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Local thrombolysis for occluded arterial grafts: is the yield worth the effort?
H Lacroix1, R Suy, A Nevelsteen
1Department of Vascular Surgery, University Hospital Gasthuisberg, Leuven, Belgium.
Insights
Local thrombolytic therapy for acute graft occlusion showed limited long-term success. While alteplase achieved high lysis rates, complications and poor graft patency highlight challenges in maintaining blood flow.
Area of Science:
- Vascular Surgery
- Interventional Radiology
- Thrombolytic Therapy
Background:
- Graft thrombosis is a significant complication in vascular surgery.
- Acute severe but reversible ischemia necessitates prompt intervention.
- Infra-inguinal synthetic grafts are commonly affected.
Purpose of the Study:
- To evaluate the efficacy and complications of local thrombolytic therapy for recently occluded grafts.
- To compare the effectiveness of different thrombolytic agents.
- To assess the late outcomes of successfully lysed grafts.
Main Methods:
- Local thrombolysis using urokinase, streptokinase, or alteplase via intra-arterial catheter.
- Analysis of complete and partial angiographical lysis rates.
- Assessment of need for complementary endovascular/surgical interventions.
- Documentation of complications and late patency/limb salvage rates.
Main Results:
- Complete lysis achieved in 72% of grafts, with alteplase showing the highest success rate (89%).
- 17 patients required additional interventions for stenosis or limb salvage.
- Complications occurred in 30% of cases, including bleeding (3 fatal) and distal embolization.
- Late outcomes were poor: 6-month primary patency was 19%, and limb salvage was 64%.
Conclusions:
- Local thrombolytic therapy can achieve initial graft recanalization but is associated with significant complications.
- Maintaining restored graft patency remains a major challenge.
- Thrombolysis is not an ideal standalone treatment for thrombosed grafts.
Abstract:
This study reports the results and complications of local thrombolytic therapy of 50 recently occluded grafts. These occurred in 41 patients with acute severe but still reversible ischemia. The majority were infra-inguinal synthetic grafts. Thrombolysis was induced with urokinase (n = 1), streptokinase (n = 11) or alteplase (n = 38) via an intra-arterial catheter. Complete angiographical lysis was obtained in 36 grafts (72%) and partial lysis in 6 (12%). The highest lysis rate was obtained with alteplase (32/36; 89%). Complementary endovascular and/or surgical intervention was needed in 17 patients to correct an underlying stenosis and/or to save the limb. Fifteen complications occurred (30%) of which distal embolization (n = 4) and bleeding (n = 8 of which 3 fatal) were the most frequent. Six of the bleeding episodes occurred in patients on chronic aspirin intake. The late results were poor. At six months, the primary patency of successfully lysed grafts dropped to 19% and the limb salvage rate to 64%. Thrombolytic therapy is far from the ideal management of thrombosed grafts: maintenance of restored patency is the challenge.