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Thrombolysis of occluded infra-inguinal bypass grafts: is it worthwhile?
S Bonhomme1, G Trotteur, H Van Damme
1Service des Urgences, CHU de Liège, Liège, Belgium. suzanne.bonhomme@chu.ulg.ac.be
Insights
Catheter-guided intra-arterial thrombolysis can reopen thrombosed infra-inguinal bypass grafts, but long-term success is limited. Selective use for recent occlusions in critical limb ischemia is recommended.
Area of Science:
- Vascular Surgery
- Interventional Radiology
- Thrombosis Management
Background:
- Infra-inguinal bypass graft thrombosis leads to limb-threatening ischemia.
- Optimal management strategies for thrombosed infra-inguinal bypass grafts remain unclear.
Purpose of the Study:
- To evaluate the safety and efficacy of catheter-guided intra-arterial thrombolysis for thrombosed infra-inguinal bypass grafts.
- To identify factors influencing graft patency and limb salvage after thrombolytic procedures.
Main Methods:
- A continuous cohort study of 106 thrombolytic procedures was conducted between 1993 and 2008.
- Analysis focused on initial success rates, re-occlusion rates, and factors affecting long-term outcomes.
Main Results:
- Initial success rate for thrombolysis was 76%, but the mid-term re-occlusion rate was 58% at 45 months.
- Factors predicting poor long-term outcomes included thrombosed vein grafts, occlusions older than 2 weeks, poor run-off, and uncorrected underlying stenosis.
Conclusions:
- Thrombolysis is most effective for recent (<2 weeks) occlusions in infra-inguinal bypass grafts in place for at least 1 year, particularly in cases of critical limb ischemia.
- While offering advantages, the long-term outcomes of thrombolysis are often disappointing, and hemorrhagic risks must be considered.
- The superiority of catheter-guided thrombolysis over surgical revascularization requires further investigation.
Background:
Thrombosis of an infra-inguinal bypass graft often results in a limb-threatening ischemia. There is no consensus on the optimal management strategy.
Aim Of The Study:
To analyse safety and efficacy of catheter-guided intra-arterial thrombolysis to re-open thrombosed infra-inguinal bypass grafts and to identify factors that influence graft patency and limb salvage rate after thrombolytic procedures.
Methods:
A continuous cohort-study of 106 thrombolytic procedures between 1993 to 2008.
Results:
Despite a high initial success rate (76%), the mid-term results are less convincing, with a 58% re-occlusion rate at 45 months follow-up. Thrombosed vein grafts, old (2 weeks or more) occlusions, poor run-off and failure to identify or rectify an underlying causative stenosis are determinant for a poor long-term outcome of thrombolytic procedures.
Comments:
The outcome results of author's experience are consistent with literature reports. Thrombolysis of occluded infra-inguinal bypass grafts should be limited to selective cases (recent occlusion, prosthetic or vein graft in place since 1 year or more, critical limb ischemia). Despite its obvious advantages, the long-term outcome of thrombolytic procedures is deceiving. The inherent risk of hemorrhagic complications should also be taken in account at the decision making of treatment strategy. The question whether, in general, catheter-guided selective intra-arterial thrombolysis offers a significant advantage over operative revascularisation (thrombectomy or new bypass) remains unanswered. A more selective approach seems to favour thrombolysis as most appropriate strategy in the management of recent (< 2 weeks) thromboses of grafts in place since at least 1 year.
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