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Published on: January 18, 2018
The Clinical Impact of Access Site Selection for Successful Thrombolysis and Intervention in Acute Critical Lower
Adam Csavajda1, Karoly Toth1, Nandor Kovacs1
1Department of Invasive Cardiology, Bacs-Kiskun County Hospital, Teaching Hospital of the Albert Szent-Györgyi Medical School, University of Szeged, Nyiri Street 38, 6000 Kecskemet, Hungary.
Insights
Catheter-directed thrombolysis (CDT) effectively treats acute limb ischemia (ALI) using radial, brachial, or femoral access, with radial approach showing fewer complications. Risk factors for adverse events include Rutherford stage IIB, iliac artery occlusion, failed thrombolysis, and diabetes.
Area of Science:
- Vascular Surgery
- Interventional Radiology
Background:
- Acute limb ischemia (ALI) presents significant clinical challenges due to high complication, comorbidity, and mortality rates.
- Effective treatment strategies for ALI are crucial for improving patient outcomes.
Purpose of the Study:
- To compare the acute success and complication rates of catheter-directed thrombolysis (CDT) across transradial, transbrachial, and transfemoral access sites for acute lower limb vascular occlusion.
- To evaluate the 1-year outcomes of CDT and medical therapy (MT) in patients with ALI.
Main Methods:
- Retrospective analysis of 84 consecutive ALI patients treated with CDT between 2008 and 2019.
- Assessment of primary safety endpoints (major adverse events [MAEs], major adverse limb events [MALEs], access site complications) and secondary efficacy endpoints (technical/clinical success, procedure time, radiation dose).
Main Results:
- CDT technical and clinical success rates were 88%. Radial access was associated with fewer access site complications compared to brachial or femoral.
- One-year mortality was 14.3%, with cumulative MAEs and MALEs at 50% and 40.5%, respectively.
- Independent predictors for MAEs included Rutherford stage IIB, external iliac artery occlusion, unsuccessful thrombolysis, and diabetes. Rutherford stage IIB and external iliac artery occlusion predicted MALEs.
Conclusions:
- CDT is a safe and effective treatment for ALI, with radial access offering an advantage in reducing access site complications.
- Identifying high-risk patients (Rutherford stage IIB, iliac artery occlusion, diabetes, failed thrombolysis) is essential for managing ALI outcomes.
Abstract:
Background: Acute limb ischaemia (ALI) is of great clinical importance due to its consequent serious complications and high comorbidity and mortality rates. The purpose of this study was to compare the acute success and complication rates of CDT performed via transradial, transbrachial, and transfemoral access sites in patients with acute lower limb vascular occlusion and to investigate the 1-year outcomes of CDT and MT for ALI. Methods: Between 2008 and 2019, 84 consecutive patients with ALI were treated with CDT in a large community hospital. Data were collected and retrospectively analysed. The primary ("safety") endpoints encompassed major adverse events (MAEs), major adverse limb events (MALEs), and the occurrence of complications related to the access site. Secondary ("efficacy") endpoints included both technical and clinical achievements, treatment success, fluoroscopy time, radiation dose, procedure time, and the crossover rate to an alternative puncture site. Results: CDT was started with radial (n = 17), brachial (n = 9), or femoral (n = 58) access. CDT was technically successful in 74/84 patients (88%), but additional MT and angioplasty and/or stent implantation was necessary in 17 (20.2%) and 45 cases (53.6%), respectively. Clinical success was achieved in 74/84 cases (88%). The mortality rate at 1 year was 14.3%. The cumulative incidence of MAEs and MALEs at 12 months was 50% and 40.5%, respectively. After conducting multivariate analysis, history of Rutherford stage IIB (hazard ratio [HR], 3.64; 95% confidence interval [CI], 1.58-8.41; p = 0.0025), occlusion of the external iliac artery (HR, 27.52; 95% CI, 2.83-267.33; p = 0.0043), being a case of clinically unsuccessful thrombolysis (HR, 7.72; 95% CI, 2.48-23.10; p = 0.0004), and the presence of diabetes mellitus (HR, 2.18; 95% CI, 1.01-4.71; p = 0.047) were independent predictors of a high MAE mortality rate at 12 months. For MALEs, statistically significant differences were detected with the variables history of Rutherford stage IIB (HR, 4.30; 95% CI, 1.99-9.31; p = 0.0002) and external iliac artery occlusion (HR, 31.27; 95% CI, 3.47-282.23; p = 0.0022). Conclusions: Based on the short-term results of CDT, acute limb ischaemia can be successfully, safely, and effectively treated with catheter-directed thrombolytic therapy with radial, brachial, or femoral access. However, radial access is associated with fewer access site complications. A history of Rutherford stage IIB, occlusion of external iliac artery, unsuccessful thrombolysis, and the presence of diabetes mellitus were independently associated with an increased risk of MAEs. A history of Rutherford stage IIB and external iliac artery occlusion are independent predictors of MALEs.
