Thrombolysis in acute peripheral arterial occlusion: predictors of immediate success

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Acute Limb Ischemia

Acute limb ischemia is a vascular event presenting with sudden decrease in limb perfusion (of <14 days' duration) that threatens limb viability. Acute thrombosis of the native artery or graft makes up the bulk of etiopathogenesis. Prompt revascularization is the cornerstone of management of acute limb ischemia in limbs that have not undergone irreversible tissue and nerve damage. Amputation is performed in patients with irreversible tissue and nerve damage.

A case of acute brachial artery occlusion after transradial coronary intervention

In 2010, a 49-year-old man was admitted to our hospital with chest pain. Angiography via the radial approach was performed. Acute brachial artery occlusion was present after the procedure. By transcatheter thrombolysis, brachial artery occlusion was recanalized. Transcatheter thrombolysis seemed to be effective and safe.

Quality improvement guidelines for percutaneous catheter-directed intra-arterial thrombolysis and mechanical thrombectomy for acute lower-limb ischemia

Percutaneous catheter-directed intra-arterial thrombolysis is a safe and effective method of treating acute and subacute lower limb ischemia, as long as accurate patient selection and procedural monitoring are ensured. Although larger, controlled trials are needed to establish the role of PTDs in ALI, mechanical thrombectomy could currently be applied combined with lytic infusion in selected cases where rapid recanalization is required or as a stand-alone therapy when the administration of thrombolytic agents is contraindicated.

Do randomized trials of thrombolysis versus open revascularization still apply to current management: what has changed?

Several randomized trials of catheter-directed thrombolysis versus operative revascularization in patients with acute lower extremity ischemia were performed in the mid-1990 s. Although the outcomes of these trials were not definitive, they did provide insight into potential uses and techniques of catheter-directed thrombolysis and lytic agents. This article reviews the outcomes of these randomized trials and describes advances in thrombolytic techniques and technology, including percutaneous mechanical thrombectomy devices and innovative catheter designs that accelerate lysis and the development of direct-acting lytic agents.

Quality improvement guidelines for endovascular treatment of iliac artery occlusive disease

Endovascular therapy is the treatment of choice for type A and the preferred treatment for type B lesions. In selective patients, this type of treatment can be applied in type C and even type D lesions. Ipsilateral femoral, contralateral femoral, and brachial approach and both the intraluminal and subintimal space can be used for successful recanalization. The application of stents has improved the immediate hemodynamic and probably long-term clinical results of iliac percutaneous transluminal angioplasty. However, the superiority of primary or direct stenting over selective stenting has not been proven yet. The choice of stent type depends on lesion morphology and location but otherwise there is insufficient evidence to support the use of a particular stent design. There is insufficient evidence to justify routine use of covered stents. All patients should receive antiaggregant therapy following endovascular recanalization of iliac arteries. There is no consensus regarding prophylaxis with antibiotics in iliac recanalization procedures.

Treatment of Acute Iliofemoral Deep Venous Thrombosis: A Strategy of Thrombus Removal

Patients with acute iliofemoral deep vein thrombosis (DVT) suffer the most severe postthrombotic sequelae. The majority of physicians treat all patients with acute DVT with anticoagulation alone, despite evidence that postthrombotic chronic venous insufficiency, leg ulceration, and venous claudication are common in patients treated only with anticoagulation. The body of evidence to date in patients with iliofemoral DVT suggests that a strategy of thrombus removal offers these patients the best long-term outcome. Unfortunately, currently published guidelines use outdated experiences to recommend against the use of techniques designed to remove thrombus, ignoring recent clinical studies showing significant benefit in patients who have thrombus eliminated. Contemporary venous thrombectomy, intrathrombus catheter-directed thrombolysis, and pharmacomechanical thrombolysis are all options that can be offered to successfully remove venous thrombus with increasing safety. The authors review evidence supporting the rationale for thrombus removal and discuss the most effective approaches for treating patients with acute iliofemoral DVT.

Early experience in the application of distal protection devices in treatment of peripheral vascular disease of the lower extremities

The objectives of this study were to reduce the risk of showering distal vessels with thromboemboli created during percutaneous interventions of the arteries in the lower extremities. Distal protection devices have been used in coronary and carotid interventions. Hence, using similar techniques, these filters and occlusion balloons were advanced past the targeted lesions and distally into femoral and popliteal arteries. Once opened, these devices allowed standard angioplasty and stent placement and captured the dislodged thromboemboli. Five cases were performed with the distal protection devices. One case used the distal occlusion balloon and four with the filter system. All five passed the lesion and were deployed. All five devices were retrieved without incident and were retrieved with substantial debris. There were no adverse events. The use of distal protection to treat high-risk or unstable lesions in the lower extremities shows great promise. Further case will be needed to evaluate the device for feasibility and safety.

Thrombolysis and mechanical thrombectomy for arterial disease

Thrombolytic therapy has been around for close to 30 years now,but its exact role in the treatment of acute and chronic arterial occlusive disease continues to be debated. Studies have produced varying and contradictory results. We are still not sure if thrombolysis has any true advantages over surgical thromboembolectomy,or which lytic agent is the best. Nonetheless, the technique still plays an important role in the treatment of arterial occlusions.

Thrombolysis as Initial Treatment of Peripheral Native Artery and Bypass Graft Occlusions in a General Community Hospital

Large series with long-term follow-up of thrombolytic therapy in the treatment of lower limb arterial occlusion from a single, general, non-university hospital are absent. We studied retrospectively the results of 129 consecutive patients who underwent thrombolysis with intraarterial urokinase as initial treatment for lower limb native artery or bypass graft occlusions. The mean age of patients was 71 years; 55% of the patients were male, and preexisting peripheral arterial disease was present in 47%. Presenting symptoms were disabling claudication (31%) and limb-threatening ischemia (69%). Forty-two percent of the patients presented with acute symptoms (<1 week duration). The mean follow-up of patients still alive at the time of analysis was 36 months (range 1-120 months). Thrombolytic treatment was successful in 93 patients (72%). In 53% of the patients acute surgical intervention could be avoided: 28 patients (22%) did not need any additional procedure and 40 (31%) underwent a concomitant angioplasty. When thrombolysis failed, 6 patients (5%) underwent successful surgical revascularization and 11 patients (8%) eventually underwent major amputation during their hospital stay. Amputation-free survival at 6 months and at last follow-up was 88% and 83%, respectively. The mortality rates were 4% at 30 days, 5% at 6 months, and 30% at last follow-up. Thrombolysis was significantly less successful when patients had diabetes (62% vs. 81%, p = 0.019) or preexisting peripheral arterial disease (61% vs. 80%, p= 0.018). Successful radiological treatment (thrombolysis+/-angioplasty) could less often be performed in patients with preexisting peripheral arterial disease (41% vs. 59%, p = 0.011) and in patients with occluded bypass grafts (33% vs. 62%, p= 0.002). Duration of symptoms and Fontaine stage at presentation did not predict thrombolysis outcomes. Thrombolytic-related complications occurred in 17 patients (13%), with significant bleeding from the puncture site in 3 patients (2%). Thrombolysis can safely and effectively be performed in a general community hospital with results comparable to those reported from specialized university centers and large randomized trials.

[Clinical pathways -- intervention or surgery for acute ischemia of the extremities]

There is still controversial discussion concerning the therapy of limb-threatening ischaemia. In a retrospective study, we investigated and compared surgical and percutaneous interventional methods in the treatment of both embolic and thrombotic vascular occlusions in patients with pre-existing arteriosclerotic disease and attempted to propose therapy guidelines for these methods in the therapy of acute limb ischaemia. Percutaneous mechanical thrombectomy represents a viable therapeutic alternative to surgical or surgical-interventional modalities, particularly in patients with occlusions consisting of soft, embolic material or located in infrapopliteal vessels. The indication for each respective method should be interdisciplinary and must be based on the individual patients' clinical and angiographic findings. Additional intraoperative endovascular procedures increase the range of therapeutic options and permit optimal revascularisation of vessels both proximal and distal to the site of occlusion.

Arterial embolism to the upper extremity in a patient with factor V Leiden mutation (APC resistance)--a case report and review of the literature

Factor V Leiden mutation has emerged as one of the leading abnormalities in inherited blood coagulation disorders, resulting in a markedly increased risk for deep leg vein thrombosis. A 24-year-old woman presented with acute onset of critical ischemia of her left thumb and index finger. Intraarterial angiography revealed an embolus in the distal radial artery and a thrombotic occlusion of the digital artery of the thumb and index finger. Immediate therapy encompassed a selective surgical embolectomy of the distal radial artery followed by a local intraarterial lysis that was continued for 3 days. Additionally, therapeutic anticoagulation and vasodilating drugs (prostaglandin E) were administered. Within 2 days, capillary refill reappeared and the initial loss of sensory function at the tip of the thumb and index finger diminished. A screening test for thrombophilic disorders led to the diagnosis of a heterozygous mutation of factor V (Leiden mutation). Arterial thromboembolic events of factor V Leiden mutation are rare and have to date been described only in the supraaortic and coronary circulation. Therefore, the arterial embolism to the left hand presented in this report constitutes a rarity that could be successfully salvaged by the combined use of a vascular surgical procedure and intensified medical management.

Terapia trombolítica intra-arterial intra-operatória

OBJETIVO: Apresentar um tratamento coadjuvante à desobstrução mecânica, nas oclusões arteriais agudas de membros. MÉTODO: A impossibilidade de desobstrução mecânica cirúrgica completa dos vasos tem levado a altas taxas de amputações. Utilizamos como coadjuvante desta a aplicação de agente trombolítico intra-operatório, intra-arterial regional, seguida da infusão de solução de diálise peritoneal à baixa temperatura. RESULTADO: Neste pequeno grupo de doentes, verificamos que o uso de fibrinolítico seguido da lavagem da árvore arterial com solução preservadora, à baixa temperatura, aumenta a taxa de sucesso cirúrgico com preservação do membro e sua função. CONCLUSÃO: A terapia trombolítica intra-arterial regional, associada ao uso de solução de diálise peritoneal heparinizada, apresentou um percentual de sucesso de 88,88% dos casos tratados com este método.

Aneurysm expansion and retroperitoneal hematoma after thrombolysis for stent-graft limb occlusion caused by distal endograft migration

PURPOSE

To describe a complication of thrombolytic therapy used to treat graft limb occlusion precipitated by distal migration and kinking of an abdominal aortic stent-graft.

CASE REPORT

A 5.5-cm abdominal aortic aneurysm (AAA) in a 66-year-old woman was treated with Vanguard bifurcated stent-graft. At the 1-year follow-up, she complained of left leg claudication. Computed tomography (CT) showed a 36% reduction in maximum AAA diameter, but the stent-graft had migrated distally approximately 5 mm, and the left graft limb was occluded. Thrombolysis was initiated, but after approximately 8 hours, abdominal pain began. Emergent CT scanning revealed rapid aneurysm expansion and a retroperitoneal hematoma. Thrombolytic treatment was stopped; transfusions and thrombogenic drugs were given to restore hemodynamic stability. The aneurysm began to decrease in size. The occluded graft limb had been reopened by the lytic therapy, uncovering a stenosis in the native artery distal to the graft limb. Stent placement restored outflow. The retroperitoneal hematoma resolved over time, and the aneurysm sac shrank to its prelytic diameter. The patient is well with a functioning endograft 18 months after the occlusion (30 months after stent-grafting).

CONCLUSIONS

Caution must be taken when using thrombolysis in patients with endovascular aortic grafts because unexpected bleeding complications might arise. Thrombectomy, femorofemoral bypass, or stent or stent-graft extensions might be safer alternatives for treating occluded stent-graft limbs.

Thrombolytic therapy for arterial thrombosis

The major development in the field of intra-arterial thrombolytic therapy over the past year was the publication of the phase II results of the Thrombolysis or Peripheral Arterial Surgery study, which compared the safety and efficacy of catheter-directed thrombolysis and surgery as the initial treatment of acute arterial occlusion. The results are consistent with those of the prior two studies, showing little or no difference between surgery and thrombolysis in the most important endpoints of survival and amputation rate. Patients receiving thrombolysis needed fewer interventions, but this benefit was balanced by increased bleeding complications. Additional studies have, therefore, been aimed at identifying subsets of patients with acute arterial occlusion who are most likely to benefit from thrombolysis. These studies have refined the selection criteria for use of thrombolytic therapy over the past year. In addition, studies have been published evaluating new drug doses and regimens aimed at broadening the scope of thrombolytic therapy in patients with acute arterial occlusion.

Surgical revascularization versus thrombolysis for nonembolic lower extremity native artery occlusions: results of a prospective randomized trial. The STILE Investigators. Surgery versus Thrombolysis for Ischemia of the Lower Extremity

PURPOSE

Early results of a prospective study that compared surgical revascularization and thrombolysis for lower extremity arterial and graft occlusions have been published. This report details the final results in patients who have native artery occlusions.

METHODS

Two hundred thirty-seven patients who had lower extremity ischemia as a result of iliac-common femoral (IF; 69 patients) or superficial femoral-popliteal (FP; 168 patients) occlusion, and had symptomatically deteriorated within the past 6 months were randomized to catheter-directed thrombolysis (150 patients) or surgical revascularization (87 patients). After diagnostic arteriographic examination but before randomization, the optimal surgical procedure was determined. Lytic patients were randomized to recombinant tissue plasminogen activator (rt-PA; 84 patients) or urokinase (UK; 66 patients). Recurrent ischemia, morbidity, amputation, and death rates were determined at 30 days, 6 months, and 1 year, and were analyzed on an intent-to-treat basis.

RESULTS

For patients randomized to lysis, a catheter was properly positioned and the lytic agent delivered in 78%. This provided a reduction in the predetermined surgical procedure in 58% of patients who had an FP occlusion and 51% of those who had an IF occlusion. rt-PA and UK were equally effective and safe, but lysis time was shorter with rt-PA (8 vs 24 hr; p < 0.05). At 1 year, the incidence of recurrent ischemia (64% vs 35%; p < 0.0001) and major amputation (10% vs 0%; p = 0.0024) was increased in patients who were randomized to lysis. Factors associated with a poor lytic outcome included FP occlusion, diabetes, and critical ischemia. No differences in mortality rates were observed at 1 year between the lysis and surgical groups.

CONCLUSION

Surgical revascularization for lower extremity native artery occlusions is more effective and durable than thrombolysis. Thrombolysis used initially provides a reduction in the surgical procedure for a majority of patients; however, long-term outcome is inferior, particularly for patients who have an FP occlusion, diabetes, or critical ischemia.

Computerized angiographic analysis of the outcome of peripheral thrombolysis

BACKGROUND

Catheter-directed peripheral thrombolysis is used increasingly for the management of acute limb ischemia. The comparison of different agents and techniques has proven difficult because of the variations in patient presentation, vessel involvement, and treatment methods.

METHODS

A computerized database in which angiographic information is stored on computerized arterial maps has been designed to record details of thrombolysis.

RESULTS

A total of 201 patients who presented with rest pain were recorded on the database, and their angiograms were analyzed. There were 123 native-vessel and 78 graft occlusions. Immediate success of lysis and 30-day outcome were not dependent on the site of the occlusion. If an underlying stenosis was revealed, limb salvage rates were significantly greater than when none was found (82% versus 58%, P < 0.01). The presence of at least 1 run-off vessel increased limb salvage rates by 30% (P < 0.001). If more than 5 arterial segments were occluded on the prelysis angiogram, limb salvage was worse than if there were fewer than 5 (57% versus 85%, P < 0.0001). For grafts, less than 5 segments of occlusion led to limb salvage rates of 90%, and more than 5 segments of occlusion led to rates of 72% (P = 0.07).

CONCLUSIONS

This simple and user-friendly system of computerized angiographic analysis will enable detailed examination of thrombolytic practice and assist in the prediction of success.