Contemporary trends and outcomes of thrombolytic therapy for acute lower extremity ischemia

Abstract

Objective Acute limb ischemia is a common vascular emergency requiring immediate intervention. Thrombolysis has been widely utilized for acute limb ischemia; the purpose of this study is to analyze contemporary trends, outcomes and complications of thrombolysis for acute limb ischemia. Methods Patients were identified from the Nationwide Inpatient Sample (2003-2013) using ICD-9. Patients undergoing emergency thrombolysis for acute limb ischemia were evaluated. Three groups were analyzed: thrombolysis alone, thrombolysis and endovascular procedure (T+ENDO), and failed thrombolysis requiring open surgery (T+OPEN). Results A total of 162,240 patients with acute limb ischemia were estimated: 33,615 patients (20.7%) underwent thrombolysis as the initial treatment. Mean age was 66.2 ± 34.9 years with 54% male. The utilization of thrombolysis increased significantly during the study period (16.8-24.2%, p < 0.0001). The most common group was thrombolysis and endovascular procedure (40.7%), followed by thrombolysis alone (34.1%), and T+OPEN (25.2%). Thrombolysis and endovascular procedure increased significantly over time (31.6-47.8%, p < 0.0001) whereas thrombolysis alone and T+OPEN significantly decreased (39.6-28.6% and 28.7-23.6%, respectively, p < 0.0001). Overall mortality was 4.9%; thrombolysis and endovascular procedure compared to thrombolysis alone and T-OPEN had a lower mortality rate (3.2% vs. 6.1% and 5.9%, p < 0001). The overall stroke rate was 1.9%; thrombolysis alone had the highest stroke rate (3.0%, p < 0.0001) with thrombolysis and endovascular procedure the lowest (1.2%) and T+OPEN 1.7%. The highest amputation rate was T+OPEN (11.6%, p < 0.001) compared to thrombolysis and endovascular procedure (5.1%) and thrombolysis alone (5.3%). T+OPEN had the highest incidence of cardiac (5.5%), respiratory (7.3%) and renal complications (12.5%), pneumonia (4.0%), and fasciotomy (16.8%) (all p < 0.0001). Conclusion Thrombolysis remains an effective treatment for acute limb ischemia with increased utilization over time. There was a significant increase in thrombolysis and endovascular procedure leading to improved outcomes. Thrombolysis alone carried the highest mortality and stroke rate, with T+OPEN associated with the highest amputation and complications. Although thrombolysis is effective, 25% of patients required an open procedure suggesting that patient selection for thrombolysis first instead of open surgery continues to be a clinical challenge.

Comparative analysis of mouse bone marrow and adipose tissue mesenchymal stem cells for critical limb ischemia cell therapy

“…P values ≤ 0.05 were considered statistically significant (s); ×10 magnification, scale bar 200 μm efficacy, but in recent years, therapies have been developed to treat this disease like stem cell therapy. Recent clinical studies suggest that stem cell transplantation is a reliable therapeutic option in selected patients with CLI [39,40]. In this study, we focus on the therapeutic neovascularization effect of BM-MSCs and AT-MSCs and provide insights into their potential for clinical use as a cell-based therapy for CLI.…”

Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia

“…The authors concluded there could be an association between the increased use of thrombolysis and other endovascular procedures and improved outcome. 27 There are few data on the level of major amputation after ALI, but in one large cohort study 34% of amputations done within 30 days were performed above the knee. 25 Better detection and medical treatment of AF and atherosclerotic disease has probably contributed to this decrease in the incidence of ALI.…”

“…Data suggest that being able to offer both open and endovascular surgery 24/7 may be associated with improved outcomes, as patients treated by an endovascular first strategy have improved survival. 23,27 Being able to offer both treatment modalities 24/7 requires a certain treatment volume, which is self evident, even if robust data are lacking to substantiate this assumption.There is a difficult trade off between the cost of delay, when a patient is transferred, and the limited expertise that may be available in the local hospital where the patient presents. All these patients can be discussed with a vascular surgeon on call; however, the discussion should take place before the difficult decision is made whether to refer the patient to another centre or treat on site with potentially limited resources.…”

Acute Limb Ischemia: An Update on Diagnosis and Management

“…Although thrombolysis is effective, 25% of patients require an open procedure, suggesting that patient selection for thrombolysis first strategy instead of open surgery continues to be a clinical challenge [34].…”