Acute Arterial Occlusion

Acute peripheral arterial occlusion is associated with a high risk of limb loss and death. The high mortality rate is as much a function of the multiplicity of baseline comorbidities as it is a result of the insult from the peripheral ischemia and reperfusion. Less invasive methods of restoring arterial perfusion have been used in an attempt to lower the morbidity and mortality rates; in this regard, percutaneous procedures have been investigated as alternatives to primary operative revascularization. The catheter-directed infusion of thrombolytic agents and the use of percutaneous mechanical thrombectomy devices can effect recanalization of the occluded vessel, unmasking the underlying culprit lesion responsible for the occlusive event. The lesion can then be treated with an endovascular approach such as balloon dilatation or stenting; alternatively, a limited open surgical approach can be performed on an elective basis. Several studies have documented a lower rate of death using this approach compared with conventional treatment with primary operation. Although recent randomized trials have failed to confirm reductions in the number of deaths, a similar rate of death and amputation has been achieved with thrombolysis versus operative therapy, concurrent with a substantial reduction in the need for open surgical procedures over midterm follow-up. These observations suggest that an initial course of catheter-directed thrombolysis with or without percutaneous mechanical thrombectomy is an appropriate first step for patients who present with acute peripheral arterial occlusion.