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Contemporary Results of Intra-Arterial Thrombolysis for Acute and Acute-On-Chronic Lower Limb Ischemia

Roberto Falso1, Elena Giacomelli1, Walter Dorigo1

  • 1Section of Vascular Surgery, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.

Annals of Vascular Surgery
|November 13, 2025
PubMed

Insights

Catheter-directed thrombolysis (CDT) effectively treats infrainguinal arterial occlusions in acute limb ischemia (ALI) and acute-on-chronic limb ischemia (ACLI). While long-term patency is limited, CDT is a safe revascularization option, especially when combined with other procedures.

Area of Science:

  • Vascular Surgery
  • Interventional Radiology
  • Cardiovascular Medicine

Background:

  • Infrainguinal arterial occlusions causing acute limb ischemia (ALI) or acute-on-chronic limb ischemia (ACLI) require effective revascularization.
  • Catheter-directed thrombolysis (CDT) is a potential treatment option, but its outcomes and safety in these specific settings need thorough evaluation.

Purpose of the Study:

  • To assess the immediate and long-term efficacy of CDT for infrainguinal arterial occlusions in patients with ALI and ACLI.
  • To evaluate the safety and durability of CDT across diverse clinical and anatomical presentations.
  • To identify factors influencing patient outcomes following CDT.

Main Methods:

  • Retrospective analysis of 128 patients undergoing CDT for infrainguinal occlusions (January 2014 - December 2024).
  • Patients categorized into ALI (n=85) and ACLI (n=43) groups.
  • Urokinase infusion via multihole catheters used for CDT; outcomes assessed via Kaplan-Meier analysis (patency, limb salvage, amputation-free survival, freedom from reintervention).

Main Results:

  • CDT achieved technical success in 85.1% of patients, with comparable rates in ALI and ACLI.
  • At 30 days, major amputation and mortality rates were 4.6% and 3.1%, respectively; three major bleeding events occurred.
  • Five-year estimated survival was 74.2%; limb salvage was 79% (ALI) vs. 86% (ACLI), and amputation-free survival was 58.5% vs. 74%. Five-year primary patency was 22% (ALI) vs. 32.5% (ACLI), and secondary patency was 26% vs. 48%. Freedom from reintervention was 36% (ALI) vs. 43% (ACLI). Chronic kidney disease independently predicted adverse outcomes (HR: 2.9).

Conclusions:

  • CDT is a safe and effective revascularization strategy for infrainguinal occlusions in both ALI and ACLI.
  • Clinical presentation and lesion anatomy did not significantly impact outcomes, whereas comorbidities, particularly chronic kidney disease, strongly correlated with poor prognosis.
  • Despite limited long-term patency, CDT is a valuable option for selected patients, especially when integrated with adjunctive endovascular or surgical techniques.
Abstract

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