THROMBOLYTIC THERAPY FOR ARTERIAL-OCCLUSION - A MIXED BLESSING

Intra-arterial thrombolytic therapy is an important advance in the tre atment of arterial occlusive disease. Reports of results, morbidity, a nd mortality have been highly variable. This review was undertaken to assess the recent results of thrombolytic therapy with urokinase (UK) at our institution. From 1988-1992, 42 lower extremities in 41 patient s with severe peripheral vascular disease underwent intra-arterial thr ombolytic therapy. Sites of occlusion consisted of 6 iliac, 21 superfi cial femoral, 11 popliteal, and 20 infra-popliteal segments. Lytic the rapy consisted of a regional infusion of UK with concomitant heparin a nticoagulation. The most common UK loading dose was 250,000 units (60, 000-750,000) followed by a continuous infusion of approximately 100,00 0 units/hour (60,000-240,000) for up to 72 hours. Technical success, d efined as partial or total resolution of the arterial occlusions, occu rred in 26 (62%) limbs. A concomitant endovascular procedure was requi red in 19 extremities following successful lysis. Immediate clinical s uccess, defined as restitution of a distal pulse or increase in ABI >0 .10, occurred in 22 of 26 technically successful procedures. The four clinical failures and all 16 technical failures required either a majo r amputation or revascularization. There were 18 major complications i n 18 patients (43%): seven thromboembolic, two arterial dissections, n ine hemorrhagic. Seven hemorrhagic complications required transfusion of 1-6 units of blood, and two deaths occurred due to postprocedural h emorrhage, shock, and myocardial infarction. Hemorrhage was not relate d either to the dose of UK or the duration of UK infusion. A combinati on of thrombolysis and endovascular intervention can be of significant benefit in selected patients with extremity ischemia. However, compli cations are frequent and may be lethal. Further prospective studies wi ll be required to define the population of patients best treated by th rombolytic therapy or primary surgical therapy.