THROMBOLYTIC THERAPY IN ACUTE LOWER-LIMB ISCHEMIA

Surgical revascularization as the initial therapy in acute lower limb ischemia (ALLI) is associated with a high cumulative mortality and amp utation rate. Catheter-directed delivery of low-dose thrombolytic agen ts (intra-arterial thrombolysis, IAT) offers the possibility for a gen tle revascularization with a minimum of stress for the patients. In tw o randomized studies, the primary rates of revascularization, amputati on, and mortality did not differ significantly between IAT and surgica l revascularization. However, in one study the 6-month event-free surv ival rate was 85% in the IAT group, and 63% in the surgical group. Als o in the second study the 12-month results were significantly better i n the IAT group (event-free survival 75%) than in the surgical group ( event free survival 52%). The high-dose urokinase regimen recommended by some authors in IAT is associated with an unacceptable cerebral ble eding rate of up to 2%. Low-dose recombinant tissue-type plasminogen a ctivator (rt-PA) (0.02 to 0.05 mg/h) is the most suitable agent in IAT because of rapid lysis and low bleeding complications. Patients with ALLI, classified as viable or threatened without neurologic deficit, b enefit most from the IAT as the initial therapy in ALLI. When IAT is p erformed as the initial therapy in ALLI, surgical intervention becomes unnecessary in approximately one-third of the patients. In another th ird the subsequent correction of the cause of the ALLI can be performe d electively, which reduces mortality and morbidity rates.