SEMINARS IN THROMBOSIS AND HEMOSTASIS—VOLUME 17, NO. 1, 1991

Local Thrombolysis for Salvage of Occluded Bypass Grafts KLAUS MATHIAS, M.D. nase. The drug was directly infused into the thrombus via an indwelling arterial catheter. Thrombotic graft occlusion occurred between 2 weeks and 6 years after the bypass procedure. All patients were treated within 10 days after graft occlusion. We used a specially designed multiple channel catheter with several sideports in 19 patients (Fig. 1). The catheter segment bearing the sideholes is available in Downloaded by: NYU. Copyrighted material.

The efficacy of local thrombolysis has been well established in recent years, but there are only a few reports about the usefulness of the method in occluded bypass grafts.1-4 Studies directly comparing streptokinase with urokinase for local thrombolysis have consistently shown a higher success rate and lower complication rate with urokinase, especially with regard to bleeding.5,6 The higher complication rate associated with streptokinase compels one more often to terminate the therapy, and thus the average thrombolysis time will be shorter with streptokinase than with urokinase. Comparing only successfully treated patients, the duration of therapy with urokinase was either equal or slightly shorter than with streptokinase. Local thrombolysis might be even more rapid with tissue-type plasminogen activator, but we have the impression that this advantage may be counteracted by a higher rate of bleeding complications.7 It seems that the complication rate is lowest with urokinase, but, nevertheless, complications certainly remain a major concern and impede a more widespread use of thrombolytic therapy. Bypass grafting for peripheral occlusive arterial disease is indicated for relief of ischemic rest pain or for limb salvage in case of gangrene. Therefore thrombotic occlusion of bypass grafts is normally associated with severe pain and loss of function. Active treatment is mandatory and immediate reoperation with thrombectomy or local thrombolysis are the therapeutic options.8 We report here our experiences with local thrombolysis in occluded bypass grafts.

METHODS AND PATIENTS The study population, which consisted of 28 patients with thrombosed grafts, was treated with uroki-

From the Institute of Diagnostic Radiology, Städtische Kliniken Dortmund, Dortmund, Germany. Reprint requests: Prof. Dr. Mathias, Director of the Institute of Diagnostic Radiology, Städtische Kliniken Dortmund, Beurhausstrasse, D-4600 Dortmund 1, Germany.

FIG. 1. Catheter for local thrombolysis with central channel for the guide wire and flushing. Urokinase is applied through multiple channels with separate sideholes and will be distributed over the whole length of the thrombotic occlusion.

Copyright © 1991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.

LOCAL THROMBOLYSIS—MATHIAS

U (mean, 2.1 million U) of urokinase was applied. After successful thrombolysis, platelet aggregation inhibitors (acetylsalicylic acid, 660 mg; dipyridamole, 150 mg) were given daily for at least 6 months.

RESULTS Therapeutic success was defined as complete resolution of the thrombus, with restoration of blood flow through the occluded graft. Twenty-seven of 28 graft occlusions (96%) could be successfully dissolved (Figs. 2, 3). The success did not depend on the implanted graft material. In early postoperative graft occlusions, bleeding may occur in preclotted graft material. Therefore, we have only treated patients with venous bypass grafts in the early postoperative period. With occluded femoropopliteal grafts, the common femoral artery should be punctured proximal to the anastomosis to avoid anastoDownloaded by: NYU. Copyrighted material.

different lengths and the length is chosen according to the length of the thrombotic occlusion. The catheter is placed in such a way that all sideholes lie within the thrombus. The catheter must not be moved during the infusion of the thrombolytic agent. In four patients an open-end infusion wire and in five patients a simple 5 F angiographic catheter were used for thrombolysis. Local thrombolysis was combined with balloon angioplasty in 12 patients to remove distal anastomotic or postanastomotic stenoses. Five patients with poor run off were additionally treated by computed tomography (CT)-guided percutaneous lumbar sympathicolysis to improve the flow rate in the lower leg arteries and the graft. The patients received initially 5000 U of heparin. The thrombus was infiltrated by a bolus injection of 150,000 to 200,000 U of urokinase. The thrombolysis then continued with 75,000 U/hr of urokinase, until the thrombus was dissolved or bleeding prevented further urokinase infusion. A total dose of 600,000 to 3.2 million

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FIG. 2. A, B: Occlusion of a femoropopliteal Gore-Tex Bypass Graft. C, D: Thrombolysis is achieved with bolus injection of 150,000 U and continous infusion of 75,000 U/hr of urokinase for 12 hours (total dose, 1.05 million U of urokinase).

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FIG. 3. A, B, C: Thrombosed femoropopliteal bypass graft. D, E, F, G: Bypass graft patent again (1.8 million U of urokinase). Poor run off with proximal anterior and distal posterior tibial artery occlusion.

LOCAL THROMBOLYSIS—MATHIAS

five patients with additional percutaneous lumbar sympathicolysis the mean acral skin temperature increased more than 3°C (Fig. 7)(Table 1). The major complication of local thrombolysis was distal embolization with intermittent severe ischemic pain for 30 minutes to 4 hours requiring analgetic therapy. With further progressing thrombolysis, most of the distal emboli and the ischemic symptoms disappeared. A clinical deterioration was observed in one patient with a poor run off. Embolization led in this case to an irreversible occlusion of collaterals of the lower leg, and the patient went on to amputation. Minor complications were hemorrhage at the puncture site in two patients, which was conservatively controlled. Twenty of the 27 successfully treated occluded grafts were patent at the end of 1 year. Of the seven grafts that reoccluded, the average duration of patency was 6 months.

TABLE 1. Results of Local Thrombolysis* Occluded grafts Aortoiliac 3 Aortofemoral 4 Femorofemoral 15 Femoropopliteal 5 Femorocrural 1 Successful thrombolysis Amputation Minor hemorrhage Additional angioplasty Additional sympathicolysis Patent after 1 year

FIG. 4. Early reocclusion of a femorofemoral bypass graft. Common femoral artery puncture proximal to the anastomosis for local thrombolysis.

No.

%

28

100

27

96 4 7

1 2 12 5 20

43 18 71

* Complications such as septicemia, renal failure, skin rash, dyspnea, and myocardial infarction have been reported in the literature but were not encountered in our series.

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motic injury and false aneurysm formation (Fig. 4). In one patient the function of an atypical infrarenal aortofemoral bypass graft could be restored (Fig. 5). All 12 patients who had a subsequent angioplasty (Fig. 6) showed an increase of ankle pressure after dilation. In the

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FIG. 5. A: Occluded atypical aortofemoral bypass graft. B: Residual thrombosis after 6 hours of thrombolysis (600,000 U of urokinase). C, D, E: Completion of thrombolysis after 10 hours (900,000 U of urokinase) with patent graft. Old occlusion of the deep femoral artery.

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FIG. 6. A: Femorofemoral bypass graft with postanastomotic stenosis. Angioplasty refused. B: Six weeks later, the graft thrombosed. C, D: Local thrombolysis for 24 hours (2.1 million U of urokinase): graft patent. E: Stenosis improved after catheter dilation.

FIG. 7. CT-guided lumbar sympathicolysis. A: Needle in exact position for the injection of the sympathicolytic solution. B: Solution of absolute alcohol, bupivacaine, and contrast medium is injected.

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LOCAL THROMBOLYSIS—MATHIAS

SEMINARS IN THROMBOSIS AND HEMOSTASIS—VOLUME 17, NO. 1, 1991

CONCLUSIONS

REFERENCES

Local thrombolysis proved to be an effective treatment modality in acute and subacute occlusion of bypass grafts with a high success rate of more than 90% and a low complication rate in comparison to operative thrombectomy or a repeated bypass procedure.8 Today, we prefer a high dose of the fibrinolytic agent (75,000 U/hr of urokinase) for local thrombolysis. In our experiences, low-dose thrombolysis, in which only 5000 U/hr of urokinase or streptokinase are infused, requires longer infusion times. 1,5 Therefore systemic effects are more often seen, bleeding does more often occur, and peripheral emboli are less effectively dissolved. Recurrent thrombotic occlusion can be avoided in more than two thirds of the patients in the first year after the intervention, when an optimal blood flow can be achieved by additional angioplasty and lumbar sympathicolysis.

1. Mathias K, H Friedburg, HW Heiss, K Hassler, V Schlosser: Katheterlyse akuter und subakuter Arterienverschlüsse. Röntgenpraxis 35:15-19, 1982. 2. McNamara TO, JR Fisher: Thrombolysis of peripheral arterial and graft occlusions: Improved results using high dose urokinase. AJR 144:769-775, 1985. 3. Gardiner GA: Thrombolysis of occluded arterial bypass grafts. Cardiovasc Intervent Radiol 11:58-59, 1988. 4. Sullivan KL, GA Gardiner, MJ Shapiro, J Bonn, DC Levin: Acceleration of thrombolysis with a high-dose transthrombus bolus technique. Radiology 173:805-808, 1989. 5. Hasler K, M Geiger, K Mathias, J Klink: Lokale Fibrinolyse peripherer arterieller Verschlüsse mit Streptokinase. Med Welt 37:807-811, 1986. 6. van Breda A, BT Katzen, AS Deutsch: Urokinase versus streptokinase in local thrombolysis. Radiology 165:109-111, 1987. 7. Valji K, JJ Bookstein: Fibrinolysis with intrathrombotic injection of urokinase and tissue-type plasminogen activator. Invest Radiol 22:23-27, 1987. 8. Green RM, K Ouriel, JJ Ricotta, JA DeWeese: Revision of failed infrainguinal bypass grafts: Principles of management. Surgery 100:646-653, 1986.

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Local thrombolysis for salvage of occluded bypass grafts.

SEMINARS IN THROMBOSIS AND HEMOSTASIS—VOLUME 17, NO. 1, 1991 Local Thrombolysis for Salvage of Occluded Bypass Grafts KLAUS MATHIAS, M.D. nase. The d...
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