Outcome after Preoperative or Intraoperative Use of Intra-arterial Urokinase Thrombolysis for Acute Popliteal Artery Thrombosis and Leg Ischemia

Abstract

Objectives To evaluate the outcome of acute popliteal artery aneurysm (PAA) thrombosis and leg ischemia after preoperative or intraoperative use of intra-arterial urokinase thrombolysis.

Materials and Methods From 2000 to 2009, 86 patients with acute leg ischemia (Rutherford grade IB to IIA) from PAA thrombosis were treated by immediate surgery including intraoperative thrombolysis (group A: 47 cases) or preoperative thrombolysis (group B: 39 cases) followed by acute (<24 hours) or elective surgery. Chi-square tests for categorical data and time to event provided two-sided p values with a level of significance at 0.05 and all confidence intervals (CIs) at the 95% level.

Results The mean follow-up was 45 months. The 2-year primary patency was 61.7% (29/47) for group A and 43.6% (17/39) for group B (hazard ratio [HR] 1.85; 95% CI: 0.96 to 3.54; p = 0.06). The 2-year secondary patency was 70.2% (33/47) for group A and 53% (21/39) for group B (HR 1.86; 95% CI: 0.91 to 3.81; p = 0.08). One-month amputation rate was 18% in group A and 29% in group B (p < 0.001), and 12-month amputation rate was 19% (9/47) in group A and 44% (17/39) in B (p = 0.05). In group A, 28% of patients required fasciotomy and in group B, 59% (p < 0.05). Effective thrombolysis allowed 82% limb salvage patency in group B. No systemic or locoregional complications during thrombolysis were recorded, but four cases of worsening ischemia were recorded.

Conclusion Our results suggest that the immediate surgery with intraoperative thrombolysis improved the outcome of patients with acute leg ischemia due to PAA thrombosis in terms of limb salvage.

Keywords

popliteal artery aneurysm - acute leg ischemia - thrombolytic therapy - intraoperative thrombolysis

• References

• 1 Garramone Jr RR, Gallagher Jr JJ, Drezner AD. Intra-arterial thrombolytic therapy in the initial management of thrombosed popliteal artery aneurysms. Ann Vasc Surg 1994; 8 (4) 363-366
• 2 Lilly MP, Flinn WR, McCarthy III WJ, Courtney DF, Yao JS, Bergan JJ. The effect of distal arterial anatomy on the success of popliteal aneurysm repair. J Vasc Surg 1988; 7 (5) 653-660
• 3 Anton GE, Hertzer NR, Beven EG, O'Hara PJ, Krajewski LP. Surgical management of popliteal aneurysms. Trends in presentation, treatment, and results from 1952 to 1984. J Vasc Surg 1986; 3 (1) 125-134
• 4 Aulivola B, Hamdan AD, Hile CN , et al. Popliteal artery aneurysms: a comparison of outcomes in elective versus emergent repair. J Vasc Surg 2004; 39 (6) 1171-1177
• 5 Melliere D, Cron J, Lange F , et al. Some popliteal aneurysms are congenital. Cardiovasc Surg 1998; 6 (1) 42-49
• 6 Hamish M, Lockwood A, Cosgrove C, Walker AJ, Wilkins D, Ashley S. Management of popliteal artery aneurysms. ANZ J Surg 2006; 76 (10) 912-915
• 7 Henke PK. Popliteal artery aneurysms: tried, true, and new approaches to therapy. Semin Vasc Surg 2005; 18 (4) 224-230
• 8 Varga ZA, Locke-Edmunds JC, Baird RN ; Joint Vascular Research Group. A multicenter study of popliteal aneurysms. J Vasc Surg 1994; 20 (2) 171-177
• 9 Cotton LT, Flute PT, Tsapogas MJ. Popliteal artery thrombosis treated with streptokinase. Lancet 1962; 2 (7265) 1081-1083
• 10 Berridge D, Kessel D, Robertson I. Surgery versus thrombolysis for initial management of acute limb ischemia. Cochrane Database Syst Rev 2002; 1
• 11 Earnshaw JJ, Whitman B, Foy C. National Audit of Thrombolysis for Acute Leg Ischemia (NATALI): clinical factors associated with early outcome. J Vasc Surg 2004; 39 (5) 1018-1025
• 12 Berridge DC, Makin GS, Hopkinson BR. Local low dose intra-arterial thrombolytic therapy: the risk of stroke or major haemorrhage. Br J Surg 1989; 76 (12) 1230-1233
• 13 Schwarz W, Berkowitz H, Taormina V, Gatti J. The preoperative use of intraarterial thrombolysis for a thrombosed popliteal artery aneurysm. J Cardiovasc Surg (Torino) 1984; 25 (5) 465-468
• 14 Ascher E, Markevich N, Schutzer RW, Kallakuri S, Jacob T, Hingorani AP. Small popliteal artery aneurysms: are they clinically significant?. J Vasc Surg 2003; 37 (4) 755-760
• 15 Dawson I, van Bockel JH, Brand R, Terpstra JL. Popliteal artery aneurysms. Long-term follow-up of aneurysmal disease and results of surgical treatment. J Vasc Surg 1991; 13 (3) 398-407
• 16 Lowell RC, Gloviczki P, Hallett Jr JW , et al. Popliteal artery aneurysms: the risk of nonoperative management. Ann Vasc Surg 1994; 8 (1) 14-23
• 17 Rutherford RB, Baker JD, Ernst C , et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997; 26 (3) 517-538
• 18 Kropman RHJ, Schrijver AM, Kelder JC, Moll FL, de Vries JPPM. Clinical outcome of acute leg ischaemia due to thrombosed popliteal artery aneurysm: systematic review of 895 cases. Eur J Vasc Endovasc Surg 2010; 39 (4) 452-457
• 19 Galland RB, Magee TR. Management of popliteal aneurysm. Br J Surg 2002; 89 (11) 1382-1385
• 20 Galland RB, Earnshaw JJ, Baird RN , et al. Acute limb deterioration during intra-arterial thrombolysis. Br J Surg 1993; 80 (9) 1118-1120
• 21 Marty B, Wicky S, Ris HB , et al. Success of thrombolysis as a predictor of outcome in acute thrombosis of popliteal aneurysms. J Vasc Surg 2002; 35 (3) 487-493
• 22 Kropman RHJ, De Vries JPPM, Moll FL. Surgical and endovascular treatment of atherosclerotic popliteal artery aneurysms. J Cardiovasc Surg (Torino) 2007; 48 (3) 281-288
• 23 Ouriel K, Shortell CK, DeWeese JA , et al. A comparison of thrombolytic therapy with operative revascularization in the initial treatment of acute peripheral arterial ischemia. J Vasc Surg 1994; 19 (6) 1021-1030
• 24 Ouriel K, Veith FJ, Sasahara AA ; Thrombolysis or Peripheral Arterial Surgery (TOPAS) Investigators. A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. N Engl J Med 1998; 338 (16) 1105-1111
• 25 STILE Investigators. Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity. The STILE trial. Ann Surg 1994; 220 (3) 251-266 , discussion 266–268