Low Dose Intraarterial Thrombolysis with Tissue Plasminogen Activator: Does It Deliver as Promised?

Abstract

The widespread use of intraarterial thrombolytic therapy has been based on perceived benefits over operative treatment and the downgrading of the magnitude of subsequent surgery. Thirty-three patients who had thrombolysis for peripheral artery occlusion were retrospectively analyzed at St. James's Hospital from 1991 to 1997. One patient received streptokinase unsuccessfully. Five other patient's records were inadequate for analysis. Twenty-seven patient's notes were analyzed for risk, duration of occlusion, duration of treatment, dosage of tissue plasminogen activator (tPA) and conduits thrombolysed. There were 15 males and 12 females. The mean age was 62 years (range, 20-87). Fourteen were current or reformed smokers. Five were diabetic. Indications for treatment included acute graft occlusion (n = 13), embolus (n = 6), and primary and secondary arterial thrombosis (n = 8). Duration of occlusion was less than 24 hours in seven, 1 to 7 days in ten, and more than 7 days in ten patients. Twelve (44.44%) patients had complete clot lysis, four (14.81%) had partial clearance, and 1 1 (40.74%) remained occluded. Eight (29.63%) had serious complications including one death. Eighteen (66.66%) patients needed further surgical intervention to maintain graft patency. Data were analyzed using the chi-square and pooled t test. No significant difference was observed in results from thrombolysis from different conduits, gender, etiology, or smoking history. Increased duration of tPA administration was associated with an increased risk of failure. Administration of total dosages greater than 60 mg was associated with a higher risk of failure. Diabetics had a poor outcome (p=0.0520). Only 44% of patients successfully underwent lysis. A primary surgical option may be a more sensible course than lysis, given that the vast majority of patients ended up having surgery anyway.

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References

1. Hess H , Ingrisch H , Mietaschk A , et al: Local lowdose thrombolytic therapy of peripheral arterial occlusions. N Engl J Med 307:1627-1630, 1982.

2. Sicard GA , Schier JJ , Totty WG , et al: Thrombolytic therapy for acute arterial occlusion. J Vasc Surg 2:65-78, 1985.

3. McNamara TO : Thrombolysis as an alternative initial therapy for the acutely ischaemic lower limb. Semin Vasc Surg 5:89-98, 1992.

4. Graor RA , Olin J , Bartholomew JR , et al: Efficacy and safety of intra-arterial local infusion of streptokinase, urokinase or tissue plasminogen activator for peripheral arterial occlusion: A retrospective review. J Vasc Med Biol 2:310-315, 1990.

5. Yusuf SW , Whitaker SC , Gregson RHS , et al: Experience with pulse-spray thrombolysis in patients with peripheral ischaemia. Br J Surg 82:338-340, 1995.

6. Gardiner GA , Harrington DP , Koltun W , et al: Salvage of occluded arterial bypass grafts by means of thrombolysis. J Vasc Surg 9:426-431, 1994.

7. Faggioli GL , Ricotta JJ : Thrombolytic therapy for lower extremity arterial occlusion. Ann Vasc Surg 7:297-302, 1993.

8. The STILE Investigators : Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischaemia of the lower extremity. Ann Surg 220:251-266, 1994.

9. Ouriel K , Veith FJ , Sasahara AA : Thrombolysis or peripheral arterial surgery: Phase I results. TOPAS Investigators. J Vasc Surg 23:64-73, 1996.

10.

10. Sullivan KL , Gardiner GA , Kandarpa K , and et al: Efficacy of thrombolysis in infrainguinal bypass grafts. Circulation 199 (suppl 1): 1105-1105, 1991.

11.

11. Hye RJ , Turner C , Valji , et al: Is thrombolysis of occluded popliteal and tibial bypass grafts worthwhile? J Vasc Surg 20:588-596, 1994.