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Is thrombolysis of occluded popliteal and tibial bypass grafts worthwhile?
1Department of Surgery, University of California School of Medicine, San Diego 92103-8401.
Insights
Pulse-spray thrombolysis effectively restores blood flow in blocked infrainguinal bypass grafts. For grafts failing within a year, replacement is recommended; older grafts may benefit from thrombolysis and revision.
Area of Science:
- Vascular Surgery
- Interventional Radiology
- Thrombosis Management
Background:
- Infrainguinal bypass graft thrombosis is a significant cause of graft failure and limb loss.
- Thrombolysis offers a potential method for restoring patency in occluded grafts.
- Pulse-spray thrombolysis is a specific technique used for graft recanalization.
Purpose of the Study:
- To analyze the short- and long-term outcomes of infrainguinal bypass graft thrombolysis.
- To evaluate factors influencing patency and limb salvage after thrombolysis.
- To assess the efficacy of pulse-spray thrombolysis for occluded grafts.
Main Methods:
- Retrospective review of 31 patients with 40 episodes of graft thrombosis treated with thrombolysis.
- Evaluation of graft age, material, anatomy, symptoms, treatment, anticoagulation, and occlusion duration.
- Assessment of pulse-spray thrombolysis technique, dose, and duration.
Main Results:
- Thrombolysis successfully reestablished patency in 92% of treated grafts.
- Mean secondary patency was significantly higher for synthetic grafts (23.8 months) compared to vein grafts (8.4 months).
- Graft age influenced outcomes, with grafts over 1 year old showing better mean secondary patency (21.5 months) than those less than 1 year old (7.0 months). Limb salvage and patient survival rates were 84% at 30 and 42 months, respectively.
Conclusions:
- Pulse-spray thrombolysis is effective for rapid recanalization of thrombosed infrainguinal bypass grafts.
- Grafts failing within the first year warrant replacement, while thrombolysis and revision are better suited for grafts older than one year.
- Vein grafts have poorer long-term patency compared to synthetic grafts following thrombosis and thrombolysis.
Purpose:
We analyzed the short- and long-term results for patients undergoing thrombolysis of occluded infrainguinal bypass grafts at our institution over a 62-month period.
Methods:
Thirty-one patients with 40 episodes of graft thrombosis in 33 grafts managed by thrombolysis were retrospectively reviewed. The effects of graft age, material, and anatomy, symptoms, treatment, anticoagulation, and occlusion duration were evaluated for impact on patency after thrombolysis. Dose and duration of therapy with use of the technique of pulse-spray thrombolysis was assessed.
Results:
Thrombolysis successfully reestablished patency in 92% of grafts treated. Mean lysis time and urokinase dose were 118 minutes and 607,000 units, respectively. Responsible lesions were identified and treated by angioplasty or surgery in 35 of 37 cases. The patency rate after thrombolysis was 28% at 30 months, and the secondary patency rate was 46% at 18 months. Duration of occlusion, symptoms, treatment, graft anatomy, and prior graft revision did not impact on patency. Mean secondary patency was 21.5 months in grafts in place over 1 year and 7.0 months in grafts in place for less than 1 year. Mean secondary patency was 23.8 months in polytetrafluoroethylene grafts and 8.4 months in vein grafts. The limb salvage rate was 84% at 30 months, and the patient survival rate was 84% at 42 months.
Conclusions:
Pulse-spray thrombolysis is effective in rapidly recanalizing thrombosed infrainguinal grafts. Grafts failing in the first year after placement should generally be replaced, reserving thrombolysis and revision for grafts greater than 1 year old. Vein grafts tolerate thrombosis less well than synthetic conduits and have decreased long-term patency.