Low-dose thrombolytic therapy for infrainguinal graft occlusions: An idea whose time has passed?

Abstract

Despite the growing enthusiasm for low-dose intra-arterial thrombolytic therapy, the efficacy and risks in specific clinical situations have not been defined. During the past 13 months, 10 infrainguinal bypass graft occlusions occurred in nine patients 2 to 48 months postoperatively and were treated with local infusions of either streptokinase or urokinase. The grafts treated included two saphenous vein femoropopliteal grafts, two expanded polytetrafluoroethylene (PTFE) femoropopliteal grafts, four saphenous vein femoroanterior tibial grafts, one saphenous vein-PTFE composite femoro-anterior tibial graft, and one saphenous vein-PTFE composite femoroperoneal graft. The graft occlusions occurred 2 to 14 days prior to initiation of treatment. The infusion failed to restore flow completely in seven grafts; and of the three successes, two patients required surgical treatment of complications. All successful recanalizations occurred within 48 hours of the initiation ofthrombolytic therapy. Of the seven failures, two patients had viable limbs and were discharged, whereas two required amputation (one above and one below knee). Three patients underwent surgical thrombectomy and revisions that were successfifl in two and resulted in a below-knee amputation in the other. Despite all precautions, complications occurred in five patients. Low-dose intra-arterial thrombolytic therapy is a poorly efficacious, risky method of infrainguinal graft occlusion management. (J VASC SURG 1985; 2:799-805.) The infrainguinal bypass graft is now widely accepted as an effective and durable method of revascularization of the ischemic lower extremity secondary to femoropopliteal occlusive disease. Nevertheless, progressive graft failure occurs over time? -6 "~vaft thrombosis in the immediate postoperative period invariably results from technical or judgmental error on the surgeon's part. There is little disagreement that prompt reoperation is indicated in this ,situation and will usually save the bypass graft. 7 When graft occlusion occurs later, weeks, months, or years after implantation, the causes may be more complex, treatment more difficult, and the results not always satisfactory. 4 Late thrombectomy of an autologous saphenous vein graft is particularly difficult From the Departments of Surgery (Drs. Perler, Ernst, and Williams) and Radiology, (Dr. White), The Johns Hopkins Medical Institutions.

Thrombolysis in Arterial Bypass Grafts

“…In several reports, success included patients in whom clinical benefit was derived by minimizing the extent of subsequent surgical repair. 15,[56][57][58][59] As with peripheral arterial occlusions, higher success rates were noted with urokinase than with streptokinase. 33,57 Later reports emphasized results of the long-term follow-up of treated grafts.…”

“…Overall limb salvage (with secondary patency), however, was higher in all series, ranging from 50 to 60%. [57][58][59][60] In a study by Belkin et al 59 , following results of successful thrombolysis of saphenous vein graft occlusions, overall 1 year patency was 37%, but with a 1 year limb salvage rate of 67%. They, as others, noted a fairly advanced degree of disease in the patient population, but concluded that routine use of thrombolytic therapy for salvage of occluded venous bypass grafts was not warranted and should be reserved for patients in whom an autogenous vein was not available for repeat bypass grafting.…”