Treatment of acute occlusion of peripheral arteries

Acute lower-extremity peripheral arterial occlusion is responsible for a wide variety of complications culminating in limb loss or death. The real incidence of acute limb ischemia (ALI) in the general population is not well known even though recent epidemiological data estimated that it occurs in 14 out of a population of 100,000 and that it accounts for 10-16% of the vascular workload. The two main causes of acute occlusion of peripheral arteries are: (i) embolism and (ii) thrombosis, which usually occurs in cases of severe atherosclerotic stenoses. Arterial flow can be restored through operative revascularization or pharmacological dissolution of thrombus. Immediate surgical revascularization is indicated in the profoundly ischemic limb. Catheter embolectomy is also usually preferred for emboli to a non-atherosclerotic limb. Catheter-directed thrombolysis has become a commonly employed technique in the treatment of ALI. It may offer definitive treatment without the need of major surgery in a significant subset of patients with acute occlusion of a native leg artery or a bypass graft. A number or reports from individual centers and three large prospective studies, which compared intra-arterial thrombolysis to surgical intervention, suggest that thrombolytic therapy may be an appropriate initial treatment of ALI, provided that the limb is not immediately or irreversibly threatened. Using this approach, the underlying lesions can be further defined by angiography, and the percutaneous or surgical revascularization procedure can be performed. However, severe bleeding is still a non-rare complication of intra-arterial thrombolysis and the risk of intracranial hemorrhage is 1-2%.