Thrombolysis in the Management of Lower Limb Peripheral Arterial Occlusion—A Consensus Document

Skin necrosis following sclerotherapy. Part 2: Risk minimisation and management strategies

Tissue necrosis is a serious but rare complication of sclerotherapy. Early detection and targeted management are essential to prevent progression and minimise serious complications. In the first instalment of this paper, we reviewed the pathogenic mechanisms of post-sclerotherapy necrosis. Here, we describe risk minimisation and management strategies.

Risk factors must be addressed to reduce the chance of necrosis following sclerotherapy. These may be treatment-related including poor choice of sclerosant type, concentration, volume or format, poor injection technique, suboptimal ultrasound visualisation and treatment of vessels in high-risk anatomical areas. Risk factors specific to individual patients should be identified and optimised pre-operatively.

Tissue necrosis is more likely to occur with extravasation of irritant sclerosants such as absolute alcohol, sodium iodide, bleomycin and hypertonic saline, whereas extravasation of foam detergent sclerosants rarely results in tissue loss. Proposed treatments for extravasation of irritant sclerosants include infiltration of an isotonic fluid and hyaluronidase. Management of inadvertent intra-arterial injections may require admission for neurovascular observation and monitoring for ischaemia, intravenous systemic steroids, anticoagulation, thrombolysis and prostanoids infusion when required. Treatment of veno-arteriolar reflex vasospasm (VAR-VAS) necrosis follows the same protocol involving systemic steroids but rarely requires hospital admission and may not require anticoagulation.

In general, treatment of post-sclerotherapy necrosis is challenging and most proposed treatment measures are not evidence-based and only supported by anecdotal personal experience of clinicians. Despite all measures, once the necrosis has set in, it is very difficult to reverse the process and all measures described here may only be useful in prevention of progression and extension of the ulceration.

Mid to long-term measures include addressing exacerbating factors, management of medical and psychosocial comorbidities, treatment of secondary infections and referrals to relevant specialists. All ulcers should be managed with compression and prescribed dressing regimes in line with the healing stage of the ulcer.

A Very Rare Cause of Thrombotic Peripheral Occlusion

A 45-year-old healthy woman presented with claudication of the right leg. The resting ankle-brachial index (ABI) was reduced to 0.6, and a duplex scan revealed an occlusion of the right popliteal artery. Angiography presented a patent superficial femoral artery that ends above the knee joint. Laterally, there was delayed retrograde contrast filling of the popliteal artery. After exploring the internal iliac artery, we crossed a thrombotic occlusion of a persisting sciatic artery (PSA). Local thrombolysis with recombinant tissue plasminogen activator (1 mg/h) was initiated. The Angiography 18 hours later showed a reduction of thrombotic material and relevant stenosis in the proximal part of the vessel. Residual thrombus and the stenosis were covered by two stentgrafts (Gore Viabahn Endoprosthesis) that were stabilized by an interwoven stent (Supera). Final angiography displayed a patent sciatic artery and a three-vessel run off. Postinterventional ABI was normalized to 1.0. The magnetic resonance imaging 6 days after the intervention demonstrated a patent PSA again and a normal blood flow on the left leg. A PSA should be included in the differential diagnosis of lower limb ischemia or suspected aneurysm formation. We demonstrated the feasibility of an interventional approach with an excellent outcome in this case.

Results of treatment of acute occlusions of limb arteries at a university hospital - retrospective study

Background

Acute arterial occlusions (AAO) in limbs have been increasing in parallel with population longevity.

Objective

To assess risk factors, limb salvage rates, and survival of patients with AAO treated at a University Hospital.

Methods

Retrospective cohort study of consecutive patients. Outcomes included: patency, symptoms, comorbidities, Rutherford category, arteries occluded, postoperative complications, and 30-day limb salvage and mortality rates.

Results

Medical records were evaluated from 105 patients, predominantly males (65.7%), with ages ranging from 46 to 91 years. Etiology: thrombotic (54.3%), embolic (35.2%), and undefined (10.5%). About 2/3 of the patients were assessed as Rutherford category II or III. Associated symptoms: pain (97.1%), coldness (89.5%), pallor (64.7%), sensory loss (44.7%), paralysis (30.5%), anesthesia (21.9%), edema (21.9%), and cyanosis (15.2%). Associated comorbidities: hypertension (65.0%), smoking (59.0%), arrhythmias (26.6%), dyslipidemia (24.0%), and diabetes (23.8%). The distal superficial femoral-popliteal segment was the most affected (80%). Thromboembolectomy with a Fogarty catheter was performed in 73.3% of cases (81.0% of embolic cases, 71.9% of thrombotic cases, and 54.5% of cases with undefined etiology) and was the only treatment used in 41 cases (39.05%), among which there were 11 reocclusion, 20 amputations, and 14 deaths. Arterial reocclusion was more frequent in thrombosis cases (12.9%, p = 0.054). Within 30 days of treatment, total mortality was 14.6%, and 19.8% of cases underwent major amputation, which was less frequent among Rutherford Class I patients (p = 0.0179).

Conclusion

Treatment of AAO was primarily performed by thromboembolectomy with a Fogarty catheter, either alone or in combination with other treatments, achieving amputation and complication rates compatible with the best results in the literature and were progressively lower in less advanced Rutherford categories.

Catheter-directed intra-arterial thrombolysis for lower extremity arterial occlusions

Catheter-directed intra-arterial thrombolysis (CDT) is a rational treatment method in patients with acute/subacute and even some chronic occlusions of lower extremity arteries and bypass grafts having salvageable limb ischemia. Immediate vessel patency can be achieved with an acceptable complication rate in many patients, especially those with fresh thrombus or emboli. It can be also an adjuvant treatment modality for endovascular interventions for chronic occlusions. There is no standard method of CDT including thrombolytic agent dose and technique. Selection of treatment strategy should be based on individual judgment based on viability of limb, lesion characteristics, and risks of hemorrhage.

Phase 2, randomized, open-label study on catheter-directed thrombolysis with plasmin versus rtPA and placebo in acute peripheral arterial occlusion

Background: Patients with acute peripheral arterial occlusion (aPAO) are candidates for operative thrombectomy, bypass, or catheter-directed thrombolysis (CDT) using a plasminogen activator. Human plasma-derived plasmin may offer another CDT option.

Objectives: To evaluate the efficacy, safety, and tolerability of two intrathrombus delivery methods and two doses of plasmin compared with recombinant tissue plasminogen activator (rtPA) and placebo in patients with aPAO.

Patients/methods: This was a phase 2, randomized, open-label study of intra-arterial CDT of plasmin in patients with aPAO. The study used infusion catheters with or without balloon occlusion (BOC) to evaluate 150 mg plasmin (2 and 5 h post-infusion) and 250 mg plasmin (5 h post-infusion). The efficacy of plasmin, rtPA and placebo was assessed.

Results: One hundred and seventy-four subjects were enrolled. Overall, the thrombolytic efficacy (>50% thrombolysis) was 59% (58/99) for 150 mg plasmin without BOC, which is comparable to 89% (8/9) for rtPA without BOC (p = 0.149) and 40% (2/5) for placebo control (p = 0.648). The thrombolytic efficacy was 33% of the 250 mg plasmin group. There was no difference (p > 0.999) in thrombolytic efficacy with BOC (59%, 58/99) or without BOC (59%, 17/29). Plasmin-treated groups experienced treatment-emergent adverse events (TEAEs) at 71% (76/107) without BOC and 63% (24/38) with BOC; 78% (7/9) of the rtPA-treated group and 89% (8/9) of the placebo group had TEAEs. Serious AEs (SAEs) occurred in 29% (31/107) of the 150 mg plasmin group without BOC and 24% (9/38) with BOC. No SAEs occurred in the 250 mg plasmin group.

Conclusions: Plasmin demonstrated less bleeding during catheter-directed administration at 150 mg and 250 mg doses compared to rtPA. BOC utilization did not improve efficacy. CDT with plasmin has a potential thrombolytic benefit in patients presenting with aPAO.

ClinicalTrials.gov Identifier: NCT01222117

Combined Direct Endarterectomy and Fogarty Thrombectomy with Endovascular Therapy for Subacute Occlusion of the Superficial Femoral Artery

A 78-year-old woman with a prior history of a right femoropopliteal bypass 5 years before and a coronary artery bypass graft 3 months before was admitted for a non-healing ulcer on her right foot. A computed tomography angiogram revealed occlusion of her superficial femoral artery (SFA) from its orifice to the anastomotic site of the bypass graft. The lesion was thought to consist of a partial atherosclerotic plaque with a large number of relatively fresh thrombi, referring to an angiogram of her lower extremity 3 months ago. We recanalized the occlusive SFA by Fogarty thrombectomy, and endovascular therapy preceded by direct SFA endarterectomy.

ACR Appropriateness Criteria® Iliac Artery Occlusive Disease

Iliac artery occlusive disease can present as a sudden-onset acute thrombotic or thromboembolic event or as a chronic progressive atherosclerotic process that presents as claudication progressing to rest pain. Depending on the clinical presentation, the diagnosis is usually confirmed through Doppler vascular ultrasound, CT angiography, or MR angiography; the choice of imaging is usually based on modality availability and the presence of patient comorbidities such as chronic kidney disease. The Trans-Atlantic Inter-Society Consensus II classification system is commonly used to describe the extent of the peripheral vascular disease. Depending on the pathophysiology, clinical presentation, and radiologic extent of the disease process, therapeutic options for acute thrombotic cases can include supportive care, anticoagulation, thrombolytic therapy, surgical or catheter-directed mechanical thrombectomy, and surgical bypass. Therapeutic options for atherosclerotic disease include supportive measures such as behavior modification, a supervised exercise program, adjunctive treatment with anticoagulation and antiplatelet medications, angioplasty, stent placement, stent-graft placement, surgical or catheter-directed endarterectomy or plaque excision, and surgical bypass. This document describes the appropriateness of imaging in this patient population, treatment procedures for specific clinical scenarios, and the likely prognosis for these patients. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Early Thrombosuction and Tirofiban Use in Knee and Below-Knee Arterial Thrombosis

BACKGROUND Acute limb ischemia (ALI) is a clinical entity with a high rate of morbidity and mortality. Despite advances and variety of its management, there is still no criterion standard treatment. The goal of this study was to evaluate the effect of tirofiban use on the early and 6-month prognosis of patients with knee and below-knee arterial thrombosis who were treated with percutaneous thrombosuction (PT) within 24 h. MATERIAL AND METHODS Data of consecutive ALI patients who were diagnosed with popliteal and infra-popliteal arterial thrombosis and underwent PT procedure within 24 h between January 2010 and September 2015 were evaluated retrospectively. Patients were separated into 2 groups according to tirofiban usage. RESULTS A total of 105 patients (mean age 67±16; 53% men) were included in the study. Atrial fibrillation (n 64, 61%) and hypertension (n 60, 57%) were the most frequent comorbidities in patients with thromboembolic events. A significantly higher rate of distal embolization (6% vs. 16%; p=0.01) and slow-flow (17% vs. 30%; p<0.01) developed in patients who were not treated with tirofiban after the PT procedure. Although major and minor bleeding were more frequent in the tirofiban group, only the rate minor bleeding was statistically significant (29% vs. 9%, p=0.001). Reverse embolic event ratio was similar in both groups. Although there was a higher rate of amputation in patients not treated with tirofiban, the difference was not significant. CONCLUSIONS Adding tirofiban to PT reduces angiographic thromboembolic complications. Usage of tirofiban in patients prone to thromboembolic events may be useful for improving success of the PT procedure, with a reasonable bleeding ratio.

Thrombolysis in peripheral artery disease

Peripheral artery disease (PAD) has been associated with severe morbidity and mortality worldwide, affecting the quality of life for millions of patients. Acute thrombosis has been identified as a major complication of PAD, with proper management including both open as well as endovascular techniques. Thrombolysis has emerged as a reasonable option in the last decades to treat such patients although data produced by randomized trials have been limited. This review aims to present major aspects of thrombolysis in PAD regarding its indications and contraindications, technique tips as well as to review literature data in order to produce useful conclusions for everyday clinical practice.

Fibrinogen Level and Bleeding Risk During Catheter-Directed Thrombolysis Using Tissue Plasminogen Activator

PURPOSE

The purpose of this study was to determine whether low fibrinogen levels (fibrinogen level <1.5 g/L) during catheter-directed thrombolysis are associated with an increased bleeding risk.

METHODS

A retrospective review was performed on patients undergoing extremity arterial or venous thrombolysis between 2005 and 2013.

RESULTS

Patients in the low fibrinogen group were younger (P = .006) and had a higher number of venous occlusive events (P = .004). The low fibrinogen group received a larger dose of tissue plasminogen activator (tPA; P = .009) and had a longer duration of thrombolysis (P = .010). The rates of major bleeding were not significantly different (P = .139). Univariate analysis showed that larger total dose and longer duration of tPA infusion were associated with increased bleeding complications (P < .01 and P = .03).

CONCLUSION

A fibrinogen level <1.5 g/L during thrombolysis was not associated with an increased bleeding risk. However, larger dose and longer duration of thrombolysis were associated with increased bleeding risk.

Should Age Limit the Use of Catheter-Directed Thrombolysis: Results of National Survey

OBJECTIVE

To determine whether advanced age should be a contraindication to catheter-directed thrombolysis (CDT) based on hemorrhagic complication rate.

METHODS

A survey was generated via Survey Monkey and sent out to vascular surgeons who were members of the society of vascular surgery (SVS).

RESULTS

Of the responders, 32.7% state they do not have an age limit for tissue plasminogen activator (TPA) infusion, and the remaining 29.2% of the responders use 80 years of age as their limitation. When asked why place limits on age for TPA infusion, 56.6% stated concern for intracranial hemorrhage. Major complications were access site hemorrhage (58.4%) and intracranial hemorrhage (41.6%). Chi-square analysis did not show age as a limiting factor to thrombolysis. Furthermore, when asked in which age-group complications occurred most commonly, 72.4% were less than 80.

CONCLUSION

Among vascular specialist, there seems to be no consensus on age limitations for TPA infusion. Serious complications do not seem to be age related and thus age alone should not be a contraindication for catheter-directed thrombolysis.

Treatment of femoral artery thrombosis with streptokinase and heparin after cardiac catheterization

Background:

Thrombosis is the most common complication during cardiac catheterization via femoral artery access. Alongside heparinization, fibrinolytic therapy is recommended if there are signs of ischemia in the lower extremity.

Objectives:

Given the paucity of data in the existing literature on streptokinase (SK) therapy in pediatrics, we designed this study to assess the efficacy of SK in pediatric patients with diagnosed femoral artery thrombosis following cardiac catheterization.

Patients and Methods:

The study population initially consisted of 1788 pediatric patients who underwent cardiac catheterization via the femoral artery access. Diminished or absent pulses in the lower extremity were detected in 123 patients, 45 of whom (2.5% of 1788) required treatment and were therefore considered for the next stage of study. Treatment was comprised of post-procedural intravenous heparin, either 50 U/kg/Q4h or 10 - 20 U/kg/h continuously. After heparinization for 24 hours, if the pulse of the affected extremity was not palpable, heparin therapy was continued (heparin-treated group, n = 28), and if the symptoms of femoral artery ischemia were persistent, heparin was discontinued and intravenous SK with a loading dose of 2000 U/kg over 20 - 30 minutes was commenced (SK-treated group, n =17).

Results:

In the presence of pulselessness in the lower extremity, a maintenance dose of SK (1000 U/kg/h, during 1 - 24 hours) was intravenously administered. Regarding the return of the pulses post-therapeutically, normal and weak/absent pulses were detected in seven (25.2%) and 21 (74.8%) of the 28 patients, respectively, in the heparin-treated group (P value < 0.001), whereas normal and weak/absent pulses were detected in 15 (88.2%) and two (11.8%) of the 17 patients, respectively, in the SK-treated group (P value < 0.001).

Conclusions:

Our findings demonstrated a high success rate and a low complication rate for systemic SK therapy in femoral artery thrombosis after catheterization.

Critical and acute limb ischemia: an overview

Some patients with peripheral arterial disease may present with critical limb ischemia, a condition associated with high rates of morbidity and mortality. Early diagnosis and effective medical therapy and revascularization are indicated to avoid amputation and reduce mortality. Ideally, a multidisciplinary approach with collaboration between endovascular interventionist, vascular surgeons, podiatrist, infectious disease, and wound care specialist is recommended for these patients.

Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) in acute lower limb ischaemia

For various reasons some patients are unable to undergo intra-arterial thrombolysis for acute limb ischaemia. This interventional case series study prospectively evaluated the effect of thrombolytic treatment with 100 mg recombinant tissue plasminogen activator (rt-PA), administered intravenously, in patients with acute thrombosis of the lower limb arteries and onset of symptoms within 12 h prior to treatment. During a 3-year period (2007-2009), 18 of 86 patients satisfied the inclusion criteria and were included in the study (age range 65-80 years; 11 women). Complete and partial thrombolysis was observed in eight (44.4%) and six (33.3%) patients, respectively. All patients experienced clinical improvement. There were no amputations during the 36-month follow-up period and no haemorrhagic complications in the first 30 days post-treatment. Five patients died (27.8%) during follow-up from unrelated causes. This small study demonstrated that thrombolytic treatment with intravenous rt-PA in selected patients with acute limb ischaemia is feasible.

Acute arterial thrombosis after covered stent exclusion of bleeding mycotic pseudoaneurysm: treatment using catheter-directed thrombolysis

Conventional absolute contraindications to catheter-directed thrombolysis include active or recent hemorrhage and the presence of local vascular infection, both of which increase the risk of procedure-related complications such as bleeding and systemic sepsis. For this reason, lytic therapy of arterial thromboembolism under these circumstances is generally precluded. Herein, we describe a unique case of safe catheter-directed lysis of an acutely thrombosed iliac artery following covered stent placement for treatment of an actively bleeding infected pseudoaneurysm. Our management approach is discussed.

[Medicamentous thrombolysis in acute occlusions of extremity arteries]

Local catheter-directed thrombolysis for thromboembolic extremity artery or bypass occlusions is a promising therapeutic option with comparatively low complication rates if the severity of the ischemia does not require an urgent surgical revascularization. This therapeutic decision has to be made by the vascular team under consideration of individual circumstances and contraindications. Apart from an adequate dosage, a strict intrathrombotic application of the fibrinolytic agent and careful clinical monitoring, including surveillance of the coagulation system is necessary. If needed, the thrombolysis therapy can be combined with interventional thrombaspiration and balloon dilatation or surgical correction of an underlying lesion.

JP, Almeida RDD, Batistela FR, Kafejian O. Derivação com veias de membro superior após trombólise de aneurisma de artéria poplítea: alternativa para salvamento de membro

Os autores relatam um caso de aneurisma de artéria poplítea trombosado em que se realizou fibrinólise com sucesso na fase aguda. Foram utilizadas veias de braço para realização do enxerto e exclusão do aneurisma, pois o paciente havia sido previamente submetido à safenectomia bilateral e revascularização do miocárdio com as veias do outro braço. Apesar das dificuldades, o salvamento do membro foi alcançado.

Catheter-directed thrombolysis for acute limb ischemia

Acute limb ischemia is a potentially life-threatening clinical event. Thrombosis in situ, bypass graft thrombosis, and embolic occlusion are the three major precipitating events leading to acute limb ischemia. Management of acute ischemia depends on the clinical status of the affected limb and patient comorbidities. Catheter-directed thrombolysis (CDT) is the treatment of choice for patients with relatively mild acute limb ischemia (Rutherford categories I and IIa) with no contraindications to thrombolytic therapy. Patients with severe acute limb ischemia (Rutherford category IIb) need emergent revascularization. CDT should be considered, nonetheless, if the relative risks compared with primary operation are favorable. CDT is a life- and limb-saving treatment for many patients despite limitations of efficacy and associated complications. This article is a review of the etiology of acute arterial occlusion; clinical triage of patients presenting with acute limb ischemia; catheter guide wire techniques, pharmacological agents, and devices in current use for CDT; as well as the outcomes of CDT.

Thrombolysis for Acute Lower Limb Ischaemia—A Prospective, Randomised, Multicentre Study Comparing Two Strategies

OBJECTIVES

To test if initial high-dose, pulse-spray thrombolysis improves the early and late outcome of lower limb ischaemia as compared with low-dose infusion alone.

DESIGN

Prospective randomised multicentre study.

MATERIAL AND METHODS

Patients with acute and sub-acute (<30 days) lower limb ischaemia were randomised following angiography. Group 1 (n=58) received pulse-spray infusion of recombinant plasminogen activator (rt-PA, 15 mg/h) for 2h followed by low-dose infusion if needed. Group 2 (n=63) were only treated with low-dose infusion (0.5mg/h) of rt-PA for 48 h. Underlying lesions were corrected if required.

RESULTS

The study was stopped prematurely. Complications were equally frequent in both groups. More than 75% lysis was accomplished in 78 versus 67% of the patients (p=0.21). Primary endpoints (re-occlusion, incomplete lysis, life-threatening complication, amputation, or death) were reached in 24 versus 32% of the patients (p=0.35). Neither vascular patency nor clinical parameters differed during the first year, but re-interventions tended to be more frequent (p=0.040 at 1 month; p=0.090 at 1 year) and of a greater magnitude (p=0.028) in group 2.

CONCLUSIONS

There was no obvious advantage with initial high-dose thrombolysis, which may be a type-2 error. A reduction of major re-interventions was recorded.

Percutaneous endovascular treatment of acute sequential systemic emboli

A 65-year-old woman was evaluated for acute right lower-extremity ischemia secondary to embolization from atrial fibrillation and subtherapeutic anticoagulation. Her symptoms quickly evolved in a dynamic fashion to involve multiple vascular beds, including a transient ischemic attack, abdominal pain secondary to mesenteric ischemia, and contralateral lower-extremity ischemia. Synchronous emboli were treated by using mechanical and pharmacologic thrombolysis via an endovascular approach under local anesthesia. This intervention allows prompt evaluation of multiple vascular beds with good short-term outcomes and minimal morbidity.