Intraoperative intra-arterial thrombolytic therapy for salvage of limbs in patients with distal arterial thrombosis

Abstract

Acute arterial embolic or thrombotic occlusion of the runoff vessels is associated with an incomplete operative thromboembolectomy and an unacceptably high rate of amputation. This report presents a six year analysis of the use of intraoperative intra-arterial thrombolytic therapy, evaluating 38 patients who presented with impending loss of limb because of an acute occlusion of the runoff vessels. All of the patients had extensive thrombosis of a distal vessel and a complete distal thromboembolectomy was not possible. Fourteen patients received infusion of streptokinase, maximum dose of 50,000 units; 26 received urokinase (UK), maximum dose of 150,000 units, and two underwent an isolated limb perfusion technique using one million units of UK. Thirty-four lower and four upper extremities were treated. Twenty-eight of 38 patients had successful revascularization procedures that resulted in salvage of the limbs, and ten of the 38 underwent an extensive amputation. In 18 of the 28 who were successfully revascularized, lysis was clearly obtained, which contributed to the ultimate success; in ten of the 28, it was unclear whether or not lysis significantly contributed to salvage of the limbs. Although four of the 38 died within 30 days postoperatively and one patient had a hemorrhagic complication, neither the deaths nor the complication could be attributed to a lytic agent. There was no evidence of systemic thrombolysis in these patients. Intraoperative intra-arterial thrombolytic therapy administered by the slow bolus injection technique is safe. It can be an important adjunct to mechanical thromboembolectomy and bypass procedures in patients with limb-threatening ischemia caused by thrombosis of the distal part of the vessel. The isolated limb perfusion technique using high dose UK is particularly valuable in acute, small vessel, multiarterial occlusion. Intraoperative intra-arterial infusion of thrombolytic agents may make the difference between salvage or amputation of the limb without causing additional risk for the patient.