Failure of thrombolytic therapy to improve long-term vascular patency

Abstract

Few data are available on long-term follow-up of arterial segments subjected to thrombolysis. We reviewed all cases of vascular occlusion treated with urokinase to identify early success and determine the influence of postlysis intervention and the nature of the thrombosed segment (i.e., artery vs graft) on long-term patency. Methods: Data on 134 cases (58 arteries, 76 grafts) treated with high-dose urokinase infusion in the lower limbs over a 7 -year period were analyzed. Limbs were divided into five groups on the basis of therapy after lytic infusion to determine long-term efficacy: group I, success with no additional therapy; group II, percutaneous angioplasty alone; group III, limited surgical procedure (operative angioplasty, jump graft); group IV, extensive procedure (new bypass); and group V, revascularization after lytic failure. Long-term results were assessed by life-table analysis and groups compared by log-rank test (Mantel-Haenszel). Results: Initial patency was established in 87 (64.9%) of 134 cases with 5 deaths (3.7%), 11 amputations (8.2%), and 16 complications (11.9%). Follow-up was available in 68.6% of cases for a mean of 10.9 months. No difference was seen between grafts and native arteries. Patency was analyzed at 6, 12, 18, and 24 months. The 24-month patency rate after lysis alone (group I -25.9%) was inferior (p < 0.05) to results after lysis and any subsequent intervention (groups II, III, and IV). The type of intervention did not influence subsequent patency. Twenty-four-month patency of procedures performed after failed thrombolysis (group V, 41.4%) was not different from those after successful lysis (groups I to IV). Twenty-four-month patency in groups II and III (minor interventions, 62.9%) was not significantly different from that of groups IV and V (major interventions, 53.2%) (p > 0.25). Conclusions: Operative intervention is required to produce long-term arterial patency, even after successful thrombolysis. No statistically significant benefit of thrombolysis on vascular patency was seen in our series.

Risk factors for haemorrhage during local intra-arterial thrombolysis for lower limb ischaemia

“…The most devastating haemorrhagic complication is intracranial bleeding, which has in larger studies been found in 1-2% [6,7,13] of thrombolytic procedures. Intracranial haemorrhage was reported in four (one fatal) of 246 patients in the TOPAS trial [6] and in one of 220 procedures in the present study.…”

Results of a Prospective Randomized Trial Evaluating Surgery Versus Thrombolysis for Ischemia of the Lower Extremity The STILE Trial

“…These findings differ from patients treated with systemic thrombolysis for venous thromboembolic disease. 27 The most devastating of the bleeding complications is intracranial hemorrhage. In reviewing these and other contemporary data,27 the baseline risk ofintracranial hemorrhage in this patient population appears to be 1% to 2% for either lytic agent, despite careful patient selection.…”

Thrombolysis in the peripheral vascular system

“…A significant group (up to 70 %) of patients with thrombosis of native vessels have an underlying structural cause for their thrombosis, and if this is identified and treated, then primary patency rates of approximately 80 % can be achieved (compared with 40±50 % if no underlying causative lesion is identified) [66,67,68,69]. This treatment will often be endovascular, particularly angioplasty, but surgery can follow thrombolysis with relative safety (though not vice versa).…”

“…Rethrombosis is a particular hazard in lysed bypass grafts and is often due to poor outflow. In those patients in whom lysis is initially effective, primary patency rates of approximately 80 % can be expected at 1 year and 70 % at 3 years [66,67].These figures are significantly lower if lysis alone is used without further intervention to treat an underlying lesion [68].…”