Fast-track Thrombolysis Protocol For Acute Limb Ischemia
Enrico Ascher, MD, Pavel Kibrik, DO, Syed Ali Rizvi, DO, Ahmad Alsheekh, MD, Natalie Marks, MD.
NYU-Langone Brooklyn, brooklyn, NY, USA.
Catheter-directed thrombolysis(CDT)in the treatment of acute lower-extremity arterial occlusions(ALI)often requires more than one interventional session to yield successful outcomes. CDT is generally expensive, requiring prolonged hospital stay that may be associated with increased local and systemic hemorrhagic complications.Five years ago, we developed the Fast-Track Thrombolysis Protocol for Arteries(FTTP-A)to address these issues.The goal of FTTP-A is to restore patency during the initial session of thrombolysis, thereby minimizing costs and complications associated with prolonged thrombolysis.
A retrospective analysis of 42 patients treated for ALI utilizing FTTP-A at our institution from January 2014 to February 2019 was performed.The protocol includes:peri-adventitial injection of lidocaine at the arterial puncture site under ultrasound guidance, contrast arteriography of the entire target segment,pharmacomechanical rheolytic thrombectomy of the occluded arterial segment, tissue plasminogen activator(tPA)infusion along the occluded segment, balloon maceration of the thrombus, and if indicated, stent placement in areas of significant(≥30%)stenosis refractory to thrombolysis and balloon angioplasty. Once the thrombus or stenosis was cleared, patients were placed on oral antithrombotic therapy.
Fourty-two primary FTTP-As(50 total interventions)were performed in 42 patients. The median age was 67.2±12.2 years(range 41-98),of which 54.8% were male.59.5% of the procedures were performed on the left lower extremity. Initial arterial access sites as obtained via the common femoral artery(CFA),in 39/42 cases(92.9%),with the remaining three being
obtained in a left bypass access site, a right femoral-popliteal graft and a right femoral-femoral graft. The mean operative time was 148.9±62.9 minutes(range: 83-313),and the mean volume of tPA infused was 9.7±4.0 mg(range: 2-20). The median cost with interventional tools and medications was$4673.19 per procedure. Mean post-operative length of stay was 3.1±4.5 days(range: 1-25).Median post-operative length of stay was 1 day.Mean post-operative follow-up was 27±19.2 months(range: 0-62). Successful single-session FTTP-A was accomplished in 81%(n=34/42) of cases.The remaining 8 cases(19%)required one additional session. Thirty-four of the 42 patients (81%)required arterial stenting. Periprocedural complications consisted of 1 patient with hematuria, which resolved,and 1 patient with thrombocytopenia, which resolved. No patients experienced re-thrombosis within 30-days of FTTP-A. Over the 5-year study period, there were no significant local or systemic hemorrhage, limb loss, or mortality related to this protocol.
FTTP-A, as presented herein, appears to be a safe, effective, and cost-effective technique in the resolution of acute lower-extremity arterial occlusions.
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