Related Experiment Videos
Outcome of catheter-directed thrombolysis for lower extremity arterial bypass occlusion
Mark R Nehler1, Renee J Mueller, Robert B McLafferty
1Section of Vascular Surgery, University of Colorado Health Science Center, Denver, CO 80262-0312, USA. Mark.Nehler@uchsc.edu
Insights
Catheter-directed thrombolysis (CDT) for lower extremity arterial bypass (LEAB) occlusion has high initial success but often fails long-term, leading to complications. Early graft replacement is recommended for better outcomes.
Area of Science:
- Vascular Surgery
- Interventional Radiology
- Cardiovascular Research
Background:
- Lower extremity arterial bypass (LEAB) occlusion is a serious condition requiring effective treatment.
- Catheter-directed thrombolysis (CDT) is a minimally invasive option for LEAB occlusion.
Purpose of the Study:
- To evaluate the clinical outcomes of patients treated with CDT for LEAB occlusion.
- To assess technical success, complications, secondary patency, and limb salvage rates.
Main Methods:
- Retrospective review of 104 patients with LEAB occlusion treated with CDT between 1988 and 2001.
- Analysis of technical success, complications, secondary procedures, graft replacement, and infection rates.
- Evaluation of limb salvage and survival rates over a mean follow-up of 45 months.
Main Results:
- CDT restored patency in 77% of LEAB occlusions.
- Secondary patency rates were 32% at 1 year and 19% at 5 years (intention-to-treat).
- Limb salvage rates were 73% at 1 year and 55% at 5 years; 5-year survival was 56%.
Conclusions:
- Despite high initial success, CDT for LEAB occlusion frequently leads to eventual failure and significant morbidity.
- Recurrent occlusions necessitate interventions, potentially leading to graft infection, replacement, or limb loss.
- An initial CDT attempt followed by liberal graft replacement for failures is advocated.
Objective:
The purpose of this study was to determine the clinical outcome of patients undergoing catheter-directed thrombolysis (CDT) for lower extremity arterial bypass (LEAB) occlusion.
Methods:
A retrospective review was performed of two university-based practices from 1988 to 2001. All patients with LEAB occlusion (<14 days by history) undergoing CDT as initial treatment were included. Technical success, complications, secondary patency, and limb salvage were examined. Additional analysis examined secondary procedures performed for residual lesions or failed CDT and the number of LEABs that were replaced or that became infected.
Results:
One hundred four patients (77% male; mean age, 65 years) had 109 LEAB occlusions. CDT restored patency in 77%. Of the 25 LEABs that failed initial CDT, 15 underwent surgical thrombectomy/revision, four were replaced, and six underwent no further interventions. Of the 84 LEABs successfully lysed, 51 had residual lesions that underwent revision with interventional (n = 30) or surgical (n = 15) techniques or both (n = 6). Median hospital stay was 8 days with three periprocedural deaths. One quarter of CDT procedures had bleeding or thrombotic complications or both. The mean follow-up period was 45 months. Secondary patency rates on an intention-to-treat basis (attempted thrombolysis) were 32% and 19% at 1 and 5 years, respectively. After successful CDT, the 1-year secondary patency rate was comparable in LEABs with or without residual lesions (42% versus 45%). Overall, the limb salvage rates were 73% and 55% at 1 and 5 years, respectively. The survival rate was 56% at 5 years. Ten of the 54 LEABs (19%) that eventually failed after successful CDT had three or more reocclusive episodes. Seven LEABs (8.3%) salvaged with CDT eventually became infected from recurrent interventions; six of these necessitated major amputation. Twenty LEABs initially salvaged with CDT were replaced (four immediately and 16 after episodes of recurrent ischemia). Two patients died during hospitalization for treatment of recurrent ischemia.
Conclusion:
Despite relatively high initial technical success for LEAB thrombolysis, eventual failure is the rule rather than the exception. Recurrent LEAB occlusions lead to significant morbidity, including recurrent interventions, eventual graft infection/replacement, and limb loss. However, LEAB replacement has substantial problems associated with limited conduit, reoperative anatomy, and subsequent wound complications. We therefore advocate an initial attempt at CDT with liberal use of graft replacement for early and late failures or as an initial strategy in those with favorable remaining conduit.