A protocol for the safe treatment of acute lower limb ischaemia with intra-arterial streptokinase and surgery

Abstract

Over a 5-year period 70 patients, presenting with subacute ischaemia of the lower limb (more than 12 h), were treated with low-dose intra-arterial streptokinase. There were 72 infusions and effective lysis was achieved in 52 (72 per cent), with an average infusion time of 25 h. A total of 23 (32 per cent) also underwent percutaneous transluminal angioplasty when lysis showed an underlying stenosis, and a further 19 (26 per cent) required surgery to remove persistent stenosis, organized thrombus or atheromatous debris. Significant bleeding occurred in 4 patients (6 per cent) and 13 (18 per cent) underwent amputation. There were five deaths (7 per cent), one of which was directly related to the infusion, while three were due to myocardial infarction. All of the major complications occurred in the early part of the study and both the selection of patients and the technique of infusion were modified to improve safety. Complementary treatment by percutaneous transluminal angioplasty and surgery was used more frequently in the later part of the study. The technique is not recommended for the white leg of acute ischaemia (less than 12 h), or for lysis of clot in a retroperitoneal Dacron graft, but may be uniquely valuable to demonstrate the cause of subacute ischaemia.

Fibrinogen Level as a Surrogate for the Outcome of Thrombolytic Therapy Using Tissue Plasminogen Activator for Acute Lower Extremity Intravascular Thrombosis

“…6,18 Concomitant heparin is used to reduce the rate of thrombotic formation at the infusion catheter, 17 but it has been shown to increase the risk of bleeding. 5 Because of this concern, some authors do not use it.…”

“…To our knowledge, most of the previous literature on this topic used nonfibrin selective thrombolytic agents such as streptokinase and urokinase rather than tPA. 4,5,17,18 Notably, the surgery versus thrombolysis for ischemia of the lower extremity trial used a combination of patients treated with tPA and urokinase. Studies that used only tPA were small in size 6,8 or did not focus on this outcome.…”

“…Many providers administer heparin postinfusion to prevent rethrombosis, 16 but there is no general consensus on heparin dosing before or during the infusion. 6,18 Concomitant heparin is used to reduce the rate of thrombotic formation at the infusion catheter, 17 but it has been shown to increase the risk of bleeding. 5 Because of this concern, some authors do not use it.…”

Thrombolytic Therapy in Acute Lower Limb Ischemia

“…15 The overall success rate of 10 descriptive clinical studies was 64% (920/1,436) and the rate of significant bleeding complications was 2.64% (38/1,436). [16][17][18][19][20][21][22][23][24][25] The greatest disadvantage of using SK, however, is the unknown concentration of plasminogen in the thrombus. SK is an indirect plasminogen activator, and therefore the dosage used can be an overdose without any fibrinolytic effect as well as an underdose with high bleeding complication rates.…”

Screening and management of asymptomatic popliteal aneurysms

“…2 There is a high association with abdominal aortic aneurysm, coexisting in 69% of people with bilateral popliteal aneurysms. 3 Most popliteal aneurysms are asymptomatic, with complication rates reported between 8% and 29%, for follow up over 3 and 8 years respectively. 4 5 Symptomatic aneurysms account for only one in 5000 general surgical admissions; one popliteal aneurysm is seen for every 15 abdominal aortic aneurysms.…”