Acute critical limb ischemia:loco regional low-dose thrombolysis makes both good early and late results, but with high logistic costs

im. The aim of this paper was to review our contemporary experience treating Acute Critical Limb Ischemia (ACLI) via thrombolysis, evaluating both clinical early and late results, periprocedural safety, survival of this group of patients and logistic problems. Methods. A retrospective review was conducted of 112 patients who were treated with loco regional low-dose thrombolysis for ACLI between January 2000 and June 2008. Urokinase (R) was always used for catheter directed thrombolysis, with a starting bolus of this thrombolytic drug followed by a constant infusion of 30000 to 50000 U.I./hour. Control angiography was repeated every 6-8 hours. Adjuvant procedures were used in order to treat any underlying lesion showed after thrombolytic dissolution of the thrombus. Periprocedural data, associated morbidity and mortality within 30 days of the procedure were analyzed and thereafter all patients were checked every 6 months. The average length of follow-up was 36 months. Results. Technical success was achieved in 96% of treated limbs within 30 days, in 81% one year after procedure and in the 64% of patients 3 years after thrombolysis. Early amputation was needed in 3.5% of treated limbs. Nine patients needed surgical adjuvant procedures after thrombolysis in order to treat the "culprit" lesion, like endoarteriectomy and by-pass; for the same reason, 64 patients underwent endovascular treatment like PTA and stenting. Bleeding complications of 4% occurred, related to the dislocation of the introducer; none of these need surgical treatment. One patient (1%) died after acute myocardial infarction, 13 patients (12%) died within the first year and 20 patients (18%) within three years. Conclusion. Low dose thrombolysis makes optimal results, often better than the results obtained with open surgery, but only in specialized centers and with adequate logistic supports to do it.