hardbound volume of six issues of the 1993 Annals of Vascular Surgery must be ordered by October 1, 1993, from Quality Medical Publishing, Inc., 11970 Borman Dr., Ste. 222, St. Louis, MO 63146. Payment of $60 in U.S. funds must accompany all orders.