Use of Thrombolysis in Acute Lower Extremity Ischemia with Known Distal Target Vessel for Revascularization
Nicholas J. Gargiulo, III, MD FACS, Maya Chandramoulli.
The Brookdale University Hospital & Medical Center, New York, NY, USA.
OBJECTIVES: Thrombolysis is an important therapeutic tool in localizing a distal arterial target vessel in patients presenting with acute lower extremity ischemia. In some patients, however, thrombolysis fails to identify a suitable target vessel for lower extremity bypass often resulting in amputation. Pre-existing knowledge of the distal target vessel may obviate the need for thrombolytic-mediated distal arterial recanalization. We report our five year experience in managing patients with acute lower extremity ischemia with a known distal arterial target vessel without thrombolytic therapy.
METHODS: Over a five year period, 27 patients presented with varying degrees of lower extremity ischemia SVS I (7), SVS II (18), SVS III (2). All patients with emboli were excluded from this experience. Twenty three of 27 patients had acute graft occlusions and the remaining four patients had native arterial occlusions. In 14 of 27 patients, the distal peripheral arterial status was unknown and required thrombolytic therapy. In the other 13 patients, a known distal arterial target vessel was used for successful revascularization without the aid of thrombolysis.
RESULTS: The 14 patients who failed to demonstrate a distal target vessel after thrombolysis ultimately required below-knee or above-knee amputation despite surgical intervention exploring distal arterial target vessels for revascularization. The other 13 patients with a known distal arterial target did not require thrombolysis and underwent successful revascularization. Despite this, 3 of these 13 patients ultimately required amputation between 3 and 6 months.
CONCLUSIONS: Pre-existing knowledge of the distal arterial target vessel obviates the need of thrombolytic therapy in those patients presenting with acute lower extremity ischemia. Additionally, amputation may be avoided in those patients who fail to manifest a distal arterial target after thrombolytic therapy in which the distal arterial target vessel is already known.
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