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The practical implications of recent trials comparing thrombolytic therapy with surgery for lower extremity ischemia
1Department of Surgery, University of Southern California, School of Medicine, Los Angeles 90033-4612, USA.
Insights
Catheter-based thrombolysis for lower extremity ischemia can reduce subsequent surgery needs. However, surgical revascularization remains optimal, though thrombolysis improves limb salvage for acute bypass graft occlusions.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
Background:
- Catheter-based thrombolysis is a common treatment for lower extremity ischemia.
- Three major trials (Rochester, STILE, TOPAS) have compared thrombolysis with surgical revascularization.
Purpose of the Study:
- To assess the comparative value of thrombolytic therapy versus surgical revascularization for lower limb ischemia.
Main Methods:
- Review of three prospective randomized trials: Rochester, STILE, and TOPAS.
- Comparison of outcomes between thrombolytic therapy and surgical revascularization.
Main Results:
- Thrombolysis as initial therapy reduces subsequent surgical procedure magnitude in 40-60% of patients.
- Recurrent ischemia is frequent, especially for native artery or chronic bypass graft occlusions.
- Thrombolysis enhances limb salvage at 1 year for acute bypass graft occlusions and may offer survival benefits for specific diabetic subgroups.
Conclusions:
- Surgical revascularization is the preferred treatment for most lower limb ischemia cases.
- Initial thrombolysis can decrease the extent of subsequent surgery and improve limb salvage in acute bypass graft occlusions.
Unlabelled:
Catheter-based thrombolysis for lower extremity ischemia is a well-accepted and frequently used technique. Three prospective randomized trials, Rochester, STILE, and TOPAS, which compared thrombolytic therapy with traditional surgical revascularization for lower limb ischemia, have recently been published.
Methods:
These three trials are reviewed with the intent of assessing the relative of value of thrombolytic therapy and surgical revascularization for lower limb ischemia.
Results:
As an initial therapy, thrombolysis reduces the magnitude of any subsequent surgical procedure in approximately 40% to 60% of patients. However, recurrent ischemia is frequent, and the subsequent need for surgical revascularization is common for any native artery occlusion or chronic (> 14 days) bypass graft occlusion. In the patient with an acute bypass graft occlusion, the incidence of recurrent ischemia is less and limb salvage at 1 year is enhanced when treated initially by thrombolysis. A possible survival benefit after thrombolysis was suggested in the Rochester trial and in the STILE trial for diabetics with femoral-popliteal occlusions.
Conclusions:
Surgical revascularization remains the optimal therapy for most patients with lower limb ischemia. However, thrombolysis as an initial therapy does reduce the magnitude of any subsequent surgical procedure and provides improved limb salvage for patients with acute bypass graft occlusions.