Fibrinolytic treatment of residual thrombus after catheter embolectomy for severe lower limb ischemia

Abstract

Intraoperative intraarterial fibrinolytic therapy (IIFT) was employed in 28 patients with acute limb ischemia. In 17 patients, significant residual calf thrombus was demonstrated by completion arteriography after standard balloon catheter thromboembolectomy, whereas in 11, pretreatment arteriography was not obtained. With the patient systemically heparinized, a bolus of fibrinolytic agent was instilled into the distal vessels below an inflow occlusion clamp. Among the 17 patients under angiographic control, arteriography was repeated after 30 minutes and a second bolus was injected if significant residual thrombus was still present. Successful lysis was achieved in 88% of these 17 limbs and streptokinase (SK) and urokinase (UK) were equally effective. The dosage of SK varied between 50,000 and 150,000 units (seven patients) and of UK between 35,000 and 150,000 units (21 patients). Serum fibrinogen levels declined significantly after IIFT (t test; p less than 0.05), but the average level remained within the normal range. Major bleeding developed in two patients, both of whom received SK and underwent a concomitant major abdominal vascular procedure, with a severe fall in fibrinogen values to 10 and 17 mg/dl. A minor groin hematoma occurred in one patient treated with UK. There was a significant difference in the incidence of bleeding between SK (2/7) and UK (1/21) (chi 2; p less than 0.05). Compartment syndrome developed in six limbs (21%). Amputation was required in two patients (7%). There was no correlation between prolongation of ischemia time as a result of IIFT and the incidence of compartment syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)