Clinical profile of saruplase: mortality and safety

The data from 6775 patients treated with saruplase were analysed to provide an overview of the clinical profile of this thrombolytic agent. Death and reinfarction rates were calculated to assess efficacy. Thirty-day mortality was 5.7% and the reinfarction rate was 5.3%. Total stroke rate was 1.3% (cerebral haemorrhage 0.6%), whereas severe bleeding was seen in 2.5% of patients. Finally, there was no conclusive evidence of allergic reactions following drug administration. As compared with other currently available thrombolytic agents, saruplase appears to be safe and effective.

Local intra-arterial thrombolysis in acute ischemic stroke

BACKGROUND AND PURPOSE

We performed a retrospective analysis of the prognostic factors in patients treated with local intra-arterial thrombolysis (LIT). The purpose of this study was to evaluate the safety and efficacy of LIT using urokinase in patients with acute ischemic stroke of the anterior or posterior circulation and to determine the influence of clinical and radiological parameters on outcome.

METHODS

Forty-three patients were treated with LIT using urokinase (median dose, 0.75x10(6) IU). The median National Institutes of Health Stroke Scale (NIHSS) score at hospital admission was 18 (range, 9 to 36). Nine patients had occlusions of the internal carotid artery (ICA), 23 of the middle cerebral artery (MCA), 1 of the anterior cerebral artery, and 10 of the basilar artery (BA). Outcome was assessed after 3 months and classified as good for Rankin Scale (RS) scores of 0 to 3 and poor for RS scores of 4 or 5 and death.

RESULTS

Nine patients (21%) recovered to RS scores 0 or 1, 17 (40%) to scores of 2 or 3, and 7 (16%) to scores of 4 or 5. Ten patients (23%) died. Outcome was good in 17 patients (80%) with MCA occlusions, in 3 patients (33%) with ICA, and in 5 patients (50%) with BA occlusions. Good outcome was associated with an initial NIHSS score of <20 (P<0.001), improvement by 4 or more points on NIHSS score within 24 hours (P=0.001), and vessel recanalization (P=0.02). Recanalization was more likely if LIT was started within 4 hours (P=0.01). Symptomatic cerebral hemorrhage occurred in 2 patients (4.7%).

CONCLUSIONS

LIT was most efficacious in patients with MCA and BA occlusions when the initial NIHSS score was less than 20 and when treated within 4 hours. It is of limited value in patients with distal ICA occlusions.

Complications associated with combined use of abciximab and an intracoronary thrombolytic agent (urokinase or tissue-type plasminogen activator)

A potent platelet inhibitor combined with an intracoronary thrombolytic agent is aggressive therapy that may be used for high-risk, complex, refractory thrombotic coronary lesions. A retrospective review of the records of 56 patients who received abciximab plus an intracoronary thrombolytic agent during a coronary interventional procedure did not reveal a prohibitive incidence of major bleeding with this combination therapy.

Comparative results of thrombolysis treatment with rt-PA and urokinase: a pilot study

BACKGROUND

The aim of the following prospective study was to investigate whether patients benefited from locoregional lysis treatment of recent deep leg vein thrombosis after 1 year.

PATIENTS AND METHODS

The prospective study included 69 patients aged between 22 and 58 years, in whom recent lower leg vein and popliteal vein thromboses were diagnosed by phlebography. Patients were randomized to one of three treatment groups: one group was treated for a maximum of 7 days with full heparinization and daily dose of 20 mg rt-PA administered locoregionally over a period of 4 hours; a second group received 100,000 IU/h urokinase locoregionally for a maximum of 7 days, in addition to full heparinization; and in the third group (control group), intravenous heparin infusions after PTT constituted the only form of treatment. All patients were given phenprocoumon from day 7 and received compression treatment. Before treatment began and before the course of phenprocoumon started, phlebography and colour duplex sonography examinations were carried out. After 12 months, follow-up duplex sonography was conducted to evaluate the reflux times over the popliteal vein and the degree of patency of the deep leg veins.

RESULTS

Complete lysis was achieved in 6 of 22 patients in the recombinant tissue plasminogen activator (rt-PA) group and in 11 of 22 patients in the urokinase group. At follow-up examination after 12 months, there were serious post-thrombotic changes in 14 of 22 patients in the rt-PA group, in 9 of 22 patients in the urokinase group and in 15 of 22 patients in the group of patients who received no lysis treatment.

CONCLUSION

Patients with recently formed thromboses in the lower leg and popliteal veins who underwent 7 days of locoregional lysis treatment with urokinase demonstrated significantly fewer clinical symptoms of post-thrombotic syndrome after 1 year than those who received locoregional treatment with rt-PA over a similar period or a control group treated with anticoagulants only.

A cohort study of the safety and feasibility of intraventricular urokinase for nonaneurysmal spontaneous intraventricular hemorrhage

BACKGROUND AND PURPOSE

Small case series have reported potential benefit from thrombolysis after spontaneous intraventricular hemorrhage (IVH). Our objective was to review our experience using intraventricular urokinase (UK) in treating selected patients with IVH.

METHODS

Using medical records, we identified all patients who received ventriculostomies for CT-confirmed nonaneurysmal nontraumatic spontaneous IVH from December 1992 through November 1996. We reviewed charts and CT images and examined the data for associations with specific outcomes.

RESULTS

We identified 40 patients, 18 treated with ventriculostomy alone and 22 receiving adjunctive intraventricular UK. The initial Glasgow Coma Scale (GCS) scores of the two groups were similar (P = 0.5). While there was a trend for patients with any intraparenchymal hemorrhage (IPH) to receive UK (P = 0.07), the mean size of IPH in those who received ventriculostomy alone was larger than in those who received adjunctive UK (P = 0.002). There was lower mortality in the group treated with UK (31.8 versus 66.7%; P = 0.03), but there was only a trend toward an increase in favorable outcome (22.2% versus 36.4%; P = 0.3). Overall, the most significant association with outcome was neurological condition at presentation (GCS >5 versus < or = 5; P = 0.003). Receiving UK did not increase the occurrence of complications or hospital length of stay for survivors (P = 0.5).

CONCLUSIONS

Intraventricular UK remains a safe and potentially beneficial intervention. While it appeared to lower mortality, a randomized, placebo-controlled trial is needed to explore whether the therapy can increase the incidence of favorable outcomes.

A study on the efficacy of intraventricular urokinase in the treatment of intraventricular haemorrhage

Twenty-one patients with intraventricular haemorrhage were randomized to two treatment groups. Both groups had bilateral external ventricular drains inserted, but only the treatment group received 50,000 IU urokinase instilled into the ventricles. The clinical and radiological progress, and 1- and 6-month outcomes were compared. The group that received urokinase treatment was shown to have an improved outcome, with a lower mortality and a lower incidence of hydrocephalus requiring shunt insertion. No haemorrhagic complications were seen in either group, although the treatment group had a slightly increased rate of drain-related ventriculitis.

[Extravasation of contrast medium in local intra-arterial fibrinolysis of the carotid territory]

The safety of fibrinolytic therapy is determined with the incidence of intraparenchymatous hemorrhage. When interpreting CT studies after local intra-arterial fibrinolysis (LIF) in the carotid territory, one must consider that a hyperdense lesion may also be caused by extravasation of contrast material during angiography. In this study we retrospectively analyzed CT scans of 24 patients performed within 24 h after LIF and correlated the results with clinical and angiographic findings before and after therapy. Three of 24 patients (12.5%) showed striatocapsular parenchymal hematomas, 2 patients died and 1 showed marked clinical deterioration. Fifteen of 24 patients (62.5%) showed hyperdense lesions without space-occupying effect within striatocapsular infarctions. In 6 of these patients (25%) these lesions were attributable to an extravasation of contrast medium during angiography. This extravasation required at least partial recanalization of the middle cerebral artery and always occurred within a striatocapsular infarction. The pathogenesis of extravasation of contrast medium during local intra-arterial fibrinolysis is unknown. The identification of these lesions, however, is essential for the assessment of safety of local intra-arterial fibrinolysis.

A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. Thrombolysis or Peripheral Arterial Surgery (TOPAS) Investigators

BACKGROUND

Recent controlled trials suggest that thrombolytic therapy may be an effective initial treatment for acute arterial occlusion of the legs. A major potential benefit of initial thrombolytic therapy is that limb ischemia can be managed with less invasive interventions.

METHODS

In this randomized, multicenter trial conducted at 113 North American and European sites, we compared vascular surgery (e.g., thrombectomy or bypass surgery) with thrombolysis by catheter-directed intraarterial recombinant urokinase; all patients (272 per group) had had acute arterial obstruction of the legs for 14 days or less. Infusions were limited to a period of 48 hours (mean [+/-SE], 24.4+/-0.86), after which lesions were corrected by surgery or angioplasty if needed. The primary end point was the amputation-free survival rate at six months.

RESULTS

Final angiograms, which were available for 246 patients treated with urokinase, revealed recanalization in 196 (79.7 percent) and complete dissolution of thrombus in 167 (67.9 percent). Both treatment groups had similar significant improvements in mean ankle-brachial blood-pressure index. Amputation-free survival rates in the urokinase group were 71.8 percent at six months and 65.0 percent at one year, as compared with respective rates of 74.8 percent and 69.9 percent in the surgery group; the 95 percent confidence intervals for the differences were -10.5 to 4.5 percentage points at six months (P=0.43) and -12.9 to 3.1 percentage points at one year (P=0.23). At six months the surgery group had undergone 551 open operative procedures (excluding amputations), as compared with 315 in the thrombolysis group. Major hemorrhage occurred in 32 patients in the urokinase group (12.5 percent) as compared with 14 patients in the surgery group (5.5 percent) (P= 0.005). There were four episodes of intracranial hemorrhage in the urokinase group (1.6 percent), one of which was fatal. By contrast, there were no episodes of intracranial hemorrhage in the surgery group.

CONCLUSIONS

Despite its association with a higher frequency of hemorrhagic complications, intraarterial infusion of urokinase reduced the need for open surgical procedures, with no significantly increased risk of amputation or death.

Treatment of thrombosed hemodialysis access grafts: Arrow-Trerotola percutaneous thrombolytic device versus pulse-spray thrombolysis. Arrow-Trerotola Percutaneous Thrombolytic Device Clinical Trial

PURPOSE

To evaluate a percutaneous thrombolytic device (PTD) designed for treating thrombosed hemodialysis access grafts.

MATERIALS AND METHODS

To compare the PTD with pulse-spray pharmacomechanical thrombolysis (PSPMT) by using urokinase, 122 randomly chosen patients with synthetic, thrombosed hemodialysis access grafts from multiple centers prospectively underwent thrombolysis with the PTD (5-F, low-speed rotational mechanical device) or PSPMT. Major outcome variables included the procedure time, the immediate technical patency rate, the complication rate, and the 3-month patency rate.

RESULTS

Sixty-four PTD and 58 PSPMT procedures were performed with intent to treat. The immediate technical patency rate was 95% (61 of 64 [PTD] and 55 of 58 [PSPMT]) in both procedures. Median procedure times were 75 minutes in the PTD group (range, 25-209 minutes) and 85 minutes in the PSPMT group (range, 50-273 minutes; P < .04). Major complications occurred in 8% (five of 64) of PTD procedures (none related to the PTD) and 9% (five of 58) PSPMT procedures (not significant). Two devices broke (one during training) with no clinical sequela. The 3-month primary patency rate was 39% (25 of 64) in the PTD group and 40% (23 of 58) in the PSPMT group (not significant).

CONCLUSION

The PTD is safe and effective for treating thrombosed hemodialysis access grafts. The technical and long-term success rates are similar to those of PSPMT; procedure times are shorter.

PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. PROACT Investigators. Prolyse in Acute Cerebral Thromboembolism

BACKGROUND AND PURPOSE

To test the safety and recanalization efficacy of intra-arterial local delivery of plasminogen activators in acute ischemic stroke, a randomized trial of recombinant pro-urokinase (rpro-UK) versus placebo was undertaken in patients with angiographically documented proximal middle cerebral artery occlusion.

METHODS

After exclusion of intracranial hemorrhage by CT scan, patients with abrupt onset of symptoms of focal ischemia likely to receive treatment within 6 hours who satisfied all clinical eligibility criteria underwent carotid angiography. Patients displaying Thrombolysis in Acute Myocardial Infarction grade 0 or 1 occlusion of the M1 or M2 middle cerebral artery were randomized 2:1 to receive rpro-UK (6 mg) or placebo over 120 minutes into the proximal thrombus face. All patients received intravenous heparin. Recanalization efficacy was assessed at the end of the 2-hour infusion, and intracerebral hemorrhage causing neurological deterioration was assessed at 24 hours.

RESULTS

Of 105 patients who underwent angiography, 59 were excluded from randomization. Among the 46 patients randomized, 40 were treated with rpro-UK (n=26) or placebo (n=14) a median of 5.5 hours from symptom onset. Recanalization was significantly associated with rpro-UK (2P=.017). Hemorrhagic transformation causing neurological deterioration within 24 hours of treatment occurred in 15.4% of the rpro-UK-treated patients and 7.1% of the placebo-treated patients (2P=.64). Both recanalization and hemorrhage frequencies were influenced by heparin dose.

CONCLUSIONS

Intra-arterial local rpro-UK infusion was associated with superior recanalization in acute thrombotic/ thromboembolic stroke compared with placebo. In this regimen, heparin dose influenced hemorrhage frequency and recanalization. Although symptomatic hemorrhage remains a concern, this study suggests that recanalization is enhanced with rpro-UK and heparin.

Multicenter clinical trial of thrombolytic therapy in 1,406 patients with acute myocardial infarction. Collaborative Group of Clinical Trial for Urokinase Therapy

OBJECTIVE

To investigate the clinical efficacy and safety of intravenous thrombolytic therapy of Urokinase Tech-Pool (UKTP) in acute myocardial infarction (AMI).

METHODS

The data were collected from the 148 participating hospitals from November, 1994 to April, 1996. A total of 1,406 patients with AMI were analyzed to evaluate the clinical efficacy, side effects and mortality of UKTP. The patency of the infarct-related artery (IRA) was evaluated in 124 patients by coronary artery angiography (CAG) 90 minutes after the onset of UKTP infusion.

RESULTS

The reperfusion rate in IRA was 73.5% by clinical standards. The patency rate was 72.6% by CAG. The total mortality during the first 5 weeks was 7.8% (109/1,406). The rate of minor bleeding was 10.2% (143/1,406), of major bleeding 0.43% (6/1,406) and of intracranial hemorrhage 0.50% (7/1,406). In elderly patients (> 75 years old), UKTP was as effective and safe as in younger patients (< 65 years old). Late thrombolytic therapy with UKTP (> 6 hours after the onset of symptom) was still effective. The appropriate dosage of UKTP might be 150 million units of infusion within 30 minutes.

CONCLUSION

UKTP is an effective, reliable and safe agent in the thrombolytic therapy of AMI.

[Thrombolytic therapy in ischemic infarct]

Thrombolytic therapy in acute ischemic stroke is safe and effective in a defined subgroup of stroke patients. Until now, different fibrinolytic substances including urokinase, streptokinase and recombinant tissue plasminogen activator (rt-PA) have been tested regarding safety, efficacy, dosage and economic parameters in patients suffering from both carotid and basilar artery territory strokes. Recently, two large multicenter placebo-controlled intravenous rt-PA studies were published. The results show that thrombolysis of acute carotid territory strokes (European Cooperative Acute Stroke Study) and of strokes with a deficit measurable on the NIH Stroke Scale (National Institute of Neurological Disorders and Stroke rt-PA Stroke Study) improves clinical and economic outcome parameters in patients who were treated within 6 hours of the onset of symptoms and had that no signs of extended early infarction on the initial CT-scan. The occurrence of intracranial hemorrhages is more frequent after thombolytic therapy, but the majority of bleeding complications referred to petechial or more confluent hemorrhage limited to the infarcted tissue, without clinical deterioration. However, the identification of the appropriate patients is difficult and depends on the level of clinical and diagnostic experience. In vertebrobasilar artery territory stroke, local intraarterial thrombolysis with urokinase or streptokinase is performed in most cases. Thrombolytic treatment within twelve hours of the onset of symptoms was associated with significantly better results concerning both survival and neurological recovery.

Relationship between clot location and outcome after basilar artery thrombolysis

PURPOSE

To identify factors that predict survival and good neurologic outcome in patients undergoing basilar artery thrombolysis.

METHODS

Over a 42-month period, 20 of 22 consecutive patients with angiographic proof of basilar artery thrombosis were treated with local intraarterial urokinase. Brain CT scans, neurologic examinations, symptom duration, clot location, and degree of recanalization were analyzed retrospectively.

RESULTS

Overall survival was 35% at 3 months. Survival in patients with only distal basilar clot was 71%, while survival in patients with proximal or midbasilar clot was only 15%. At 3 months, 29% of patients with distal basilar clot and 15% of patients with proximal or midbasilar clot had good neurologic outcomes (modified Rankin score of 0 to 2 and Barthel index of 95 to 100). Complete recanalization was achieved in 50% of patients; 60% of those survived and 30% had good neurologic outcomes. Of patients with less than complete recanalization, only 10% survived. Neither duration of symptoms before treatment (range, 1 to 79 hours), age (range, 12 to 83 years), nor neurologic status at the initiation of treatment (Glasgow Coma Scale score range, 3 to 15) predicted outcome. Pretreatment CT findings (positive or negative for related ischemic changes) did not predict outcome or hemorrhagic transformation.

CONCLUSION

The single best predictor of survival after basilar thrombosis and intraarterial thrombolysis was distal clot location. Complete recanalization favored survival. Radiologically evident related infarctions, advanced age, delayed diagnosis, and poor pretreatment neurologic status did not predict poor outcome and therefore should not be considered absolute contraindications for intraarterial thrombolysis in patients with basilar artery thrombosis.

Basilar artery rethrombosis: successful treatment with platelet glycoprotein IIB/IIIA receptor inhibitor

We describe the use of abciximab to prevent rethrombosis of the basilar artery after transluminal angioplasty. A 60-year-old patient with vertebral basilar insufficiency and acute occlusion of the basilar artery underwent revascularization with urokinase and angioplasty. Despite the repeated use of urokinase and angioplasty under anticoagulation with heparin, the basilar artery immediately rethrombosed. In a final attempt to prevent rethrombosis, abciximab was administered before the final angioplasty, resulting in a widely patent basilar artery and no rethrombosis.

Direct thrombolysis of superior sagittal sinus thrombosis with coexisting intracranial hemorrhage

We present a case of dural cerebral venous thrombosis with coexisting left frontal hemorrhage that was successfully treated with 13.79 million units of urokinase over a period of 165 hours.

Increasing age is a major risk factor for hemorrhagic complications after pulmonary embolism thrombolysis

We reviewed our database of 312 patients with pulmonary embolism who received thrombolysis in five clinical trials. At baseline, none had a history of stroke, internal bleeding within 6 months, surgery within 10 days, or occult blood in stool. Sixty-six major bleeding episodes occurred within 72 hours of administering thrombolysis in 61 (20%) patients: bleeding at the catheterization site (34 cases), gross hematuria (9), intracranial hemorrhage (5), and 18 other bleeding episodes that led to at least a 10% hematocrit decrease. Patients with a major bleeding complication were on average older than patients with no hemorrhagic complication (mean age 62.9 +/- 1.9 years vs 56.2 +/- 1.1 years; p = 0.005). In an adjusted analysis, there was a fourfold increased risk of bleeding among patients older than 70 years compared with patients younger than 50 years (relative risk [RR] 3.9; 95% confidence interval [CI] 1.7 to 8.9). By using age as a continuous variable, we found a 4% (RR 1.04; 95% CI 1.02 to 1.06) increase in risk of bleeding for each incremental year of age. In addition, patients with higher body mass index had an increased risk of bleeding. Patients who had undergone catheterization had a five times greater risk of bleeding (RR 5.2; 95% CI 1.5 to 17.8). In summary, increasing age, larger body mass index, and catheterization predisposed to bleeding complications after pulmonary embolism thrombolysis.

Arterial changes after thrombolysis and percutaneous transluminal angioplasty in vertebrobasilar thrombosis

We present clinicopathologic findings in a patient treated with intraarterial thrombolysis and angioplasty for vertebrobasilar thrombosis. Autopsy revealed a marked inflammatory infiltrate within the vertebral artery at the site of catheter manipulation. This finding may have important implications for the use of interventional angiography in cerebrovascular disease.

Endovascular treatment for acute thrombotic occlusion of the middle cerebral artery: local intra-arterial thrombolysis combined with percutaneous transluminal angioplasty

We report our experience in treating 15 patients with acute thrombotic occlusion of the M1 or M2 segment of the middle cerebral artery who underwent intra-arterial thrombolytic therapy alone or in combination with percutaneous transluminal angioplasty (PTA). The results were compared with those of 30 patients with acute embolic occlusion of the same artery. Intra-arterial thrombolysis was performed in 10 patients and thrombolysis combined with PTA in 5 in whom symptoms reappeared due to restenosis or reocclusion, or in whom recanalisation was not successfully accomplished by thrombolysis alone. In the patients with embolism recanalisation was observed in 28 (93 %) and there was no patient with reocclusion. In the patients with thrombosis recanalisation immediately after thrombolysis alone was observed in 9 of 15 (60%). Restenosis, with reappearance of symptoms, occurred in 2 of these (22 %). In the patients who also underwent PTA, angiography after 1 month did not demonstrate any restenosis or reocclusion. Thrombolysis combined with PTA for acute thrombotic stroke may provide an effective procedure for restoring patency and preventing reocclusion of the occluded artery.

Cardiac rupture complicating cerebral intraarterial thrombolytic therapy

We report a case of fatal cardiac rupture occurring during intraarterial thrombolytic therapy for acute embolic stroke in a patient with recent myocardial infarction.

[Chronic intermittent urokinase therapy: anti-ischemic and hemodynamic effects]

Long-term intermittent urokinase therapy has been developed for patients with severe coronary artery disease and refractory angina pectoris. This therapeutic approach is predominantly effective at the microcirculatory level based on a combination of rheologic and fibrinolytic effects; furthermore, plaque regression seems to be a possible mechanism. Patients with refractory angina pectoris are characterized by severe coronary artery disease without a therapeutic option for conventional revascularization procedures, only slight impairment of left ventricular systolic function and hyperfibrinogenemia, which results in further enhancement of myocardial ischemia due to microcirculatory impairment of blood flow. In this article data on the anti-ischemic effectiveness as well as first results on the impact of this therapeutic approach on hemodynamics are described. A dose-response study, which compared 3 x 50,000 IU with 3 x 500,000 IU urokinase three times a week over a treatment period of 12 weeks demonstrated subjective as well as objective antiischemic effectiveness. Only patients who were treated with 500,000 IU per injection achieved marked increases in exercise capacity, while some patients in the low-dose group presented even with a deterioration of exercise performance. First hemodynamic studies could not show marked changes of systolic parameters, either at rest or during exercise. But a decrease of pulmonary capillary wedge pressure at rest after treatment with 500,000 IU per injection indicates an improvement of diastolic function as a result of enhanced myocardial perfusion. Echocardiographic measurements of transmitral Doppler flow in 21 patients with end-stage coronary artery disease demonstrated normalization of early and late diastolic filling rates in most cases. These changes were accompanied by a reduction of clinical signs of heart failure. Long-term intermittent urokinase therapy is a valuable approach as it not only improves quality of life during the actual treatment period but by the persistence of therapeutic effects following the cessation of therapy.

Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: a prospective, double-blind study

Intrapleural administration of fibrinolytics has been shown in small numbers of patients with complicated parapneumonic effusions (CPE) and pleural empyema to be effective and relatively safe. Although streptokinase (SK) is recommended as the fibrinolytic of choice, there are no comparative studies among fibrinolytics. We therefore compared the efficacy, safety, and the cost of treatment two of the most used thrombolytics, SK and urokinase (UK). Fifty consecutive patients with CPE or empyema were randomly allocated to receive either SK (25 patients) or UK, in a double-blind fashion. All patients had inadequate drainage through chest tube (< 70 ml/24 h). Both drugs were diluted in 100 ml normal saline and were infused intrapleurally through the chest tube in a daily dose of 250,000 IU of SK or 100,000 IU of UK. The chest tube was clamped for 3 h after instillation. Response was assessed by clinical outcome, fluid drainage, chest radiography, pleural ultrasound, and/or computed tomography. Clinical and radiologic improvement was noted in all but two patients in each group, who required surgical intervention. The mean volume drained during the first 24 h after instillation was significantly increased; 380 +/- 99 ml for the SK group (p < 0.001) and 420.8 +/- 110 ml for the UK group (p < 0.001). The total volume (mean +/- SD) of fluid drained after treatment was 1,596 +/- 68 ml for the SK group, and 1,510 +/- 55 ml for the UK group (p > 0.05). The SK instillations (mean +/- SD) were 6 +/- 2.16 (range, 3 to 10) and those of UK 5.92 +/- 2.05 (range, 3 to 8). High fever as adverse reaction to SK was observed in two patients. The total cost of the drug in the UK group was two times higher than that of SK ($180 +/- 47 for SK and $320 +/- 123 for UK). The mean total hospital stay after beginning fibrinolytic therapy was 11.28 +/- 2.44 d (range, 7 to 15) for the SK group and 10.48 +/- 2.53 d (range, 6 to 18) for the UK group (p = 0.32). We conclude that intrapleural SK or UK is an effective adjunct in the management of parapneumonic effusions and may reduce the need for surgery. UK could be the thrombolytic of choice given the potentially dangerous allergic reactions to SK and relatively little higher cost of UK.

Comparison of streptokinase and urokinase in local thrombolysis of peripheral arterial occlusions for lower limb salvage

PURPOSE

To compare the efficacy and safety of streptokinase (SK) and urokinase (UK) in the treatment of local thrombolysis.

PATIENTS AND METHODS

Over a 24-month period, 40 patients with 45 lower limb arterial occlusions of less than 45 days duration underwent intraarterial fibrinolysis. Twenty occlusions were treated with recombinant UK and tissue culture-derived UK, and 25 occlusions were treated with SK. The study was retrospective, but the two groups were very homogeneous in terms of vascular surgical history, medical risk factors, and occlusion characteristics.

RESULTS

Complete lysis (95% or more) was achieved in 84% of SK infusions and 89% of UK infusions. Endoluminal and surgical interventions as well as clinical outcomes of SK and UK treatment were comparable. However, infusion time was significantly longer for SK treatment: 28.5 hours versus 19.1 hours for UK treatment (P = .035). Complication rates were not statistically significantly different. Average length of stay in the intensive care unit was identical (2.2 days) for both groups, and the difference in hospital stay was not statistically significant (7.7 days for SK vs 8.7 days for UK).

CONCLUSION

At the concentrations and doses used, the efficacy and safety of SK and UK were comparable, despite longer SK infusion time.

Pulmonary emboli from pulse-spray and mechanical thrombolysis: evaluation with an animal dialysis-graft model

PURPOSE

To compare pulmonary emboli resulting from pulse-spray pharmacomechanical thrombolysis (PSPMT) and mechanical thrombolysis performed to declot dialysis-access grafts.

MATERIALS AND METHODS

Polytetrafluoroethylene arteriovenous shunts were created in eight dogs and were deliberately clotted at monthly intervals. Animals were randomly assigned to treatment with pulse-spray urokinase thrombolysis or a low-speed rotational percutaneous thrombolytic device. Perfusion imaging, pulmonary-artery pressure measurements, and pulmonary arteriography were performed before and after each procedure.

RESULTS

A total of 22 procedures were performed (11 PSPMT and 11 mechanical thrombolysis). Declotting was successful in all procedures, with 100% 30-day patency. Segmental defects were seen on perfusion images after 10 (91%) of 11 PSPMT procedures and two (18%) of 11 mechanical thrombolysis procedures (P < .002). Transient increases in pulmonary-artery pressure occurred in the PSPMT group. Complete resolution of emboli and return to baseline pressures were seen in all cases, even after multiple (up to four) procedures in the same animal. There was no histologic evidence of pulmonary infarction in either group.

CONCLUSION

The percutaneous thrombolytic device is effective for declotting dialysis grafts in dogs and results in statistically significantly fewer pulmonary emboli compared with PSPMT.

Prospective, randomized trial of prolonged intracoronary urokinase infusion for chronic total occlusions in native coronary arteries

OBJECTIVES

The purpose of this study was to determine the safety and efficacy of three dosing regimens of intracoronary urokinase for facilitated angioplasty of chronic total native coronary artery occlusions.

BACKGROUND

Percutaneous transluminal coronary angioplasty of chronically occluded (>3 months) native coronary arteries is associated with low initial success secondary to an inability to pass the guide wire beyond the occlusion.

METHODS

Patients were enrolled if a chronic total occlusion >3 months old could not be crossed with standard angioplasty equipment. Of the 101 patients enrolled, 41 had successful guide wire passage and were excluded from urokinase treatment. The remaining 60 patients were randomized to receive one of three intracoronary dosing regimens of urokinase over 8 h (group A = 0.8 million U; group B = 1.6 million U; group C = 3.2 million U), and angioplasty was again attempted after completion of the urokinase infusion in 58 patients.

RESULTS

Coronary angioplasty was successful in 32 patients (53%) (group A 52%, group B 50%, group C 59%, p = 0.86). This study had a 90% power to detect at least a 50% difference between dosing groups at alpha 0.05. Bleeding complications requiring blood transfusion did not differ significantly among the dosing groups (A 0%, B 15%, C 6%, p = 0.14), although major bleeding episodes were less common in group A (p < 0.05). There were no major procedural or in-hospital complications. Angiographic follow-up in 69% of the patients with successful angioplasty revealed target vessel patency in 91% but an angiographic restenosis rate of 59%.

CONCLUSIONS

A prolonged supraselective intracoronary infusion of urokinase can be safely administered and may facilitate angioplasty of chronic total occlusions. Lower doses of urokinase are equally effective and result in fewer bleeding complications than do higher dosage regimens. Vessel patency is frequently maintained, but restenosis remains a problem.

Thrombolytic therapy for acute deep venous thrombosis: how much is enough?

Twenty-eight patients treated with thrombolytic therapy for acute deep venous thrombosis were monitored prospectively with non-invasive testing every 12-24h during treatment to evaluate thrombus response and whether duration of therapy was appropriate. Some 75% (21 of 28) of patients demonstrated improvement with lytic therapy with 36% (10 of 28) demonstrating complete lysis; 95% of responders (20 of 21) initiated lysis within 24h. Some 33% (7 of 21) of all responders and 64% (7 of 11) of those having partial lysis had treatment terminated during thrombus resolution but before maximal lysis. Non-invasive testing indicated that thrombolytic therapy for acute deep venous thrombosis is frequently terminated before maximal lysis of the thrombus. Monitoring thrombus response with venous duplex imaging should be part of the treatment strategy of deep venous thrombosis if thrombolytic therapy is used. This approach should increase efficacy and potentially reduce complications of thrombolytic therapy for acute deep venous thrombosis.

Thrombolysis or peripheral arterial surgery: phase I results. TOPAS Investigators

PURPOSE

Thrombolytic therapy is widely used in the treatment of peripheral arterial occlusion, but prospective, randomized comparisons with standard therapy remain few. A multicenter trial of thrombolysis or peripheral arterial surgery (TOPAS) was organized to compare critically the use of recombinant urokinase (rUK) or surgery for the initial treatment of acute lower-extremity ischemia. Phase I of the trial was designed as a dose-ranging trial to evaluate the safety and efficacy of three doses of rUK in comparison with surgery.

METHODS

In a multicenter, prospective, double-blind comparison, 213 patients who had acute lower-extremity ischemia for 14 days or fewer were randomized to one of two groups. The first group received one of three dosages of rUK (catheter-directed at 2000, 4000, or 6000 IU/min for 4 hours, then 2000 IU/min to a maximum of 48 hours). The second group underwent surgery. Successful thrombolysis was followed by surgical or endovascular interventions when anatomic lesions responsible for the occlusion were unmasked. Patients were followed-up for 1 year; data were evaluated on an intent-to-treat basis.

RESULTS

The 4000 IU/min rUK dosage was chosen as the most appropriate thrombolytic regimen because it maximized lytic efficacy against the risk of bleeding. Complete (> 95%) lysis of thrombus was achieved in 71% of the 49 patients who were randomized to the 4000 IU/min group, with a mean infusion time of 23 hours. In contrast, complete lysis was achieved in 67% of patients who received 2000 IU/min and in 60% of patients who received 6000 IU/min. Hemorrhagic complications occurred in 2% of the 4000 IU/min group versus 13% of the 2000 IU/min group (p = 0.05) and 16% of the 6000 IU/min group (p = 0.03). In a comparison of the 4000 IU/min group with the surgical group, the 1-year mortality rate (14% vs 16%) or amputation-free survival rate (75% vs 65%) did not differ significantly. The frequency and magnitude of surgery in the patients randomized to rUK were decreased (p < 0.001).

CONCLUSION

The preliminary results suggest that an initial rUK dose of 4000 IU/min is safe and efficacious in the treatment of acute lower-extremity ischemia. rUK therapy is associated with limb salvage and patient survival rates similar to those achieved with surgery, concurrent with a reduced requirement for complex surgery after thrombolytic intervention.

Local thrombolytic therapy for cerebrovascular disease: current Oregon Health Sciences University experience (July 1991 through April 1995)

PURPOSE

This report details experience with local intraarterial or intradural sinus thrombolytic therapy for cerebrovascular thromboembolic occlusions in 40 patients.

PATIENTS AND METHODS

Between July 1991 and April 1995, intracranial local thrombolytic therapy with urokinase was used to treat 40 patients with occlusive vascular disease. Twenty-six patients had acute occlusions of the central retinal artery, middle cerebral artery, basilar artery, or combined internal carotid and middle cerebral arteries. Three patients had embolic complications related to cerebral vascular embolization procedures. Five patients were undergoing intracranial angioplasty procedures for occlusive atheromatous disease. Six patients had dural sinus thrombosis.

RESULTS

Local intraarterial thrombolytic therapy for acute thromboembolic arterial occlusions resulted in excellent restoration of perfusion in 18 patients, partial restoration of flow in four patients, and no effect in five patients. Fourteen of these patients had excellent clinical outcomes, seven made moderate improvements, and six died. In the two patients with central retinal arterial occlusions, no angiographic or clinical response to thrombolytic therapy could be ascertained. There was no angiographic improvement response from thrombolytic therapy in five patients with primary intracranial atheromatous stenosis, and one patient may have had an embolic complication related to this therapy. Three of six patients with dural sinus thrombosis had clearing of the thrombus and an excellent clinical result. The remaining three with extensive dural thrombosis did not have clearing of the thrombus; one patient became blind, and two patients died. Among the 40 patients treated, significant cerebral hemorrhage occurred after therapy in four.

CONCLUSION

Local thrombolytic therapy for thromboembolic occlusive cerebrovascular disease is useful in restoring perfusion of acutely occluded vessels. Further experience is needed to fully identify the most appropriate patients for therapy, dose of thrombolytic agent, timing and length of therapy, and risk factors for hemorrhage.

Clinical studies with the new glycosylated recombinant prourokinase

Recombinant prourokinase (r-ProUK) is a single-chain urokinase-type plasminogen activator that is produced from a mammalian cell line. It is administered as a zymogen and remains inactive until converted to the active two-chain form on the surface of a clot. The clot specificity of this agent, therefore, is conferred by the site of conversion to the active form on the surface of the clot. Two pilot studies were conducted to evaluate the safety and efficacy of r-ProUK in patients with acute myocardial infarction. In the first study, the 90-minute patency rate was 66.7% in 21 patients receiving 60 mg over 60 minutes and 72.2% in 18 patients receiving 60 mg over 90 minutes. In the second study, the 90-minute patency rates were 45.5% in the group primed with recombinant urokinase who were given 60 mg of r-ProUK infused over 60 minutes (11 patients) and 80.8% in the primed group given 60 mg infused over 90 minutes (26 patients). Only 4.6% of patients experienced severe bleeding complications, with no patient developing intracranial hemorrhage. These two studies describe the first application of r-ProUK in patients. Although two doses were selected for evaluation, the small number of patients studied did not permit the selection of one dose as superior to the other. The results, however, did indicate that r-ProUK is a very effective thrombolytic agent in achieving patency of occluded coronary arteries. It is especially effective in maintaining coronary patency, having shown only a 1.4% rate of reocclusion. Serious bleeding complications were few and no intracranial hemorrhages were noted in this group of 131 patients. Additional clinical trials will be needed to compare the efficacy of r-ProUK with that of other available thrombolytic agents.

Drug variables in thrombolytic therapy

Fibrinolytic therapy has become an accepted treatment modality for recent peripheral arterial and bypass graft occlusions and, in some cases, for chronic arterial occlusions. Streptokinase, urokinase, and tissue plasminogen activator have all been used for intraarterial infusion with varying protocols and results. This review focuses on dosing variables and clinical results for the various thrombolytic agents in peripheral arterial and bypass graft occlusions. Also discussed are new thrombolytic agents and the effects of concomitant use of other drugs as part of the treatment regimen.

Pharmacoeconomic considerations in peripheral arterial thrombolytic therapy

Intraarterial thrombolytic therapy with urokinase (UK) offers documented advantages to alternatives for treating both subacute and the initial presentation of acute peripheral arterial occlusion (PAO), including reduced morbidity and mortality. Treatment with intraarterial UK does not increase overall health care costs; hospital length of stay is either similar to that with other therapies (acute PAO) or is shortened (subacute PAO). Total hospital charges associated with use of intraarterial UK are also not significantly elevated. Thus, thrombolysis with UK offers both a clinically superior and a cost-beneficial way to treat PAO.

Safety and efficacy of extended urokinase infusion plus stent deployment for treatment of obstructed, older saphenous vein grafts

This study was designed to determine the safety and efficacy of extended, continuous infusion of urokinase plus stent deployment to treat older saphenous vein bypass grafts obstructed by both thrombus and atheromatous material. Thirty patients with angiographic evidence of thrombus and atheromatous material obstructing older vein grafts (mean age 8.3 years) underwent the combined interventions of urokinase infusion and stent deployment. The continuous infusion of urokinase was administered directly into each obstructed vein graft over a mean of 20.5 +/- 8.1 hours (median dose 2.2 +/- 0.7 million units). Stents were deployed at the sites of atheromatous obstruction either before (5 patients) or after (25 patients) infusion of urokinase. Twenty-eight of the 30 patients were successfully treated with the combined interventions (success rate 93.3%). In these 28 patients, percent diameter stenosis at the site of obstruction decreased from 86.0% to -0.2% and Thrombolysis in Myocardial Infarction trial flow increased from 1.0 to 2.5. Two patients (6.7%) developed stent thrombosis followed by myocardial infarction (1 with Q-wave infarction, 3.3%) and congestive heart failure. Minor complications included non-Q-wave myocardial infarction (5 patients, 16.7%) and access-site hemorrhage (5 patients, 16.7%). At 2-week follow-up, anginal symptoms were decreased in all 28 successfully treated patients. At 7.2 +/- 3.7-month follow-up, 5 of the 28 successfully treated patients (17.9%) had reacceleration of angina and angiographically documented restenosis at the site of stent deployment.(ABSTRACT TRUNCATED AT 250 WORDS)

Angioplasty of complex lesions in ischemic rest angina: results of the Thrombolysis and Angioplasty in Unstable Angina (TAUSA) trial

OBJECTIVES

This study sought to analyze the role of complex lesion morphology on the acute results of angioplasty.

BACKGROUND

Acute complications of angioplasty are higher in unstable than in stable angina. The unstable culprit lesion is usually complex, indicative of plaque disruption and thrombus formation. Previous nonrandomized studies have shown that the presence of intracoronary thombus increases morbidity after coronary angioplasty. The role of complex morphology in coronary angioplasty outcome was studied in a prespecified subgroup analysis of a large multicenter coronary angioplasty trial.

METHODS

The results of coronary angioplasty from the Thrombolysis and Angioplasty in Unstable Angina (TAUSA) trial were analyzed. This large trial randomized 469 patients in double-blinded manner to receive either intracoronary urokinase or placebo during coronary angioplasty of the culprit lesion in ischemic rest angina with or without recent infarction. The study presented here analyzes in detail the results of coronary angioplasty in complex versus simple lesions in the urokinase and placebo groups. Complex lesions were defined before angioplasty by a core laboratory as having one or more of the following: irregular borders, overhanging edges, ulcerations or intraluminal filling defects proximal or distal to the lesion.

RESULTS

Of the 469 patients, 458 had identifiable culprit lesions, of which 245 were complex and 213 were simple. Complex lesions were associated with a higher abrupt closure rate than simple lesions (10.6% vs. 3.3%, respectively, p < 0.003). Patients with complex lesions also had higher recurrent in-hospital angina (p < 0.02) and emergent bypass surgery (p < 0.02). Further analysis of complex lesions revealed that abrupt closure was particularly high in the urokinase group (15.0% vs 5.9% for the placebo group, p < 0.03), and most abrupt closures were thrombotic. Composite clinical end points were also significantly higher with complex lesions and urokinase. In the placebo group, complex lesions had a higher abrupt closure rate as well as postcoronary angioplasty filling defects, but clinical end points were not significantly different.

CONCLUSIONS

Complex lesions before coronary angioplasty increase acute complication rates after coronary angioplasty. Urokinase as administered in the TAUSA trial had significant adverse effects, especially in complex lesions. However, even in the placebo arm, complex lesions were associated with higher complication rates than simple lesions. Newer antithrombotic measures that particularly target the platelet may eventually decrease complication rates in these lesions.

Initial experience with an intracoronary flow support device providing localized drug infusion: the Scimed Dispatch catheter

Two cases are presented illustrating the use of a new intracoronary infusion catheter providing flow support using a unique spiral coil design. Good clinical outcomes were obtained employing 4-hr inflations with localized infusion of urokinase at the site of dissection and extensive clot formation, respectively. This low-profile catheter-mounted device may provide an alternative to stent placement in cases of acute dissection complicated by thrombus formation.

Danger of urokinase as an anticoagulant with left ventricular assist devices

The sole administration of urokinase causes no initial prolongation of activated partial thromboplastin time (A-PTT), but thereafter produces serious progressive prolongation of A-PTT; it also causes a progressive, severe decrease in fibrinogen levels and alpha 2-plasmin inhibitor activity by depletion. The antithrombogenicity of urokinase is not caused by prevention of blood coagulation system activation by antithrombin effect, but by secondary fibrinolysis by plasmin. Consequently, the administration of urokinase as a sole anticoagulant results in activation of coagulation and fibrinolysis, and, as a result, induces disseminated intravascular coagulation. Therefore, it is concluded that administration of urokinase is an inadequate anticoagulation therapy unless it is combined with other antithrombin agents.

The performance of commercially available sealed Dacron vascular grafts in intraarterial thrombolytic therapy

The purpose of this study was to assess whether two commercially available, sealed arterial prostheses would tolerate catheter directed, intraarterial thrombolytic therapy. Sealed vascular grafts were implanted in 12 mongrel dogs for 3, 4, and 6 week intervals as iliac artery interposition grafts. This allowed direct comparison of two types of sealed grafts in the same animal. The indications for graft failure consisted of clinically evident bleeding, transluminal extravasation, or anastomotic leakage of contrast medium documented by angiography. Thrombolytic therapy (urokinase) was delivered immediately proximal to the grafts in the distal aorta, thereby exposing the intraluminal surfaces to urokinase delivered directly from the catheter tip, as well as to the accumulated systemic levels of urokinase and urokinase activated plasmin. There was no evidence of postoperative bleeding or extravasation of contrast medium during any follow-up arteriogram in any animal. There was no discernible extravasation of contrast medium noted at the anastomotic sites. At the time of explantation, no graft demonstrated any evidence of subclinical extravasation, such as separation of the external capsule from the abluminal surface of the graft. It is concluded that it appears safe to use thrombolytic therapy in these grafts as early as 3 weeks postimplantation.

Treatment of severe intraventricular hemorrhage by intraventricular infusion of urokinase

During the last three years, seven patients with severe intraventricular hemorrhage admitted to our clinic were treated with direct intraventricular infusion of urokinase. In each case, hemorrhage extended into the entire ventricular cavity and cast formation as well as an expansion of third and fourth ventricles were found. On the average, both the third and fourth ventricles became clear on the third day and the lateral ventricle on the ninth day after hemorrhage. Five of the seven patients showed good recovery or only moderate disability, and two died. Infection, convulsion, rebleeding, and peripheral or secondary hemorrhage due to the side effects of urokinase was not encountered during therapy. We conclude that this procedure can be applied effectively and safely in severe intraventricular hemorrhage.

[Efficacy and safety of thrombolytic therapy in the elderly with severe pulmonary embolism]

Thrombolytic therapy leads to more rapid dissolution of thrombi in severe pulmonary embolism than conventional heparin therapy but is considered with much reserve in elderly patients because of the risk of haemorrhage, which is thought to be potentially greater in these subjects. The object of this study was to assess the efficacy and safety of thrombolytic therapy in patients over 70 years of age with severe pulmonary embolism, compared with patients under 70 years of age with the same condition. Eighty-nine patients with severe pulmonary embolism (Miller score > 17/34) were prescribed thrombolytic therapy in the absence of a contraindication without taking age into consideration. Fifty-three were under 70 years of age (54 +/- 15; range: 18 to 70 years) and 36 were over 70 years of age (78 +/- 5; range: 71 to 88 years). Apart from age, there was no difference in the clinical presentation of the two groups. Thrombolytic therapy was initiated with streptokinase 100,000 IU/hr for twelve hours after an initial bolus of 250,000 IU or with urokinase or plasminogen tissue activator in cases with a contraindication to streptokinase. An uncomplicated course was observed in the same percentage of cases in the two groups. The Miller score and mean pulmonary pressures fell in the same way in the two groups. Three patients died during the hospital period, two aged under 70 (3.7%) and one over 7 years of age (2.7%). Major bleeding occurred in 3 subjects under 70 (5.6%) and 5 subjects over 70 (13.8%) (p = 0.29).(ABSTRACT TRUNCATED AT 250 WORDS)

Late results of a prospective study of direct intra-arterial urokinase infusion for peripheral arterial and bypass graft occlusions

The outcome of 72 direct intra-arterial urokinase infusions was studied prospectively. Thirty four were performed for native arterial occlusion and 38 for bypass graft occlusion; the immediate success rates were 67.5 and 84% respectively. The overall incidence of complications was 26%. Median follow-up was 36 (range 1-60) months. Seventeen patients (27%) died during follow-up; nine (14%) required a major amputation. Among patients with native arterial occlusion, 29% had no adjunctive procedure after thrombolysis; of these patients, 85% remained patent at a median of 21 (range 3-42) months. Among bypass occluded patients, only two (6%) had no lesion revealed after successful lysis; both bypasses remain patent at 54 and 58 months respectively. For patients treated with balloon angioplasty immediately after successful thrombolysis, 62% with native arterial occlusion remained patent at a median of 39 (range 2-60) months, whereas only 27% of bypass occlusion patients were patent at a median of 11 (range 2-40) months. Of patients requiring a surgical procedure after thrombolysis, 23 new bypasses (15 vein, eight prosthetic) were placed (nine in native arterial occlusion patients, 14 in bypass occlusion patients). In addition, there were 15 other surgical procedures, including six thrombectomies, four vein patch angioplasties, four vein jump grafts and one endarterectomy. The primary and secondary patencies for the 15 new vein bypasses placed were 81 and 88% respectively at a median follow-up of 36 months. Good immediate results were experienced with urokinase thrombolysis for peripheral arterial and graft occlusions. However, multiple adjunctive procedures were required to maintain patency.(ABSTRACT TRUNCATED AT 250 WORDS)