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Published on: November 26, 2013
Catheter Directed Thrombolysis for Not Immediately Threatening Acute Limb Ischaemia: Systematic Review and
Sabrina A N Doelare1, Thomas W A Koedam2, Harm P Ebben1
1Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Vrije Universiteit Amsterdam, Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands.
Insights
Catheter directed thrombolysis (CDT) for acute lower limb ischaemia (ALI) shows high initial success but poor long-term outcomes, including low patency and amputation risk. Further research is needed to clarify its role.
Area of Science:
- Vascular Surgery
- Interventional Radiology
- Cardiology
Background:
- Acute lower limb ischaemia (ALI) poses a significant risk to limb viability and patient survival.
- Catheter directed thrombolysis (CDT) is a minimally invasive treatment option for ALI.
- This review focuses on Rutherford class I ALI, which is not immediately threatening.
Approach:
- A systematic review and meta-analysis was conducted using data from PubMed, Embase, and Cochrane Library.
- Studies published between 1990 and 2022 involving patients with Rutherford I ALI treated with CDT were included.
- Outcomes assessed included treatment duration, angiographic success, bleeding, amputation, mortality, patency, and functional outcomes.
Key Points:
- Thirty-nine studies with 1,861 patients were analyzed, revealing a pooled treatment duration of 2 days and 80% angiographic success.
- Thirty-day amputation-free survival was high (98%), with a 5% major bleeding rate and 3% mortality.
- However, one-year amputation-free survival was 71%, and one-year patency rates were only 48%, indicating poor long-term results.
Conclusions:
- CDT for Rutherford I ALI demonstrates high technical success but is associated with suboptimal long-term limb salvage and patency.
- The risk of major amputation remains substantial despite initial treatment success.
- Further research is warranted to evaluate CDT's effectiveness considering patient factors like age and comorbidities.
Objective:
This systematic review and meta-analysis reports the outcomes of catheter directed thrombolysis (CDT) in patients with not immediately threatening (Rutherford I) acute lower limb ischaemia (ALI).
Data Sources:
PubMed, Embase, and the Cochrane Library.
Review Methods:
A systematic search of PubMed, Embase, and the Cochrane Library was performed to identify observational studies and trials published between 1990 and 2022 reporting on the results of CDT in patients with Rutherford I ALI. A meta-analysis was performed using a random effects model with 95% confidence intervals (CIs). The outcomes of interests were treatment duration, angiographic success, bleeding complications, amputation and mortality rates, primary and secondary patency, and functional outcome expressed as pain free walking distance.
Results:
Thirty-nine studies were included, comprising 1 861 patients who received CDT for not immediately threatening ALI. Funnel plots showed an indication of publication bias, and heterogeneity was substantial. Data from 5 to 13 studies were included in the meta-analysis. The pooled treatment duration was 2 days (95% CI 1 - 2), with an angiographic success rate of 80% (95% CI 73 - 86) and a 30 day freedom of amputation rate of 98% (95% CI 92 - 100). The major bleeding rate was 5% (95% CI 2 - 14), with a 30 day mortality rate of 3% (95% CI 1 - 5). The amputation free survival rate was 71% (95% CI 62 - 80) at the one year and 63% (95% CI 51 - 73) at the three year follow up. Long term patency rates were retrieved from four studies: 48% at one year (95% CI 27 - 70). No data could be retrieved on patient walking distance.
Conclusion:
Although CDT in the treatment of not immediately threatening ALI showed high angiographic success, the long term outcomes were relatively poor, with low patency and a substantial risk of major amputation. Further research is required to interpret the outcome of CDT in the context of potential confounders such as age and comorbidities.
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