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Thrombolysis of occluded femoropopliteal grafts
Insights
Urokinase thrombolysis demonstrated superior outcomes (77% success) and fewer complications (23%) compared to streptokinase for occluded femoropopliteal grafts. This effective treatment offers advantages over thrombectomy, preserving graft integrity and improving distal circulation.
Area of Science:
- Vascular Surgery
- Interventional Radiology
- Thrombolytic Therapy
Background:
- Femoropopliteal graft occlusion is a significant clinical challenge.
- Thrombectomy has limitations in treating occluded grafts.
Purpose of the Study:
- To compare the efficacy and safety of streptokinase versus urokinase for thrombolytic therapy in occluded femoropopliteal grafts.
- To evaluate the long-term patency and outcomes of thrombolytic treatment.
Main Methods:
- A series of 44 patients with occluded femoropopliteal grafts were treated.
- 22 patients received streptokinase, and 22 received urokinase via indwelling arterial catheter.
- Heparin infusion was used concomitantly to prevent recurrent thrombosis.
Main Results:
- Urokinase achieved a higher success rate (77%) with fewer complications (23%) compared to streptokinase (41% success, 50% complications).
- 11 out of 26 successfully treated grafts remained patent at an average of 12 months.
- Surgical thrombectomy was ineffective in revascularizing limbs in failure cases.
Conclusions:
- Urokinase is a more effective and safer thrombolytic agent for femoropopliteal graft occlusion than streptokinase.
- Thrombolysis offers advantages over thrombectomy, including less graft trauma and improved distal runoff.
- Despite time and cost, thrombolysis provides significant benefits for selected patients with occluded femoropopliteal grafts.
Abstract:
In a series of 44 occluded femoropopliteal grafts, streptokinase was used for thrombolytic therapy in 22 cases and urokinase in 22 cases. In most cases, thrombolytic agents were administered via an indwelling arterial catheter directly into the proximal thrombus. The catheter tip was advanced as thrombolysis occurred. Compared with streptokinase infusions, urokinase bolus injection followed by infusion had better results (77% vs 41%) and fewer complications (23% vs 50%). During thrombolytic infusion, concomitant heparin infusion was usually used to reduce the frequency of thrombus formation on the infusion catheter or recurrent thrombosis of the graft, once the tip of the infusion catheter was advanced distally. Follow-up in 23 of 26 successful cases showed that 11 of the grafts remained open at an average follow-up of 12 months or until the patient died. The 12 grafts that reoccluded remained open an average of 3 months. In none of the 18 failures was simple surgical thrombectomy or thrombectomy with graft revision effective in revascularizing the distal limb. The advantages of thrombolysis compared with thrombectomy are less trauma to the graft, which is especially important in vein grafts, and improved distal runoff due to lysis of infrapopliteal thrombus. Even among cases considered failures in this series, the surgical approach was often simplified because of partial thrombolysis. Thrombolysis requires a considerable amount of time, effort, and expense, but in certain patients where thrombectomy is indicated for the treatment of occluded femoropopliteal grafts this technique offers important advantages.