Risk factors for haemorrhage during local intra-arterial thrombolysis for lower limb ischaemia

Abstract

Assessment of clinical risk factors for haemorrhagic complications in patients undergoing intra-arterial thrombolysis for lower limb ischaemia. Retrospective reviews of consecutive patients subjected to intra-arterial thrombolysis due to lower limb ischemia at the Vascular Center, Malmö University Hospital, during a 5-year period from 2001 to 2005. Two hundred and twenty intra-arterial thrombolytic procedures were carried out in 195 patients (46% women), median age 73 years. Haemorrhagic complications were recorded in 72 procedures (33%), of which 13 were discontinued. Haemorrhage at the introducer and distant sites occurred in 53 and 32 procedures, respectively. Thrombolysis for occluded synthetic grafts was associated with higher risk of haemorrhage (P = 0.043). The platelet count was lower (P = 0.017) and the dose of alteplas higher (P = 0.041) in bleeders than in non-bleeders. Age was not associated with haemorrhage (P = 0.30). Two patients died during thrombolysis, one of them due to intracerebral haemorrhage. The grade of thrombolysis was an independent predictor of both in-hospital amputation (P < 0.001; OR 3.5 [95% CI 2.1-5.8]) and mortality (P = 0.021; OR 3.0 [95% CI 1.2-7.9]). The in-hospital amputation-free survival rate was 85% (188/220). Haemorrhage associated with thrombolysis is common, but does seldom require discontinuation of treatment. Insertion of introducers for local thrombolysis through synthetic grafts, lower platelet count and higher alteplas dose were found to be risk factors for haemorrhage. An algorithm for clinical management of haemorrhage has been proposed.

Thrombolysis for lower extremity bypass graft occlusion

“…Conrad et al, on the other hand, suggested repeat operation with a completely new bypass graft as a more appropriate option due to poor short-term results of thrombolysis of occluded prosthetic grafts. 15 In contrast with previous findings, 16 this patient series did not exhibit an increased risk of major hemorrhagic complications after thrombolysis of synthetic grafts.…”

Thrombolysis for acute occlusion of the superior mesenteric artery

“…13 Hence, the fear of fatal or life-threatening gastrointestinal hemorrhage during thrombolysis seems to be unfounded and might be exaggerated. In the absence of acute peritonitis, the risk of bleeding complications [14][15][16] should not deter the clinician to go ahead with thrombolysis for the treatment of this life-threatening condition. If needed, early explorative laparotomy can be performed after discontinuation of thrombolysis and reversal of heparin with protamine.…”

“…In case of severe bleeding, there is no need of reversal of alteplase after thrombolysis is stopped because it has a short duration of effect and a negligible effect on coagulation factors, whereas reversal of heparin is mandatory. 16 A detailed analysis of the relaparotomies showed that these procedures mostly were performed on-demand due to unsuccessful endovascular intestinal revascularization or development of bowel infarction, or both, and were associated with high mortality. Hence, few patients underwent a planned routine second-look relaparotomy.…”

Outcome and complications after intra-arterial thrombolysis for lower limb ischaemia with or without continuous heparin infusion

“…A higher dose of rtPA can accelerate the thrombolysis and achieve faster restoration of blood flow, a potential advantage to patients with acute ischaemia14,25,26. Faster thrombolysis with a higher dose of rtPA is counterbalanced by a higher rate of bleeding complications16,25; the risk of bleeding must be weighed against the risk of surgery or amputation for each patient27. The two hospitals in the present study used significantly different amounts of rtPA, but had equivalent success rates.…”

“…A recent study of thrombolytic procedures at Malmö University Hospital, Sweden, recorded a high rate of bleeding complications (33 per cent)15,16. At Uppsala University Hospital, Sweden, a different treatment algorithm was used during the thrombolytic procedure, with lower doses of both heparin and rtPA.…”