Thrombolytic Salvage of the Frostbitten Upper Extremity: A Systematic Review

Abstract

Background Vascular thrombosis secondary to frostbite can lead to ischemic tissue damage in severe cases. Threatened extremities may be salvaged with thrombolytics to restore perfusion; however, current data are limited to single institution case series. The authors performed a systematic review to determine the efficacy of thrombolytic therapy in treating upper extremity frostbite. Methods PubMed, EBSCO, and Google Scholar were queried using the keywords “thrombolytics,” “frostbite,” “fibrinolytics,” and “tPA.” Exclusion criteria were failure to delineate anatomic parts injured, failure to report number of limbs salvaged, animal studies, and non-English language publications. Thrombolytic therapy was defined as intraarterial (IA) or intravenous (IV) administration of tissue plasminogen activator (tPA), alteplase, urokinase, streptokinase, or any tPA derivative. Results A total of 42 studies were identified, with 13 satisfying inclusion criteria. Eight studies reported catheter-directed IA thrombolysis, four reported systemic IV administration, and 1 reported both methods. A total of 157 patients received thrombolytics. In all, 73 upper extremity digits were treated by IA route and 136 digits were treated by IV route. Overall upper extremity digit salvage rate was 59%. There was a significantly higher salvage rate in digits treated by the IA route compared to the IV route. Conclusions Thrombolytics, particularly when administered by the intra-arterial route, are emerging as a promising treatment of severe frostbite of the upper extremity, increasing digit salvage rates.

Iloprost for the treatment of frostbite: a scoping review

“…The distribution of affected digits, whether upper of lower extremities, was not consistently described. Some authors suggest that the long-term outcome may be affected by the location of the lesions [ 5 ]. No studies included other areas that can be affected by frostbite, such as the torso, face, ears or nose.…”

“…The risk of amputation rises quickly as the grade increases from a rate of 30% proximal to the distal phalanx to 100% proximal to the metacarpals/tarsals [ 3 ]. Other factors also affect outcomes: delayed presentation to healthcare facility, multiple freeze-thaw cycles and delay in pharmacologic treatment initiation [ 4 , 5 ].…”

Bedside Fluorescence Microangiography for Frostbite Diagnosis in the Emergency Department

“…25 Recent studies on IV and intra-arterial tPA in frostbite have shown complication (rates between 2.3-10 % (compartment syndrome, bleeding requiring transfusion, and hematoma). 26,27 Thus, judicious administration of thrombolytics is an important decision that should be made with appropriate clinical information.…”

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2024 Update

“…46 Intra-arterial angiography or IV pyrophosphate scanning should be considered to evaluate the initial injury and monitor progress after tPA administration as directed by local protocol and resources. The various reports on the use of thrombolytics in frostbite through 2022 55 include the following: 1 randomized controlled prospective trial in which tPA was combined with iloprost, 16 patients), 56 1 retrospective observational study (125 patients), 57 3 retrospective cohort studies (59 patients), 47,52,58 11 retrospective case series (∼200 patients), 48,50,[59][60][61][62][63][64][65][66][67] and 3 case reports. 49,68,69 Further work is needed to determine the absolute efficacy of tPA for frostbite injury and to compare intra-arterial and IV tPA to IV prostacyclin.…”