The role of thrombolysis in the management of thromboembolic disorders: a four-year review

Recombinant tissue plasminogen activator versus urokinase for local thrombolysis of femoropopliteal occlusions: a prospective, randomized multicenter trial

PURPOSE

To report the outcome of a prospective, randomized, open multicenter trial comparing (1) the effects of local thrombolysis with recombinant tissue plasminogen activator (rtPA) or urokinase (UK) and (2) 2 administration techniques.

METHODS

Two hundred thirty-four patients with thromboembolic occlusions in 223 native femoral or popliteal arteries (95%) and 11 bypass grafts (5%) were randomized to rtPA (n = 124) or UK (n = 110) administered either through an endhole catheter (Hess technique) in 81 patients or a microporous balloon catheter (Schneider technique) in 153 patients. When lysis was incomplete, additional catheter interventions were applied to achieve patency. Results were analyzed by fluoroscopy during intervention and by angiography evaluated by independent experts blinded to the methods applied.

RESULTS

The only significant difference between rtPA and UK was found at the end of lysis using the Hess technique. Complete reperfusion (TIMI grade 3) was produced in 60% of patients by rtPA versus 37% by UK (p = 0.045). By both techniques TIMI grade 3 was achieved in 62% with rtPA and in 50% with UK (p = 0.18). Independent of delivery technique, thrombolytic agent, or additional catheter interventions, TIMI grade 3 was achieved in 81% and angiographic patency in 88%. Primary patency at 6 months was 66%, which was increased by secondary interventions to 75%. Major amputations were performed in 6%, all in patients with initial Fontaine stage III/IV ischemia.

CONCLUSIONS

With local thrombolysis alone, rtPA appears to be more effective than UK; however, additional catheter interventions further improved patency, abolishing the difference between the lytic agents.

Indications for directed thrombolysis or new bypass in treatment of occlusion of lower extremity arterial bypass reconstruction

The long-term results after directed thrombolytic therapy for thrombosis of infrainguinal arterial bypass reconstructions are disappointing if broad indications are applied. This work presents criteria for determining the indications for thrombolysis or the insertion of a new bypass. In a retrospective study we compared the secondary cumulative patency after bypass thrombolysis (n = 82) and after replacement bypass (n = 143). Using multivariate analysis, the influence of prognostic factors on secondary long-term patency was investigated. Our results showed that brief occlusions (< or = 3 days) in older bypasses (> or = 11 months) should be treated by thrombolysis. In all other cases, efforts should be made to replace the bypass with autologous vein. In the absence of autologous vein, we found umbilical vein to be a suitable material for vessel replacement.