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OBJECTIVES:
The role of catheter directed thrombolysis (CDT) in the treatment of acute arterial and venous thrombosis may require prolonged periods of time (days) to achieve successful lysis. Prolonged thrombolysis increases the incidence of intracranial bleed, stroke, and local complications. It is expensive and increases hospital length of stay. To minimize these potentially negative outcomes we developed an aggressive Fast Track Approach (FTA) that included the use of balloon angioplasty and stenting before the thrombus was completely lysed. The goal of a FTA is to restore patency during the first procedure thus eliminating the need for thrombolysis check(s).
METHODS:
A single surgeon’s experience (EA) with 31 consecutive patients treated with FTA over a recent 18 months period was analyzed. The FTA protocol included an angiogram of the inflow and outflow vessels as well as segmentally alongside the occluded segment. This was followed by intra-clot infusion of thrombolytic agent and mechanical thrombectomy. Next, balloon angioplasty of the remaining occluded segment(s) and stenting in case of recoil as shown during deflation and re-inflation of the angioplasty balloon (waste) were performed.
RESULTS:
Thirty-seven procedures were performed in 31 patients. The median age was 63 (41-98) years. Of these, 58% were females. The indications for lytic therapy were acute arterial occlusion in 29 patients (78%) and acute venous thrombosis in 8 (22%). Co-morbidities included hypertension, diabetes mellitus, and hypercholesterolemia in 73.0%, 43.5%, and 37.8% of patients, respectively.
The average operating room time was 135 minutes (69-244 min) and the average total alteplase and heparin infusion per procedure was 10.4 mg and 8,000 units, respectively. The average cost with interventional tools and medications was \,053 per procedure. Median post-operative length of stay was 1 day (range 0-7 days). Successful FTA occurred in 78% (29/37 cases). Periprocedural complications included acute renal failure in 2.7% and blood transfusion in 5.4%. No deaths, limb loss, pulmonary embolism, myocardial infarction nor compartment syndrome occurred in this series. Extent of the thrombotic process, gender, duration of symptoms, venous versus arterial were not related to outcome of FTA.
CONCLUSIONS:
This preliminary data suggest that an aggressive approach at balloon angioplasty and stenting prior to complete lysis of the thrombotic event can generate acceptable results and minimize complications related to prolonged thrombolytic therapy.