Tertiary Center Experience of Catheter-Directed Thrombolysis for Immediately Threatened Acute Lower Limb Ischemia of Native Vessels and Bypass Graft Thrombosis

摘要

Background: Catheter-directed thrombolysis (CDT) is an effective therapy and a class I indication for patients with acute limb ischemia (ALI, Rutherford categories I and IIa) of less than 14 days duration, and class IIb indication for ALI (Rutherford category IIb) with symptoms more than 14 days duration. However, there is no consensus on the initial management option for ALI (Rutherford category IIb) with symptoms less than 14 days duration. Purpose: To evaluate the safety, efficacy and outcome of CDT, with or without bailout Angiojet mechanical thrombectomy, in patients with immediately threatened acute lower extremity ischemia (Rutherford category IIb) as a minimally invasive alternative to emergent surgical revascularization. Methods: We retrospectively reviewed data on 69 consecutive patients (mean age 67 ± 14.15 years, 50.72% women) with ALI (Rutherford category IIb) who underwent CDT only (57.9%) or CDT plus bailout Angiojet mechanical thrombectomy (36.78%) at Aurora St. Luke’s Medical Center from January 2004 to October 2014. Data were collected from electronic medical records, procedures reports, laboratory data and billing codes. Continuous variables were expressed as means ± standard deviation and range; categorical variables were expressed as frequency count and percentage. Results: Sites of target vessel for CDT were native vessel arterial thrombosis (68.11%) and vascular bypass graft thrombosis (27.5%). Reestablishment of blood flow and clinical success was achieved in 75.4% of patients, while limb salvage at 30 days was achieved in 87.1%. Amputation at 30 days occurred in 12.9%. Surgical embolectomy was required in 15.9%, and lower extremity bypass surgery was required in 8.7%. Time to lysis was 26.12 ± 18.6 hours. Bleeding complications that required blood transfusion occurred in 21% and hemorrhagic stroke in 1.44%. Conclusion: Catheter-directed thrombolysis for acute limb ischemia with symptoms less than 14 days (Rutherford category IIb) in native artery or bypass graft thrombosis has high immediate clinical success rate and very high limb salvage rate at 30 days. CDT is a reasonable minimally invasive alternative option to emergent surgical revascularization.