Introduction
The intravascular administration of thrombolytic agents originated in the 1960s with the intravenous (IV) treatment of pulmonary embolism. Thrombolysis by means of selective catheter infusion for vascular occlusion entered the mainstream during the 1970s. Since then, techniques for thrombolysis have branched in several directions with the treatment of thrombus and/or thrombosis in the coronary arteries, peripheral vascular and visceral arteries, dialysis grafts, veins, and IV catheters.1,2 This article is intended to serve as a review of arterial native and bypass peripheral vascular thrombolysis.3,4,5
Peripheral thrombolysis, case 1. Thrombolysis of
an iliac thrombus with distal occlusions. Pretreatment
angiogram shows an intraluminal nonocclusive thrombus of the
left common iliac artery. A Motarjeme catheter was placed just
proximal to the lesion, and urokinase was infused at a rate of
60,000 U/h.
Peripheral thrombolysis, case 1. Thrombolysis of
an iliac thrombus with distal occlusions. Pretreatment
angiogram shows an intraluminal nonocclusive thrombus of the
left common iliac artery. A Motarjeme catheter was placed just
proximal to the lesion, and urokinase was infused at a rate of
60,000 U/h.
Peripheral thrombolysis, case 2. Low-dose
urokinase infusion to manage femoral-popliteal occlusion. The
patient had undergone left femoral-popliteal bypass grafting.
Pretreatment anteroposterior (AP) pelvic image shows severe
atherosclerotic disease with attenuated flow through the left
superficial femoral artery (SFA), which suggests a distal
occlusion. The bypass graft is not seen.
Peripheral thrombolysis, case 2. Low-dose
urokinase infusion to manage femoral-popliteal occlusion. The
patient had undergone left femoral-popliteal bypass grafting.
Pretreatment anteroposterior (AP) pelvic image shows severe
atherosclerotic disease with attenuated flow through the left
superficial femoral artery (SFA), which suggests a distal
occlusion. The bypass graft is not seen.
Peripheral bypass thrombolysis, case 3. The
patient underwent right femoral-anterior tibial bypass with
ischemic symptoms in the right lower extremity. Oblique pelvic
image shows complex postsurgical anatomy with a graft ostium at
the proximal superficial femoral artery (SFA). A high-grade
left external iliac artery stenosis is incidentally
noted.
Peripheral bypass thrombolysis, case 3. The
patient underwent right femoral-anterior tibial bypass with
ischemic symptoms in the right lower extremity. Oblique pelvic
image shows complex postsurgical anatomy with a graft ostium at
the proximal superficial femoral artery (SFA). A high-grade
left external iliac artery stenosis is incidentally
noted.
Peripheral bypass thrombolysis, case 4.
Thrombolysis of an occluded left femoral below-the-knee
popliteal bypass by using the McNamara technique. Pretreatment
anteroposterior (AP) image shows underlying atherosclerosis, as
well as the postsurgical anatomy on the contralateral right
side. The column of contrast material terminates at the left
common femoral artery without an extensive collateral bed; this
finding indicates an acute component to the patient's
presentation.
Peripheral bypass thrombolysis, case 4.
Thrombolysis of an occluded left femoral below-the-knee
popliteal bypass by using the McNamara technique. Pretreatment
anteroposterior (AP) image shows underlying atherosclerosis, as
well as the postsurgical anatomy on the contralateral right
side. The column of contrast material terminates at the left
common femoral artery without an extensive collateral bed; this
finding indicates an acute component to the patient's
presentation.
Peripheral thrombolysis, case 5, part 1.
Anteroposterior (AP) view of knees shows relatively
disease-free distal run-off.
Peripheral thrombolysis, case 5, part 1.
Anteroposterior (AP) view of knees shows relatively
disease-free distal run-off.
Peripheral native arterial thrombolysis, case 5,
part 2. One-year follow-up angiogram demonstrates a
flow-limiting stenosis, which is consistent with progression of
disease in the same location as the residual stenosis
demonstrated on the final postthrombolytic image obtained a
year ago. The reason for the relatively rapid progression of
disease is unclear. Note the relative hypertrophy of the
profunda femoris branches feeding the calf.
Peripheral native arterial thrombolysis, case 5,
part 2. One-year follow-up angiogram demonstrates a
flow-limiting stenosis, which is consistent with progression of
disease in the same location as the residual stenosis
demonstrated on the final postthrombolytic image obtained a
year ago. The reason for the relatively rapid progression of
disease is unclear. Note the relative hypertrophy of the
profunda femoris branches feeding the calf.
In May 2009, the American Heart Association/American Stroke Association (AHA/ASA) revised the guidelines for the administration of tPA following acute ischemic stroke, expanding the treatment window from 3 hours to 4.5 hours after symptom onset. This expansion of the tPA window has not yet been approved by the Food and Drug Administration, and it is emphasized that time is still of the utmost importance when treating stroke.
6 Saver et al reported that treatment with tPA in the 3- to 4.5-hour window confers benefit on approximately half as many patients as treatment in under 3 hours, with no increase in the conferral of harm. According to the authors, about 1 in 6 patients has a better outcome and 1 in 35 has a worse outcome as a result of therapy.
7,8 According to Baekgaard et al, the use of catheter-directed thrombolysis (CDT) in acute iliofemoral venous thrombosis (IFVT) achieved good patency and vein function after 6 years of follow-up in a highly selected group of patients (first episode of IFVT, age 60 y, age of thrombus < 14 days, and open distal popliteal vein). In this study, 82% of the affected limbs had patent veins with competent valves and without any skin changes or venous claudication. The authors noted that venous patency without reflux is an early indicator of clinical outcome.
9 Choice Of Agent And Mechanism Of
Action
A number of pharmacologic regimens have been used. Each agent mediates thrombolysis by converting plasminogen to plasmin, which then degrades fibrin and fibrinogen to their fragmentary byproducts. Thrombolytic agents have been used alone or with anticoagulants (eg, heparin), platelet-receptor antagonists (eg, abciximab), and plasminogen or thrombin inhibitors (eg, Argatroban). No thrombolytic agent or regimen has been clinically proven to be the most effective, though techniques are well published and accepted. Peripheral thrombolysis remains essentially an off-label treatment despite many years of successful clinical experience.
The original mainstay agents for peripheral thrombolysis were streptokinase and urokinase. After 1999, tissue-type plasminogen activator (tPA) became the de facto agent of choice. In 1998, the US Food and Drug Administration (FDA) put on hold shipments of Abbokinase, the form of urokinase that was commercially available and in the United States. On January 25, 1999, the FDA issued an Important Drug Warning letter in which it recommended that "Abbokinase be reserved for only those situations where a clinician has considered the [therapeutic] alternatives and determined that Abbokinase is critical to the care of a specific patient in a specific situation."
In the ensuing years, other agents were substituted for urokinase for peripheral thrombolysis. American experience was greatest with tPA, which became the de facto substitute agent of choice. In popular dosing regimens, tPA was substantially cheaper to use than urokinase. Reteplase was also used less than tPA. Urokinase has since returned to the US marketplace at close to pre-1998 pricing. It has failed to regain substantial market share, not in small part because of cost. The first author currently uses tPA. In general, tPA is equally efficacious to urokinase except for the treatment of chronic arterial occlusive disease. Published data are limited regarding this subset of peripheral thrombolysis.
Urokinase
Urokinase is a 2-chain serine protease that contains 411 amino acid residues. Urokinase is extracted from human urine or long-term cultures of neonatal kidney cells. It is commercially available in North America as Abbokinase in vials containing 250,000 IU. It has a half-life of 15 minutes and is primarily metabolized in the liver. Like streptokinase, urokinase lacks fibrin specificity and induces a systemic lytic state. Urokinase is typically given with full heparinization (activated partial thromboplastin time [aPTT] 1.5-2 times control values). Titration of the dose of heparin dose is often difficult to achieve.
For the original Bookstein (pulse-spray) technique, urokinase is prepared as 250,000 U in 10 mL (25,000 U/mL) and injected in 0.2-mL (5000-U) pulses twice per minute (10,000 U/min) for 15-20 minutes. Then, the concentration is reduced to 5,000-10,000 U/mL, and 1 pulse is given each minute until lysis is complete. The patient is given 5000 U of heparin as a bolus followed by an infusion of 1000 U/h until the procedure is completed. Bookstein reported mean infusion times of 60-90 minutes.10,11
Peripheral thrombolysis, case 21, part 2.
Because of the severity of the patient's acute ischemia, an
initial course of pulse-spray thrombolysis is administered
within the femoral-popliteal graft. Minimal change is noted
after the administration of 250,000 U.
Peripheral thrombolysis, case 21, part 2.
Because of the severity of the patient's acute ischemia, an
initial course of pulse-spray thrombolysis is administered
within the femoral-popliteal graft. Minimal change is noted
after the administration of 250,000 U.
Peripheral thrombolysis, case 21, part 2. After
the initial pulse-spray course of urokinase, the patient's
vascular result was deemed stable enough for a low-dose
infusion. Coaxial infusion in the femoral-popliteal bypass was
begun with the proximal infusion port just above the origin of
the graft. The infusion wire was placed in the midportion of
the graft based on the fluoroscopic evaluation of flow of
contrast material through the wire.
Peripheral thrombolysis, case 21, part 2. After
the initial pulse-spray course of urokinase, the patient's
vascular result was deemed stable enough for a low-dose
infusion. Coaxial infusion in the femoral-popliteal bypass was
begun with the proximal infusion port just above the origin of
the graft. The infusion wire was placed in the midportion of
the graft based on the fluoroscopic evaluation of flow of
contrast material through the wire.
Urokinase may be delivered as a continuous infusion through a single port or multiple ports (McNamara technique) or as a pulse-spray (Bookstein technique). Dosing as a continuous infusion has traditionally be divided into low-dose (60,000 U/h), medium-dose (120,000 U/h), and high-dose (240,000 U/h) regimens. The choice of regimen depends on the degree of ischemia, the interval to the next angiographic evaluation, and the physician's preference. Urokinase is reconstituted with sterile, nonbacteriostatic water and then placed in an IV bag of normal sodium chloride solution. The concentration is adjusted for an infusion rate of at least 30 mL/h per port and no more than 120 mL/h total.10,11,12,13,14
The coauthor recommends an infusion of 240,000 IU/h for 2 h or until antegrade flow is restored. This dosage is reduced to 120,000 IU/h for another 2 h and then 60,000 IU/h until lysis is complete.
The first author's experience is predominantly with acute-on-chronic severe and limb-threatening ischemia, which is an outlier group in most published data. Infusions of 60,000-100,000 U/h for as long as 72 h had the greatest patency rate and the lowest major bleeding rate. Success (complete or near-complete lysis) of approximately 90% was achieved (unpublished observations; Veterans Affairs [VA] West Side, Chicago, Ill, 1991-2002). Rates of nonsurgical catheter-site bleeding were 20-30%. Transfusions were required in 5%. Periprocedural mortality was less than 1%. The development of increasing catheter-site bleeding (typically in the middle of the night) heralded complete lysis, and urokinase was discontinued until confirmatory angiography the next morning. The first author's anecdotal experience with chronic occlusive disease showed that urokinase was associated with a lowered rate of clinical failure due to nonlysis.
Streptokinase
Early thrombolysis efforts were with streptokinase, which is obtained from group c beta-hemolytic Streptococcus bacillus. It has no intrinsic enzymatic activity. After patients receive streptokinase, their antibody titers to the agent transiently increase. The antibodies irreversibly inactivate the streptokinase in a 1:1 ratio. All antibody sites must be saturated before streptokinase can be effective. Should the patient receive streptokinase again before the titers returned to baseline, the residual circulating antibodies neutralize some of the dose administered and reduce the bioeffectiveness of the agent. These inactivating antibodies result from previous streptococcal infections.
After the antibodies are depleted, the half-life of streptokinase is about 80 minutes. levels of antibodies vary among individuals. Alpha2-antiplasmin does not inhibit the streptokinase-plasminogen complex.
Uncertainty in appropriate dosing has contributed to the unpopularity of streptokinase in clinical practice despite its substantial cost advantage over other lytic agents. Results also suggest that bleeding complications might be higher with streptokinase than with urokinase or tPA. Despite these relative disadvantages, streptokinase remains a feasible thrombolytic agent.
Although allergic reactions are rare, the main difficulty with streptokinase is related to its antigenicity. Adverse reactions include allergic reactions, rare instances of anaphylaxis, and fever. Streptokinase is supplied as Streptase in vials containing 250,000, 750,000, or 1,500,000 IU of the protein.
Recombinant human tissue-type plasminogen activator
Alteplase is a serine protease that is produced by recombinant DNA technology and that is chemically identical to human endogenous tPA. It acts by stimulating fibrinolysis of blood thrombi. Alteplase promotes the binding of plasminogen to the fibrin thrombus in conjunction with the increased affinity of fibrin-bound tPA for plasminogen, and it facilitates the ordered adsorption of plasminogen and its activator to the fibrin surface. Of special importance is the fact that alteplase appears to have a shorter half-life (about 5 min) and a higher fibrin specificity than those of urokinase in vitro.
The clinical differences between tPA and urokinase are incompletely understood. Extensive clinical experience and trials have established the safety and efficacy of alteplase in the treatment of myocardial infarction, pulmonary embolism, and acute ischemic cerebral infarction. This agent is emerging as the thrombolytic of primary consideration in the setting of peripheral arterial occlusion. Alteplase (Activase) is now firmly established as the thrombolytic treatment of choice for the management of acute myocardial infarction. It is also indicated for the treatment of acute massive pulmonary embolism and acute ischemic stroke.
Several tPA products are available. A double-chain formulation is produced under roller-bottle (rb) culture conditions, whereas alteplase (Activase) refers to primarily the single-chain, suspension-culture product available from Genentech. For clinical trials conducted outside North America, the single-chain suspension culture product is referred to as alteplase, which is produced by Boehringer Ingelheim, as licensed by Genentech.
Since, 1999, recombinant tPA (r-tPA) has been the agent most frequently used in peripheral arterial occlusion. Early data with tPA dosing suggested by cardiology data with concomitant heparin indicated troubling rates of intracranial bleeding complications in patients treated with doses of tPA higher than those currently used. Current regimens use 0.25-1.00 mg tPA/h with subtherapeutic heparin dosing of 300-500 U/h. Clinical results similar to those of urokinase with no increased rate of intracranial hemorrhage are reported.
The author uses tPA at a rate of 0.48 mg/h for low-dose infusion protocols (4 mg tPA/500 mL normal saline at 60 mL/h) and 0.96 mg/h for high-dose infusion protocols (4 mg rtPA/250 mL normal saline at 60 mL/h). IV heparin is given at 400 U/h. The aPTT is not followed during the course of treatment.
Other thrombolytic agents
Reteplase has been used in peripheral vascular occlusion with favorable results. It is a nonglycosylated mutant of human tPA lacking the finger-epidermal growth factor and Kringle 1 regions. Reteplase is somewhat attractive as a suitable replacement for urokinase. The agent has a half-life similar to that of urokinase (13 vs 14 min, respectively). Like urokinase, reteplase lacks the fibrin affinity of r-tPA, a property theoretically linked to an increased risk of distant hemorrhagic complications. Dosing of 0.2-0.5 U/h has been shown to be effective. Concomitant abciximab 0.25 mg/kg given as a bolus and as an infusion of 0.125 mcg/kg/min substantially reduces embolic events.
Anistreplase is an equimolar complex of streptokinase and para -anisoylated human Lys-plasminogen, or anisoylated plasminogen-streptokinase complex (APSAC), in which the active site in the plasminogen moiety is reversibly blocked by acylation. Anistreplase is not being used for peripheral vascular work. Several other new thrombolytic agents are under review, but only recombinant human urokinase, recombinant glycosylated pro-urokinase, and recombinant staphylokinase have been used for peripheral arterial occlusion. Early data suggest that recombinant glycosylated pro-urokinase and recombinant staphylokinase may be effective without inducing fibrinogen depletion. This fibrinogen-conserving property may prove to be a tremendous advantage in lessening hemorrhagic complications from thrombolytic therapy. Recent publications describe the use of Tenecteplase and Alfimeprase. The author has not had experience with these agents.
Streptokinase and APSAC are not generally used in peripheral vascular occlusion. In vivo studies have shown that ultrasound augments fibrinolysis and plasminogen activator, but further studies are needed before ultrasound can be introduced into clinical practice.15,16
Acute And Chronic Ischemia
Peripheral vascular ischemia results from a combination of atherosclerotic stenosis and thrombosis. In situ thrombosis occurs in a region of low flow due to a critical stenosis. Thromboemboli or atheroemboli may also lodge in stenoses or bifurcations, causing occlusion. Thrombosis propagates in the now-stagnant blood until it reaches an area where collateral blood flow is rapid enough to inhibit further thrombosis. Local flow dynamics eventually mold the occlusion into the typical chronic occlusion appearance.
This process is generally a slow one that allows the body to partially compensate by developing collateral circulation. Depending on the severity and comorbid factors, progressive arterial insufficiency may cause claudication (exertional pain), rest pain, or necrosis or gangrene. Treatment may begin electively unless the patient presents with an acute ischemia component that threatens limb loss.
The paradigm for acute limb-threatening ischemia (ALLI) is a patient presenting with an acute thromboembolic occlusion. This may occur in the absence of clinically significant preexisting atherosclerotic stenoses. Thrombi may originate from the heart, a proximal aortic aneurysm, or a hypercoagulable state. The patient presents with ALLI because the body has had inadequate time to develop adequate collateral circulation. Severe acute ischemia requires urgent treatment. In its purest and most severe form, acute arterial occlusion should be remedied within 4-6 h of the onset of symptoms.
A patient with preexisting disease often has an acute setback and presents with a combination of acute and chronic ischemia.
The clinical boundary between threatened and irreversible ischemia is somewhat subjective and may be affected by differences in treatment philosophy and clinical experience. Familiarity with the clinical language used in the treatment of lower-extremity ischemia can help bridge the gaps of perception and clinical approach. The following is adapted from the 1993 American Heart Association (AHA) Special Report on Angioplasty.
The Fontaine classification is the classic scheme used to describe chronic peripheral vascular ischemia. This scheme has been updated.
Table 1. Original Fontaine Classification Scheme for Chronic Ischemia
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Table
| Stage | Symptoms |
|---|
| I | Asymptomatic |
| II | Intermittent claudication |
| II-a | Pain-free, claudication with walking >200 m |
| II-b | Pain-free, claudication with walking <200 m |
| III | Rest and/or nocturnal pain |
| IV | Necrosis and/or gangrene |
| Stage | Symptoms |
|---|
| I | Asymptomatic |
| II | Intermittent claudication |
| II-a | Pain-free, claudication with walking >200 m |
| II-b | Pain-free, claudication with walking <200 m |
| III | Rest and/or nocturnal pain |
| IV | Necrosis and/or gangrene |
Table 2. Updated Fontaine Classification Scheme for Chronic Ischemia
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Table
| Grade | Grade and Category | Clinical Details |
|---|
| 0 | 0 | Asymptomatic |
| I | 1 | Mild claudication; patient can complete treadmill exercise. |
| 2 | Moderate claudication |
| 3 | Severe claudication; patient cannot complete treadmill exercise. |
| II | 4 | Ischemic rest pain |
| 5 | Minor tissue loss; patient has a nonhealing ulcer and/or focal gangrene |
| III | 6 | Major tissue loss; patient has a functional foot that is no longer salvageable |
| Grade | Grade and Category | Clinical Details |
|---|
| 0 | 0 | Asymptomatic |
| I | 1 | Mild claudication; patient can complete treadmill exercise. |
| 2 | Moderate claudication |
| 3 | Severe claudication; patient cannot complete treadmill exercise. |
| II | 4 | Ischemic rest pain |
| 5 | Minor tissue loss; patient has a nonhealing ulcer and/or focal gangrene |
| III | 6 | Major tissue loss; patient has a functional foot that is no longer salvageable |
From a treatment perspective, disease stages III and IV or grades II and III may be considered to involve chronic threatened limb loss.
Acute limb ischemia may be categorized as viable, threatened, or irreversible, as shown in Table 3.
Table 3. Classification of Acute Limb Ischemia
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Table
| Description | Category |
|---|
| Viable | Threatened | Irreversible |
|---|
| Clinical description | Not immediately threatened | Salvageable if promptly treated | Major tissue loss, amputation unavoidable |
| Capillary return | Intact | Intact, slow | Absent (marbling) |
| Muscle weakness | None | Mild, partial | Profound, paralysis (rigor) |
| Sensory loss | None | Mild, incomplete | Profound anesthetic |
| Arteriovenous Doppler finding | Audible | Inaudible or audible | Inaudible |
| Description | Category |
|---|
| Viable | Threatened | Irreversible |
|---|
| Clinical description | Not immediately threatened | Salvageable if promptly treated | Major tissue loss, amputation unavoidable |
| Capillary return | Intact | Intact, slow | Absent (marbling) |
| Muscle weakness | None | Mild, partial | Profound, paralysis (rigor) |
| Sensory loss | None | Mild, incomplete | Profound anesthetic |
| Arteriovenous Doppler finding | Audible | Inaudible or audible | Inaudible |
Elevation pallor may be graded on a scale of 1-4. The return of color and the venous filling time may be classified as normal, moderate ischemia, and severe ischemia.
In the author's experience, irreversible ischemia may be successfully treated if intervention is begun in a timely fashion. The paradigm is a patient with subacute thrombosis of a distal femoral–below-the-knee venous bypass. As time passes the thrombosis progresses down the tibial vessels, eventually causing profound ALLI and pain. Successful treatment is expected to take several days, with a nontrivial incidence of bleeding. The patient must be monitored for improvement or deterioration of vascular status, signs of sepsis, bleeding, or disseminated intravascular coagulation (DIC). Close collaboration with vascular surgical and ICU teams is a must. A variation on this presentation is the patient with an additional thrombosis of an aorto-bifemoral bypass graft.
Clinical improvement after treatment may be graded as shown in Table 4.
Table 4. Classification of Clinical Improvement
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Table
| Grade | Clinical Description |
|---|
| +3 | Markedly improved; symptoms absent or markedly improved; ABI* >0.90 |
| +2 | Moderately improved; still symptomatic but improvement of at least 1 category; ABI increase >0.10 |
| +1 | Minimally improved; ABI increase >0.10 but no categorical improvement, or vice versa |
| 0 | No change in category or ABI change <0.10 |
| -1 | Mildly worse; no category change or ABI change <0.10 |
| -2 | Moderately worse; 1 category worse or unexpected minor amputation |
| -3 | Markedly worse; more than 1 category worse or unexpected major amputation |
| Grade | Clinical Description |
|---|
| +3 | Markedly improved; symptoms absent or markedly improved; ABI* >0.90 |
| +2 | Moderately improved; still symptomatic but improvement of at least 1 category; ABI increase >0.10 |
| +1 | Minimally improved; ABI increase >0.10 but no categorical improvement, or vice versa |
| 0 | No change in category or ABI change <0.10 |
| -1 | Mildly worse; no category change or ABI change <0.10 |
| -2 | Moderately worse; 1 category worse or unexpected minor amputation |
| -3 | Markedly worse; more than 1 category worse or unexpected major amputation |
*ABI indicates ankle-brachial pressure index.
Indications And Contraindications
Catheter-mediated thrombolysis is useful in the treatment of both acute and chronic vascular occlusion and thromboembolus, and it is an option for native bypass graft occlusions. Thrombolysis is a reasonable option for patients with acute lower-limb ischemia for the prevention of amputation, with a mortality rate comparable to that of surgical interventions, with improved outcomes.
Chronicity alone is not a contraindication for thrombolysis. Results in individual patients vary substantially, and offering a trial of thrombolysis to patients with salvageable limbs regardless of the age of the occlusion is reasonable. Most angiographers have anecdotal experience with the incidental lysis of a long-standing native arterial occlusion in the treatment of a bypass graft occlusion.
More germane than chronicity is the degree and severity of ischemia and whether an acute limb-threatening situation is present. The limb threat that chronic ischemia causes is typically less time sensitive than the threat due to acute ischemia. Patients with chronic ischemia often present with chronic rest pain or tissue loss. The relative stability of the situation allows the treatment team the opportunity to treat the patient on a relatively elective basis, both in terms of the length of treatment and when to start therapy. When the patient's condition allows it, thrombolytic therapy can be scheduled for a Monday morning. This scheduling minimizes issues about the availability of clinical support during the course of treatment and should reduce complications.
In contrast, ALLI is a vascular surgical emergency. The classic constellation of signs and symptoms are the 5 P s: pain, pallor, pulselessness, paralysis, and paresthesia. In the traditional surgical doctrine, the acutely ischemic limb can be successfully revascularized within 4-6 h after the start of symptoms. The feared complication of delayed revascularization is reperfusion syndrome.
Reperfusion syndrome occurs when prolonged and severe ischemia occurs. Reperfusion syndrome, which follows extremity ischemia, has 2 components: (1) a local response, which consists of limb swelling with its potential for aggravating tissue injury, and (2) a systemic response resulting in multiorgan failure and death. Skeletal muscle tissue appears to be most vulnerable to ischemia.
Pathophysiologic studies reveal that irreversible damage to muscle tissue starts after 3 h of ischemia and is nearly complete at 6 h. Progressive microvascular damage appears to follow rather than precede skeletal-muscles tissue damage. The more severe the cellular damage, the greater the microvascular changes. With the death of tissue, microvascular flow ceases within a few hours; this is the no-reflow phenomenon. Compartment syndrome occurs at this point, and further tissue swelling ceases.
The inflammatory responses after reperfusion vary greatly. Thrombotic or embolic limb occlusion is the most common cause of reperfusion syndrome, in which a variable degree of ischemic damage occurs in the zone where collateral blood flow is possible. The extent of this region determines the magnitude of the inflammatory response, whether local or systemic. Only in this region is therapy of any benefit. Treatments may include fasciotomy to prevent pressure occlusion of the microcirculation or anticoagulation to prevent further microvascular thrombosis. Because the process of clotting generates many of the inflammatory mediators, anticoagulation has additional benefit of decreasing the inflammatory response. When most of the lower extremity is involved, amputation rather than attempts at revascularization may be the most prudent course to prevent the toxic product in the ischemic limb from entering the systemic circulation.17
Adult respiratory distress syndrome, shock, DIC, and renal failure are common systemic sequelae. The mortality rate associated with reperfusion syndrome is high.
Catheter-mediated thrombolysis has allowed modification of the traditional doctrine. The gradual way in which thrombolysis reestablishes flow allows the toxic metabolites to be mobilized over time and allows the patient to tolerate the systemic effects more easily than before. Patients with small-vessel occlusion are poor candidates for surgery because of the absence of a good distal bypass target. These patients should especially be offered a trial of thrombolysis. Exceptions to this approach are situations involving contraindications to thrombolysis or other emergency comorbidities or ischemia so severe that the treatment time is of paramount importance.
Candidates for thrombolysis are rarely in an ideal clinical condition. The major contraindications of thrombolysis are recent stroke or malignancy, particularly with the possibility for brain metastases. Renal insufficiency, allergy to contrast material, cardiac thrombus, diabetic retinopathy, coagulopathy, and recent arterial puncture or surgery are relative contraindications. The presence of a suitable arterial access site and the patient's ability to tolerate the treatment and cooperate during the procedure must be considered. Thrombolysis is rarely a treatment-versus-nontreatment decision. Rather, a range of surgical and nonsurgical strategies may be considered in treating the difficult case.
Thrombolysis Technique
Treatment paradigm
Lower-extremity arterial occlusion typically occurs as part of broad processes involving in situ thrombosis and/or embolization, for which the author uses the term thromboembolic occlusion. In situ thrombosis occurs when a local flow disturbance acts as a nidus to initiate the coagulation cascade. The flow disturbance can be due to local thrombosis or proximal embolus (typically thrombus.) Local thrombosis may be caused by a flow disturbance due to an underlying flow-limiting lesion, either a stenosis or an extrinsic or positional compression.
Hypercoagulable states, congenital or acquired (eg, dehydration), may also promote the formation of thrombus. Coagulation disorders should be considered in all patients presenting with early bypass failure, for whom the incidence is higher than that of the general population.
Once begun, thrombosis propagates both proximally and distally to the nidus until blood flow from an adjacent vessel is sufficient to prevent further propagation. Most bypass grafts have no internal branching, and occlusion extends the length of the graft. The thrombus may eventually continue into the native arterial system. The contour of the leading edge of the thrombus evolves in response to the local flow pattern, becoming smooth and physiologic in appearance with time.
Patient assessment and treatment
The treatment paradigm is based on the following factors: (1) The lesion underlying an arterial occlusion is often smaller than the overall thrombosis. (2) Short lesions are more likely than long ones to have a good clinical outcome. (3) If a long-segment occlusion can be converted to a short one, the success rate and longevity (patency) of the intervention improves.
A patient with an occlusion is given a trial of thrombolysis. If successful, this treatment shortens or at least softens the occlusion. After the thrombus resolves, the shortened lesion may be treated with conventional surgical or percutaneous techniques based on the new size and configuration of the lesion. Technical success and patency results are then based on the postthrombolytic appearance of the smaller lesion.18
This paradigm has been called thrombolysoangioplasty (TLA). Bypass occlusions typically have a relatively short segment, high-grade stenosis at the distal anastomosis, which may be addressed with surgery or angioplasty. A focal stenosis, such as one in the adductor canal region, may cause occlusions in the superficial femoral artery (SFA). The SFA and popliteal arteries have relatively few collateral connections and therefore allow a thrombosis to extend for some distance. The angiographic appearance may yield few clues about the underlying disease. Because atherosclerosis tends to be bilaterally symmetrical, the contralateral diagnostic angiogram may offer clues to the merits of attempting TLA.
Thrombolysis may be considered after initial consultation and patient evaluation. The patient must be in medically stable condition with adequate renal and coagulation function and an ability to cooperate and safely tolerate the therapy. Written informed consent must be obtained with an explanation of the disease process, proposed treatment indication, technique, risks, and alternatives.
If clinically significant pain, dementia, delirium, or psychiatric illness is present, an anesthesiologist may be consulted. Use of intravenous sedatives and/or analgesics or a nerve block may be considered. General anesthesia may be considered for uncooperative patients with limb-threatening ischemia and a high surgical risk. Because of the risk of bleeding, spinal anesthesia should be avoided. Likewise, any measures that reduce a patient's level of consciousness should be used with caution, because a change in mental status is an early sign of intracranial hemorrhage.
The lytic agent may be delivered by using a slow infusion through 1 or more sites or ports (McNamara technique) or by using a pharmacomechanical pulse-spray technique (Bookstein method). Pulse-spray thrombolysis can have a speed advantage compared with slow infusion techniques, but it is labor intensive, and it may be associated with a higher rate of distal arterial embolization. The author reserves the pulse-spray infusion for cases of severe acute limb-threatening ischemia or iatrogenic thromboembolus.
Peripheral thrombolysis, case 12. Late image
shows reconstitution of the right common iliac artery at the
level of the deep circumflex iliac branch. Low-dose urokinase
infusion was begun by using the McNamara
technique.
Peripheral thrombolysis, case 12. Late image
shows reconstitution of the right common iliac artery at the
level of the deep circumflex iliac branch. Low-dose urokinase
infusion was begun by using the McNamara
technique.
Peripheral thrombolysis, case 12. Contralateral
oblique image shows that the stenosis in the proximal right
external iliac artery is smooth and circumferential. The distal
lesion is not seen in its ideal profile. Low-dose urokinase
infusion is continued by using the McNamara
technique.
Peripheral thrombolysis, case 12. Contralateral
oblique image shows that the stenosis in the proximal right
external iliac artery is smooth and circumferential. The distal
lesion is not seen in its ideal profile. Low-dose urokinase
infusion is continued by using the McNamara
technique.
In McNamara's original paradigm, an end-hole catheter is placed in or near the proximal portion of the thrombus. Urokinase is infused at a rate of either 1000 U/min (low dose) or 4000 U/min (high dose). Follow-up angiography is performed after each 500,000 U administered at 8 hours for low doses and 2 hours for high doses.
19,12,13,14 Between interventions, the patient should be monitored in a setting in which experienced nursing staff can closely observe the patient. Although not required, a surgical intensive care setting is recommended. For a 60-mL/h infusion rate, 500,000 U of UK are placed in 500 mL of normal saline for low doses and in 125 mL of normal saline for high doses.
The author prefers to use an intra-arterial infusion at a rate of no less than 30 mL/h to maintain catheter patency.20 Heparin is intravenously infused for an aPTT of 1.5-2 times that of the control value. The platelet count should be monitored for antiheparin antibodies in all patients receiving heparin. The use of hematological testing during thrombolysis is controversial.
Some interventionalists advocate the use of tests to monitor the presence of a fibrinolytic state and to predict clinical outcome and occurrence of complications. However, in common clinical practice, hematologic testing is unnecessary. The result of a single coagulation procedure has no direct clinical association with outcomes of fibrinolytic testing and reperfusion, reocclusion, or hemorrhage. This is borne out by the fact that low fibrinogen level marks an increased hemorrhage risk but does not accurately predict hemorrhage in a particular patient moreover hemorrhagic complications can occur with normal levels of fibrinogen. Useful tests include daily hemoglobin or hematocrit determinations to detect occult bleeding.
Equipment required for the pulse-spray technique includes a special catheter (Mewissen, Boston Scientific; Natick, Mass), a Touhy-Borst–type side-port adapter, guidewire, a stopcock, and a 1-mL syringe. The catheter has multiple, tiny side holes through which the thrombolytic agent may be directly administered within the thrombus at a high rate. The catheter is placed within the thrombus. Depending on the catheter used, a guidewire may be required to occlude the end hole.
Peripheral native arterial thrombolysis, case 5,
part 1. Day 1 follow-up angiogram. The guidewire was removed,
and contrast agent was injected through the Mewissen catheter.
The superficial femoral artery (SFA) is partially recanalized,
with good distal flow. No distal emboli were noted (images not
shown).
Peripheral native arterial thrombolysis, case 5,
part 1. Day 1 follow-up angiogram. The guidewire was removed,
and contrast agent was injected through the Mewissen catheter.
The superficial femoral artery (SFA) is partially recanalized,
with good distal flow. No distal emboli were noted (images not
shown).
Peripheral native arterial thrombolysis, case 5,
part 1. Because antegrade flow is restored,
multiple–side-port infusion is no longer required. A
Mewissen catheter is replaced with an end-hole straight
catheter. The guidewire and Touhy-Borst adapter are no longer
needed, so nursing care in the ICU is simplified. The treatment
team elected to increase therapy to a high-dose urokinase
infusion for several hours and to recheck the patient in the
afternoon.
Peripheral native arterial thrombolysis, case 5,
part 1. Because antegrade flow is restored,
multiple–side-port infusion is no longer required. A
Mewissen catheter is replaced with an end-hole straight
catheter. The guidewire and Touhy-Borst adapter are no longer
needed, so nursing care in the ICU is simplified. The treatment
team elected to increase therapy to a high-dose urokinase
infusion for several hours and to recheck the patient in the
afternoon.
Initial catheterization
The choice of arterial access site is one of individual preference and patient-specific findings. The author prefers the contralateral, retrograde, femoral approach for lower-extremity occlusions extending above the knee. A diagnostic aortoiliofemoral run-off angiogram may be obtained, and the infusion systems may be placed with relative ease in most cases. Ipsilateral antegrade (downhill) puncture may be considered when the contralateral femoral pulse is poor or when in-line access to the lesion is expected to be required, such as for small-vessel catheterization or native-vessel recanalization. The antegrade approach cannot be used for aortoiliac angiography, which would require a prior study or separate puncture.
Antegrade puncture may be associated with an increased rate of bleeding complications. Suprainguinal ligament (high) arterial puncture may occur, particularly in the obese patient. High punctures are associated with clinically silent retroperitoneal bleeding, which often manifests as hypotensive shock in the early hours of the morning. Antegrade puncture is also poorly suited for treating proximal femoral graft or native arterial occlusions because the approach provides little working room in the artery for catheter, sheath, and guidewire manipulation.
A diagnostic angiogram may be obtained to delineate the arterial anatomy. The occluded vessel or bypass graft is usually identifiable as a residual pouch or nipple. Review of previous angiograms or surgical reports and consultation with the vascular surgeon may be needed to identify the target for lysis in patients with complex anatomy. The nipple is catheterized and probed with a floppy-tip guidewire. The leading edge of thrombus is often resilient and resistant to catheterization. The catheter can then be introduced into the thrombus. Beyond the thrombus, the initial firmness conventional techniques may be used. Increased care is required when a native arterial occlusion is probed because of a risk of dissection and perforation of the artery.
The initial attempt to traverse the leading edge of the thrombus is described as a guidewire traversal test. The guidewire is passed through the whole length of the thrombus before initiation of prolonged infusion with the catheter embedded in the proximal thrombus. If a guidewire cannot be passed through the thrombus, it is probably organized and less likely to clear with thrombolysis. With passage of nonhydrophilic guidewire, initial success with clot lysis is most likely with a thrombus less than 7 days old.19,21,22
Special lytic-agent infusion techniques are required only until antegrade flow is restored in the vessel. Once partial patency is restored, the agent needs to be infused only from a point proximal to the residual thrombus. The agent is then carried by the flowing blood and bathes the residual thrombus until the endpoint is reached.
Choice of technique and catheters
The choice of technique is mostly a personal one that is influenced by personal experience and based on the particular details of the individual patient and the issues related to the medical center or referring clinicians. No single dose or technique is generally accepted for performing thrombolysis. In vitro evidence suggests the choices between continuous versus pulsed infusion and between UK and sodium chloride solution involve trade-offs in speed of lysis and in the size and number of distal emboli treated. The author prefers low-dose infusion protocols in patients with noncritical ischemia. The somewhat slower rate of lysis allows more flexibility in the follow-up schedule and seems to provide more time for recognizing bleeding complications when they occur. At the author's institution, this approach is well tolerated by patients and accepted by clinicians.
Catheter infusion systems are available in different configurations and French sizes, and either general-purpose or function-specific types are available. The author prefers to use a 5F catheter placed through a 6F introducer sheath. The use of the oversized 6F introducer sheath allows the intensive care team to obtain blood samples while avoiding the risks of phlebotomy during thrombolysis.
The infusion catheter may be specifically designed for lysis (eg, Mewissen; Boston Scientific), or it may have a general-purpose end hole (straight or curved) or multiple side holes (Motarjeme, Merit Medical Systems, South Jordan, Utah; Neff, Cook, Bloomington, Ind) The author finds the Neff catheter to be particularly versatile in this regard. The multiple side holes allow the injection of contrast material at rates as high as 15 mL/s for diagnostic angiography. The curve and material of the catheter allow it to be used for the selective catheterization the occluded vessel down to the midthigh area. The Neff and the similarly shaped Motarjeme catheters may be used with a 0.035-in coaxial infusion microcatheter or wire. General-purpose catheters are relatively inexpensive and can be used in situations in which direct infusion over a long proximal segment of the occlusion is not needed.
Advantages of end-hole catheters:
- End-hole catheters permit extension of the diagnostic angiogram. They are used for initially traversing the occluded segment.
- These catheters are simple to use.
- They are inexpensive.
- Follow-up angiography can be readily performed.
- Peripheral small-vessel occlusions are best managed with end-hole catheters because the occluded target vessels are usually too numerous and too small to be infused separately.
- End-hole catheters are suitable alternatives when the anatomy is unfavorable for the use of coaxial or multihole catheters.
Disadvantages of end-hole catheters:
- These catheters are relatively unstable.
- Continuous monitoring is needed when the catheter is advanced.
Advantages of coaxial end-hole catheters:
- These are more stable than conventional end-hole catheters. Their construction protects against inadvertent dislodgement of the infusion catheter.
- These catheters have a smaller profile and therefore result in less pericatheter thrombosis.
- The need to manipulate catheter is reduced.
- Although the evidence is not conclusive, lysis may be faster with coaxial end-hold catheters than with other catheters.
Disadvantages of coaxial end-hole catheters:
- The tip of the catheter is difficult to see on fluoroscopy.
- The infusion guidewire is fragile.
- Manipulation of catheter is still necessary.
- Two infusion pumps may be required.
- Fluids and lytic agents may not flow easily because of the small lumen.
Advantages of multi–side hole catheters:
- The catheters tend be more stable than end-hole catheters.
- They permit wider exposure of the thrombus to the lytic agent.
- The lytic agent is evenly dispersed.
- The need for catheter monitoring is reduced.
- These catheters are simple to use.
- Their flow characteristics are better than those of coaxial systems.
Disadvantages of multi–side hole catheters:
- Multi–side hole catheters are expensive.
- Their structure is more complex than that of other catheters.
- Many require 2 infusion pumps when co-axial catheters are used.
- Many require obturating wires.
- Angiographic studies are difficult to perform through some of these catheters.
The first major modification to the McNamara technique was the development of coaxial infusion. Coaxial infusion is designed to provide uniform delivery of the agent to the thrombus while maintaining the convenience of a slow infusion. This technique is particularly helpful for treating bypass grafts. After the proximal firm thrombus is traversed, the risk of wire induced vessel damage is low. The central portion of a thrombosed graft generally contains soft thrombus that allows for easy wire and catheter manipulation.
Three devices are required for coaxial infusion: (1) an infusion catheter, (2) an infusion wire or microcatheter, and (3) a Touhy-Borst–type side-port adapter. The infusion catheter is usually a 5F catheter with multiple distal side holes for infusion with a tapered end hole to seal against the inner device. Another design may be used to limit infusion to the side holes. The catheter may be function specific (Mewissen; Boston Scientific), or it may be a general-purpose device (Neff; Cook; Motarjeme; Merit Medical Systems, Inc). The infusion wire or microcatheter is usually a 0.035- or 0.038-in (3F) device with either an end hole (Sos; Cook) or multiple side holes (Katzen; Boston Scientific). The size of the infusion wire should be matched to the size of the catheter end hole for proper function. A Touhy-Borst–type side-port adapter is used to allow simultaneous infusion and to make a fluid-tight seal between the inner and outer catheters.
The infusion wire is placed through the infusion catheter. The outer infusion catheter is placed so that the infusion from the proximal side hole bathes the leading edge of the thrombus. The inner infusion wire is placed to infuse the distal portion of the occlusion. The ideal position of the inner wire allows for flow of the agent so that the distal thrombus plug lyses only after most of the proximal thrombus has been dissolved. This way, the risk of distal embolization is minimal. The same total lytic agent dose is used as with the original McNamara technique, divided between the ports. The division can be equal or unequal depending on the clinical circumstances. With the same concentration as above, low-dose tPA can be delivered at a rate of 30 mL/h per port, for a total dose of 0.48 mg/h.
Short occlusions may be treated with a multiple–side-port catheter without the infusion wire. Infusion catheters are available with infusion lengths of 20 cm or longer, and they may be used with a conventional guidewire. Coaxial and multiple–side-hole infusion devices are not required for successful thrombolysis.
Both end-hole and multiple–side-hole diagnostic catheters may be used with an adjustment of the position of the catheter tip so that a gentle test injection distributes contrast material through the proximal portion of the occlusion. This test fairly closely recreates the distribution of the lytic agent achieved with multiport infusion catheters, particularly with occluded bypass grafts. The author has not found any significant difference in clinical results or complication rates with different slow-infusion lysis techniques or with the vigor of the initial guidewire test. During this initial phase of treatment, use of the Touhy-Borst adapter and guidewire might also be avoided to simplify nursing care and to minimize human error.
The dose rate and follow-up schedule may be adjusted depending on clinical and time-management issues. The author uses an 8- to 24-hour follow-up schedule for low-dose infusion (tPA 0.48 mg/h) and a 1- to 4-hour follow-up schedule for high-dose infusions (tPA 0.96 mg/h). On occasion, 48 hours may pass before patient with a long-segment chronic occlusion undergoes angiography. In these patients, telephone and clinical follow-up are performed at 24 hours.
Two clinical factors are involved with determining the need for follow-up: (1) Treatment can be facilitated when the configuration of the infusion system is adjusted to the flow pattern and distribution of residual thrombus. (2) The bleeding risk increases with higher doses; with resolution of the thrombus; and, possibly, in the early hours of the morning.
Suction thrombectomy is an occasionally useful technique, particularly in treating small distal thromboemboli. It requires the placement of a nontapered catheter through the introducer sheath with the distal end at the thrombus. A large syringe is attached, and suction is applied while the catheter is removed in a smooth motion. The aspirate may be evaluated for thrombi by filtering the blood through gauze.
Adjunctive Medications During
Thrombolysis
In clinical practice, thrombolytic techniques vary widely in terms of the choice of lytic agent and dose, the infusion technique, and the use of adjunctive agents. These variances depend on the patient population, the treatment setting, and the experience and preference of the practitioner and of the referring and consulting physicians. Thrombolytic agents such as reteplase and prourokinase may also be used, as may platelet receptor antagonists. Plasminogen and thrombin inhibitors promote lysis with tPA but not with urokinase. The author has no experiences with these agents.
Heparin is commonly though not universally used during thrombolysis. Its use ranges from dilute mixtures (3000 U/L) in flush solutions to full systemic anticoagulation with an aPTT at 1.5-2 times the control value. However, many believe that this regimen, while fine for urokinase, should be lowered significantly for tPA or r-tPA infusions because of increased risk of complications during these infusions in patients fully anticoagulated.
The author has found that maintaining therapeutic anticoagulation a significant challenge. The aPTT often strays substantially above or below the traditional target of 1.5-2 times the control value. This issue cannot be easily explained solely on the basis of human error. A patient's coagulation homeostasis is likely in a state of flux as the therapy progresses.
The cardiology community has suggested theories of a diurnal rhythm in the balance between thrombosis and lysis. However, no scientific data specifically address the advantages or disadvantages of heparin therapy during thrombolysis. Despite this lack, current practice suggests that concomitant heparin administration may restrict pericatheter thrombosis and can be administered by a systemic route or around the catheter through a proximal sheath. Anticoagulation following the procedure is appropriate and should be continued until the underlying cause of occlusion has been resolved.
Heparin is contraindicated in the presence of antiheparin antibodies because dangerous thrombocytopenia can develop. Although not routinely ordered, an assay for the antibody is available. In all patients receiving thrombolysis and heparin, both the aPTT and the platelet counts should be monitored on a continuing basis. Once again, personal experience and input from the referring and vascular surgical teams are important considerations.
Treatment And Posttreatment Issues
Treatment endpoints
Several factors influence the speed of lysis, including the age and nature of the clot, the infusion technique, the lytic agent and dose, and the chosen treatment endpoint. Acute thrombosis generally responds faster than chronic occlusion. The literature suggests that thrombolysis can typically be performed in 18-36 hours. In the author's practice, patients often present with a picture of acute-on-chronic arterial and/or graft occlusion. These patients are often successfully treated with a 72- to 96-hour course of therapy, though some patients respond within 1 day. Although a 72- to 96-hour course of therapy seems to work well, it is not a standard treatment and many interventionalists confine thrombolysis to 18-36 hours.
The choice of therapeutic endpoint may be subject to discussion. The theoretical endpoints to thrombolytic therapy are the following: (1) clinical success, that is, the resolution of thrombus and symptoms; (2) treatment arrest or failure, or the failure to improve either angiographically or clinically; and (3) complications necessitating the termination of therapy, for example, major bleeding, stroke, sepsis, gangrene, pulmonary edema, heart failure, shock, or an inability to cooperate.
The patient's overall condition and the treatment alternatives, as well as the experiences of the clinicians involved, affect these seemingly clear endpoints. The degree of thrombus resolution that indicates success varies from 95% lysis to total lysis without evidence of residual thrombus.
The treatment team at the author's institution is aggressive in treating patients with severe peripheral vascula, who often have severe atherosclerosis, bypass grafts, and calf-vessel occlusion. These patients have already undergone several surgical interventions, and they have multiple comorbidities, including defects of coagulation. Because they are poor surgical candidates, they are offered an aggressive course of thrombolytic therapy that usually extends over several days. In the absence of major complications, treatment is continued until the thrombus is completely resolved or until no evidence of clinically significant improvement is noted in 4-24 h.
Catheter-site infection is a potentially serious complication of prolonged thrombolysis. As a precaution, all patients receiving thrombolysis for more than 72 hours are given prophylactic antibiotics. To reduce the incidence of infection, the sheath should be changed if any stents are going to be used to treat the underlying lesions, especially if the sheath has been in place for a prolonged period.
Complications
A trade-off exists between the risks of bleeding complications and the risks of thromboembolic complications. The decision is partially based on the clinical factors and the institutional tolerance for moderate bleeding complications. This trade-off also comes into play in determining the treatment endpoint. Patients in the author's practice often present with severe limb-threatening, acute-on-chronic ischemia. A significant minority of patients develop cosmetically relevant but surgically insignificant hematomas (predominantly related to the catheter site) if the target aPTT is 1.5-2 times the control value.
Slow infusion techniques are used to minimize distal embolization, which is poorly tolerated in patients with severe calf-vessel disease. The author prefers to leave a short segment of thrombus distal to the infusion device to act as a temporary barrier to embolization of the small thrombi that may break off during the lysis process. Ideally, the distal thrombus plug lyses as the proximal thrombus embolization risk abates. Transient distal embolization is a common event during thrombolysis and appears as a transient increase in rest pain or as deterioration perfusion on physical examination. These emboli resolve in a matter of hours in most patients if the lytic infusion is allowed to continue. Aggressive pain management and close clinical follow-up is recommended. Warning the patient and the nursing and surgical staff about this possibility reduces undue concern. Rarely is angiographic or surgical intervention indicated.
The overall risk of hemorrhagic stroke from a thrombolysis procedure has been reported to be 1-2.3%. About 50% of hemorrhagic complications occur during the thrombolytic procedure. Hematoma at the vascular puncture site has been reported 12-17% and gastrointestinal bleeding has been variably recorded between 5-10%, hematuria following thrombolysis should provoke search for urinary tumors.
Anaphylactic reactions to streptokinase are rare, but allergic responses do occur. These are usually characterized by flushing, vasodilatation, rashes, and hypotension. The symptoms usually respond well to discontinuation of the streptokinase infusion and the administration of hydrocortisone and antihistamine. Delayed serum sickness–symptoms are a rare occurrence with streptokinase. Patients present with joint pains, fever, and microscopic hematuria 10-21 days after treatment. Most patients recover without sequelae, though irreversible renal impairment is described.
The incidence of hemorrhagic complications is decreased with alteplase compared with streptokinase, but no difference has been found in hemorrhagic complication rates between alteplase and urokinase.
Posttreatment issues
After successful thrombolysis is accomplished, the patient should be evaluated for any underlying vascular lesions that could explain the cause of the vascular occlusion. If identified, these lesions must be treated (radiologically or surgically) to prevent early recurrence of the occlusion. Patients with early bypass failure should also be evaluated for occult coagulation anomalies. Some patients may benefit from posttreatment anticoagulation or antiplatelet therapy. All patients must receive close clinical follow-up. Some clinicians recommend periodic surveillance noninvasive blood-flow evaluations for the early detection of restenosis.
Clinical trials
Prospective randomized studies performed to direct compare different thrombolytic agents are limited. The largest body of evidence supporting recombinant-based thrombolytics for this indication was derived from trials of alteplase. One open trial was performed to compare intra-arterial streptokinase to intra-arterial and IV alteplase in 60 patients with recent-onset or deteriorating limb ischemia. The initial angiographic success was significantly greater with intra-arterial r-tPA (100%) than with intra-arterial SK (80%; P <.04) or IV alteplase (45%, P <.01). The 30-day limb-salvage rates were 80%, 60%, and 45%, respectively.
Activase has been used extensively in the treatment of peripheral vascular occlusion. Most of the studies in this regard have been based on dose ranging.23,24
The largest group studied included 65 patients, with both peripheral arterial and bypass graft occlusions.25,26 In this study, Activase was infused through an embedded catheter into the thrombus. Angiographically documented clot lysis was achieved in 94% of patients, whereas clinically evident thrombolysis was noted in 90% of patients, with a mean infusion time of 5.25 hours. Two failures were recorded in patients in whom the catheter could not be placed at the thrombus. Minor hematomas developed at the catheter entry site in 12.3% of patients; 4.6% developed major hematomas.
After thrombolysis, 76% of patients required additional procedures, such as percutaneous transluminal angioplasty or surgical revision (20 patients), and seven patients required anticoagulation to maintain patency. One death was due to intracranial hemorrhage, which occurred 48 hours after thrombolytic therapy while the patient was receiving heparin.
In another open randomized trial (32 patients), alteplase initially produced significantly faster lysis than urokinase, but the 24-hour and 30-day success rate was not statistically different. In the Surgery Versus Thrombolysis for Ischemia of the Lower Extremity (STILE) study, designed to evaluate surgery versus thrombolysis for lower extremity ischemia, efficacies or bleeding complications did not differ in patients receiving alteplase compared with those receiving urokinase.
A study by Krupski et al in 1989 was designed to evaluate the efficacy of 2 doses of alteplase (Activase) in patients with acute or subacute peripheral arterial occlusion. The patients were randomly assigned to receive 0.05 or 0.025 mg/kg/h given through catheter positioned adjacent to the thrombus. No heparin was administered during the procedure, but all patients were given IV heparin after successful thrombolysis. The mean infusion duration was 3.1 hours among patients who received the high rate and 7.4 hours in patients treated with the low infusion rate. Secondary procedures were required in 5 of 7 patients to maintain patency.27
A randomized, controlled trial was performed to compare intra-arterial alteplase (Activase) and urokinase in 32 patients with peripheral arterial occlusion of up to 90 days' duration.28,29 The endpoint of this study was clot lysis of greater than 95%, as evaluated with serial angiograms at baseline and at 4, 8, 16, and 24 hours. Alteplase (Activase) was administered to 16 patients as a 10-mg bolus followed by an infusion of 5 mg/h for up to 24 hours. Urokinase was given to 16 patients as a 60,000-IU bolus followed by an infusion of 240,000 IU/h for 2 hours, 120,000 IU/h for 2 hours, and 60,000 IU/hr for up to 20 hours. All patients received concomitant heparin (3000-5000 U bolus, 600-1000 U/h).
Eight patients treated with alteplase (Activase), and 9 patients given urokinase required surgical intervention within 30 days. Three Activase-treated patients and 5 urokinase-treated patients underwent angioplasty within 30 days. Hemorrhagic events were similar in the 2 groups. The fibrinogen level at 24 hours was significantly lower among patients who received Activase than those who received urokinase. The authors concluded that alteplase (Activase) therapy was associated with faster clot lysis; however, 30-day clinical success rates did not significantly differ. The incidence of hemorrhagic complications was greater with alteplase (Activase) therapy than with urokinase, though this difference was not statistically significant.
A nonrandomized comparison of alteplase and UK was performed in 28 patients who received intra-arterial urokinase 40,000-200,000 U.30 An additional 28 patients received alteplase 2.5-7.5 mg. The occlusions were as old as 4 months. The length of the thrombus averaged 7 cm in the alteplase group and 8 cm in the urokinase group. Primary success was achieved in 86% in the alteplase group (mean duration of treatment, 2 h) and 75% in the urokinase group (mean duration of treatment, 6 h). Angioplasty was required in 18% of alteplase group and 21% of urokinase group. Local hematoma was twice as common in the urokinase group than in the alteplase group (7% vs 14%).
Findings from another trial of alteplase (Activase) or urokinase for peripheral arterial occlusion confirmed the efficacy and safety of alteplase. After diagnostic angiography, 22 patients received urokinase 4000 U/min, and 23 patients received alteplase 0.05 mg/kg/h. Arterial patency was assessed with serial arteriography at 4, 8, and 18-24 hours. Patency was graded from 0 (no flow) to 3 (full flow, no residual thrombus). Complete thrombolysis was successful in 86% in the urokinase group and in 91% of the alteplase group. The mean infusion times for alteplase and urokinase were 4.5 and 18.7 hours, respectively, with mean doses of 27 and 4.34 million U, respectively.
Four patients in the alteplase group developed catheter-site bleeding compared with 1 patient in the urokinase group. One patient treated with urokinase had an intracranial bleed. Nausea and vomiting occurred in 14 urokinase-treated patients. Patients in whom reperfusion was not achieved with either agent were characterized by severe, uncorrectable disease that was intrinsic or immediately adjacent to the artery or bypass graft.
In another study to confirm the efficacy of alteplase, investigators evaluated 120 patients, who were matched for age, sex, and disease severity (Fontaine classification), who were treated with alteplase (n = 60) or urokinase (n = 60) administered through an intra-arterial catheter.31
In a randomized study, thrombolysis with alteplase or urokinase was used in conjunction with heparin delivered intra-arterially and locally.31 Heparin therapy was initiated prior to thrombolysis and continued for 5 days after therapy. Alteplase was given as a 5-mg bolus followed by a 5-mg/h infusion, whereas urokinase was infused at 60,000 IU/h.
Initial patency was achieved in 85% and 73% of patients in the alteplase and urokinase groups, respectively, as assessed by means of angiography. Reocclusion developed in 8 patients within 72 hours in the alteplase group and within 10 hours of the urokinase group. The duration of therapy was 1-4 hours (median, 2 h) for alteplase and 6-72 hours (median, 24 h) for urokinase. Catheter-site bleeding occurred in 15% and 8% of patients alteplase and urokinase, respectively. No major bleeding complications occurred during thrombolysis; however, during postlytic treatment with heparin, GI hemorrhage developed in 1 patient in the urokinase group; this responded to conservative management. At 6-month follow-up, patients treated with alteplase had rates of amputation, reocclusion, and Fontaine stage III and IV disease lower than those of patients in the urokinase group.
A combination of streptokinase and heparin was compared with alteplase in a dose-ranging trial evaluating safety and efficacy in 28 patients with limb-threatening ischemia of less than 1-month duration (median, 7.5 d). Four infusion rates of alteplase were studied in 23 patients: 0.25, 0.5, 1.0, and 2.5 mg/h. The median duration of infusion was 22 hours for alteplase and 38 hours for streptokinase and heparin. Clot lysis was achieved in all patients in the alteplase group; the speed of clot lysis appeared to be dose related. All patients received heparin therapy after successful thrombolysis.32
Hemorrhagic complications occurred in 29% of patients. Four patients (17%) had major hemorrhagic complications: Three cases occurred at the infusion rate of 2.5 mg/h, and 1 patient receiving 2.5 mg/h developed an intracerebral bleed. Fibrinogen concentrations decreased below 120 mg/dL in 22% of patients treated with alteplase and in 40% of SK/heparin-treated patients; this was identified as a risk factor for bleeding. The authors concluded that an infusion of alteplase at 0.5 mg/h was effective and had fewer complications than higher doses of alteplase.33
Further work by the same group involved an intra-arterial dose of alteplase 0.5 mg/h given to 13 patients with acute and subacute occlusion. Two patients required a second therapeutic course of alteplase: 1 for reocclusion 2 weeks after angioplasty of a residual stenosis the other for rethrombosis at 4 months after initially successful thrombolysis. The mean duration of ischemia was 18 days. The mean length of the occlusion was 18 cm; three patients (23%) had occlusions longer than 25 cm. Six patients (46%) had no demonstrable distal runoff vessels at the time of angiography.
Patients were treated with alteplase 0.5 mg/h for a mean of 26.2 hours. Patients received heparin for 5 days after thrombolysis or angioplasty, and warfarin therapy was started on day 3. Angiographic evidence of lysis was noted in all patients; however, this was not enough to reperfuse the distal limb in 2 patients with previously noted absence of runoff. Minor groin hematomas developed in 4 patients. (Three of these patients underwent angioplasty.) Two other patients developed reocclusion despite angioplasty. Fibrinogen levels were reduced to 66% of baseline. No major complications were reported. The limb-salvage rate at 30 days was 87%. The authors concluded that intra-arterial alteplase at 0.5 mg/h appeared to be a safe and effective regimen for the treatment of acute peripheral arterial occlusion.
In a separate analysis, these 13 patients were compared with 15 patients who received intra-arterial alteplase 0.5 mg/h plus intra-arterial heparin. The mean total dose of alteplase was 15 mg. Patients with emboli less than 2 days old or neurologic deficit of the involved limb were excluded. Results of combination therapy were similar to those achieved by alteplase alone. This finding prompted the authors to comment that the use of concurrent heparin did not appear to produce additional benefit. Two patients in each group developed rethrombosis. No major hemorrhagic complications occurred. Puncture-site hematomas occurred in 13% of patients.
Another group compared intra-arterial streptokinase and alteplase in 98 and 69 patients with peripheral arterial occlusive disease, respectively. Patients received streptokinase (5000 U/h) or alteplase (0.5 mg/h in 51 patients and 0.25-2.5 mg/h in 18 patients). Criteria for successful lysis included angiographic proof, increase in the ankle-brachial index (ABI), limb salvage at 30 days, absence of clinical evidence of rethrombosis, or no need for intervention (other than angioplasty) at the site of thrombolysis.
With these criteria, successful thrombolysis was achieved in 41% of patients treated with streptokinase and in 58% of those receiving alteplase. The mean time to thrombolysis was shorter among those treated with alteplase (22 vs 40 h). Among the 5 patients treated with alteplase who had a major or intracranial bleed, 3 received the highest dose (2.5 mg/h). (The duration of treatment was not indicated.) Two major bleeds occurred in the remaining 64 patients treated with the low doses.
Multimedia
| Media file 1:
Peripheral thrombolysis, case 1. Thrombolysis of
an iliac thrombus with distal occlusions. Pretreatment
angiogram shows an intraluminal nonocclusive thrombus of the
left common iliac artery. A Motarjeme catheter was placed just
proximal to the lesion, and urokinase was infused at a rate of
60,000 U/h. |
Peripheral thrombolysis, case 1. Thrombolysis of
an iliac thrombus with distal occlusions. Pretreatment
angiogram shows an intraluminal nonocclusive thrombus of the
left common iliac artery. A Motarjeme catheter was placed just
proximal to the lesion, and urokinase was infused at a rate of
60,000 U/h.
 | Media file 2:
Peripheral thrombolysis, case 1. Follow-up
angiogram obtained on day 1 shows slight improvement in the
size of the thrombus. The image suggests stenosis of the
proximal common iliac artery. |
Peripheral thrombolysis, case 1. Follow-up
angiogram obtained on day 1 shows slight improvement in the
size of the thrombus. The image suggests stenosis of the
proximal common iliac artery.
 | Media file 3:
Peripheral native arterial thrombolysis case 1.
Angiogram obtained with an injection given more vigorously than
before shows good antegrade flow. |
Peripheral native arterial thrombolysis case 1.
Angiogram obtained with an injection given more vigorously than
before shows good antegrade flow.
 | Media file 4:
Peripheral thrombolysis, case 1. Proximal calf
vessels show evidence of chronic, possibly thromboembolic,
disease. |
Peripheral thrombolysis, case 1. Proximal calf
vessels show evidence of chronic, possibly thromboembolic,
disease.
 | Media file 5:
Peripheral native arterial thrombolysis, case 1.
Vascular occlusions in the distal calf may respond to directed
thrombolytic infusion. |
Peripheral native arterial thrombolysis, case 1.
Vascular occlusions in the distal calf may respond to directed
thrombolytic infusion.
 | Media file 6:
Peripheral thrombolysis, case 1. A 0.035-in.
coaxial infusion wire is placed in the tibioperoneal
trunk. |
Peripheral thrombolysis, case 1. A 0.035-in.
coaxial infusion wire is placed in the tibioperoneal
trunk.
 | Media file 7:
Peripheral native arterial thrombolysis, case 1.
Angiogram obtained by means of the infusion wire confirms
proper positioning and the flow pattern. |
Peripheral native arterial thrombolysis, case 1.
Angiogram obtained by means of the infusion wire confirms
proper positioning and the flow pattern.
 | Media file 8:
Peripheral native arterial thrombolysis, case 1.
Test injection given through the outer infusion catheter with
the infusion wire in place. Although only limited injection is
possible, the proper position and flow are
confirmed. |
Peripheral native arterial thrombolysis, case 1.
Test injection given through the outer infusion catheter with
the infusion wire in place. Although only limited injection is
possible, the proper position and flow are
confirmed.
 | Media file 9:
Peripheral thrombolysis, case 1. Final images
obtained at day 2 follow-up show a mild residual stenosis of
the left common iliac artery with a small residual trailing
thrombus. The lesions are not flow limiting. |
Peripheral thrombolysis, case 1. Final images
obtained at day 2 follow-up show a mild residual stenosis of
the left common iliac artery with a small residual trailing
thrombus. The lesions are not flow limiting.
 | Media file 10:
Peripheral native arterial thrombolysis, case 1.
Distal calf angiogram shows no change in this patient's distal
small-vessel disease, suggesting chronicity. The patient was
symptom-free at this time. In consultation with the referring
vascular surgeon, the treatment was terminated. |
Peripheral native arterial thrombolysis, case 1.
Distal calf angiogram shows no change in this patient's distal
small-vessel disease, suggesting chronicity. The patient was
symptom-free at this time. In consultation with the referring
vascular surgeon, the treatment was terminated.
| Media file 11:
Peripheral thrombolysis, case 2. Low-dose
urokinase infusion to manage femoral-popliteal occlusion. The
patient had undergone left femoral-popliteal bypass grafting.
Pretreatment anteroposterior (AP) pelvic image shows severe
atherosclerotic disease with attenuated flow through the left
superficial femoral artery (SFA), which suggests a distal
occlusion. The bypass graft is not seen. |
Peripheral thrombolysis, case 2. Low-dose
urokinase infusion to manage femoral-popliteal occlusion. The
patient had undergone left femoral-popliteal bypass grafting.
Pretreatment anteroposterior (AP) pelvic image shows severe
atherosclerotic disease with attenuated flow through the left
superficial femoral artery (SFA), which suggests a distal
occlusion. The bypass graft is not seen.
 | Media file 12:
Peripheral bypass thrombolysis, case 2.
Anteroposterior (AP) thigh image shows occlusion in the mid
superficial femoral artery (SFA) with dense calcium in the
distal aspect. |
Peripheral bypass thrombolysis, case 2.
Anteroposterior (AP) thigh image shows occlusion in the mid
superficial femoral artery (SFA) with dense calcium in the
distal aspect.
 | Media file 13:
Peripheral bypass thrombolysis, case 2.
Left-knee angiogram shows an outpouching corresponding to the
residual nipple of the below-the-knee anastomosis. The bypass
graft is occluded; however, the recipient popliteal artery is
still patent. If left untreated, this vessel will eventually
become thrombosed as well. Symptoms worsen as the thrombosis
progresses, eventually causing the individual to seek
treatment. |
Peripheral bypass thrombolysis, case 2.
Left-knee angiogram shows an outpouching corresponding to the
residual nipple of the below-the-knee anastomosis. The bypass
graft is occluded; however, the recipient popliteal artery is
still patent. If left untreated, this vessel will eventually
become thrombosed as well. Symptoms worsen as the thrombosis
progresses, eventually causing the individual to seek
treatment.
 | Media file 14:
Peripheral thrombolysis, case 2. Diseased
posterior tibial artery run-off to the ankle. |
Peripheral thrombolysis, case 2. Diseased
posterior tibial artery run-off to the ankle.
 | Media file 15:
Peripheral thrombolysis, case 2. Magnified view
of the ankle shows distal occlusion of the posterior tibial
artery. The distal bifurcation of the proximally occluded
peroneal artery acts as a bridging collateral to reconstitute
the dorsalis pedis. |
Peripheral thrombolysis, case 2. Magnified view
of the ankle shows distal occlusion of the posterior tibial
artery. The distal bifurcation of the proximally occluded
peroneal artery acts as a bridging collateral to reconstitute
the dorsalis pedis.
 | Media file 16:
Peripheral bypass thrombolysis, case 2. Day 1
follow-up image obtained after low-dose urokinase therapy given
at a rate of 60,000 U/h by injecting contrast material directly
into the femoral-popliteal bypass. Residual thrombus is noted.
Anteroposterior (AP) pelvic image (not shown) demonstrated slow
flow down the bypass compared with flow in the profunda
femoris. |
Peripheral bypass thrombolysis, case 2. Day 1
follow-up image obtained after low-dose urokinase therapy given
at a rate of 60,000 U/h by injecting contrast material directly
into the femoral-popliteal bypass. Residual thrombus is noted.
Anteroposterior (AP) pelvic image (not shown) demonstrated slow
flow down the bypass compared with flow in the profunda
femoris.
 | Media file 17:
Peripheral thrombolysis, case 2. Close-up image
of the thrombus in the femoral-popliteal bypass after 1 day of
low-dose urokinase treatment. |
Peripheral thrombolysis, case 2. Close-up image
of the thrombus in the femoral-popliteal bypass after 1 day of
low-dose urokinase treatment.
 | Media file 18:
Peripheral bypass thrombolysis, case 2. Day 2
follow-up image obtained high in the thigh shows complete
resolution of the femoral-popliteal thrombus with low-dose
urokinase infusion. |
Peripheral bypass thrombolysis, case 2. Day 2
follow-up image obtained high in the thigh shows complete
resolution of the femoral-popliteal thrombus with low-dose
urokinase infusion.
 | Media file 19:
Peripheral thrombolysis, case 2. Day 2 low-thigh
image. No thrombus is seen. |
Peripheral thrombolysis, case 2. Day 2 low-thigh
image. No thrombus is seen.
 | Media file 20:
Peripheral bypass thrombolysis, case 2. On day
2, the distal anastomosis is free of residual thrombus.
Irregularity consistent with chronic atherosclerosis is noted
in the popliteal artery. |
Peripheral bypass thrombolysis, case 2. On day
2, the distal anastomosis is free of residual thrombus.
Irregularity consistent with chronic atherosclerosis is noted
in the popliteal artery.
 | Media file 21:
Peripheral bypass thrombolysis, case 2. Diseased
2-vessel run-off to the ankle is noted, as is improved patency
of the peroneal artery. No further improvement was expected
with urokinase, and therapy was stopped. Except for the poor
quality of the calf run-off, no underlying lesion in need of
treatment was found. The patient is at a high risk for repeat
occlusion, and long-term antithrombotic therapy may be
considered. |
Peripheral bypass thrombolysis, case 2. Diseased
2-vessel run-off to the ankle is noted, as is improved patency
of the peroneal artery. No further improvement was expected
with urokinase, and therapy was stopped. Except for the poor
quality of the calf run-off, no underlying lesion in need of
treatment was found. The patient is at a high risk for repeat
occlusion, and long-term antithrombotic therapy may be
considered.
| Media file 22:
Peripheral bypass thrombolysis, case 3. The
patient underwent right femoral-anterior tibial bypass with
ischemic symptoms in the right lower extremity. Oblique pelvic
image shows complex postsurgical anatomy with a graft ostium at
the proximal superficial femoral artery (SFA). A high-grade
left external iliac artery stenosis is incidentally
noted. |
Peripheral bypass thrombolysis, case 3. The
patient underwent right femoral-anterior tibial bypass with
ischemic symptoms in the right lower extremity. Oblique pelvic
image shows complex postsurgical anatomy with a graft ostium at
the proximal superficial femoral artery (SFA). A high-grade
left external iliac artery stenosis is incidentally
noted.
 | Media file 23:
Peripheral bypass thrombolysis, case 3.
Pretreatment close-up of anteroposterior (AP) image of a
proximal anastomotic nipple originating from the superficial
femoral artery (SFA). Once identified, it should be selectively
catheterized, probably with relative ease. (If the thrombus is
resistant to passage of the wire, the initial infusion may be
accomplished from this point for the first 24 h, after which
the thrombus is often softened.) |
Peripheral bypass thrombolysis, case 3.
Pretreatment close-up of anteroposterior (AP) image of a
proximal anastomotic nipple originating from the superficial
femoral artery (SFA). Once identified, it should be selectively
catheterized, probably with relative ease. (If the thrombus is
resistant to passage of the wire, the initial infusion may be
accomplished from this point for the first 24 h, after which
the thrombus is often softened.)
 | Media file 24:
Peripheral bypass thrombolysis, case 3.
Pretreatment close-up image of the adductor canal shows the
typical appearance of a chronic distal superficial femoral
artery (SFA) occlusion. Note the smooth tapering of the
thrombosis. Angiogram of the thigh (not shown) depicted no
clinically significant disease in the proximal
SFA. |
Peripheral bypass thrombolysis, case 3.
Pretreatment close-up image of the adductor canal shows the
typical appearance of a chronic distal superficial femoral
artery (SFA) occlusion. Note the smooth tapering of the
thrombosis. Angiogram of the thigh (not shown) depicted no
clinically significant disease in the proximal
SFA.
 | Media file 25:
Peripheral thrombolysis, case 3. Pretreatment
close-up image of the knee shows reconstitution of the
below-the-knee popliteal artery. Three-vessel run-off to the
ankle was seen on the calf image (not shown). |
Peripheral thrombolysis, case 3. Pretreatment
close-up image of the knee shows reconstitution of the
below-the-knee popliteal artery. Three-vessel run-off to the
ankle was seen on the calf image (not shown).
 | Media file 26:
Peripheral bypass thrombolysis, case 3.
Posttreatment angiogram of calf after low-dose coaxial infusion
of a femoral-tibial bypass shows postanastomotic stenoses of
the recipient anterior tibial artery, which probably
predisposed this patient to thrombosis. Proximal images (not
shown) depicted a good luminal diameter in the bypass and no
residual thrombus. Distal images (not shown) demonstrated
in-line flow into the dorsalis pedis in the
foot. |
Peripheral bypass thrombolysis, case 3.
Posttreatment angiogram of calf after low-dose coaxial infusion
of a femoral-tibial bypass shows postanastomotic stenoses of
the recipient anterior tibial artery, which probably
predisposed this patient to thrombosis. Proximal images (not
shown) depicted a good luminal diameter in the bypass and no
residual thrombus. Distal images (not shown) demonstrated
in-line flow into the dorsalis pedis in the
foot.
| Media file 27:
Peripheral bypass thrombolysis, case 4.
Thrombolysis of an occluded left femoral below-the-knee
popliteal bypass by using the McNamara technique. Pretreatment
anteroposterior (AP) image shows underlying atherosclerosis, as
well as the postsurgical anatomy on the contralateral right
side. The column of contrast material terminates at the left
common femoral artery without an extensive collateral bed; this
finding indicates an acute component to the patient's
presentation. |
Peripheral bypass thrombolysis, case 4.
Thrombolysis of an occluded left femoral below-the-knee
popliteal bypass by using the McNamara technique. Pretreatment
anteroposterior (AP) image shows underlying atherosclerosis, as
well as the postsurgical anatomy on the contralateral right
side. The column of contrast material terminates at the left
common femoral artery without an extensive collateral bed; this
finding indicates an acute component to the patient's
presentation.
 | Media file 28:
Peripheral bypass thrombolysis, case 4. Close-up
image of the occlusion of the left common femoral artery. The
appearance is unusual; the thrombosis has progressed in
retrograde fashion from the proximal anastomosis, leaving a
native-artery stump. This scenario is ideal for a simplified
infusion technique, as was done in this case. An end-hole
catheter was placed in the stump, and low-dose urokinase was
administered overnight. (Images of thigh and knee [not shown]
revealed only small-vessel collateral flow.) |
Peripheral bypass thrombolysis, case 4. Close-up
image of the occlusion of the left common femoral artery. The
appearance is unusual; the thrombosis has progressed in
retrograde fashion from the proximal anastomosis, leaving a
native-artery stump. This scenario is ideal for a simplified
infusion technique, as was done in this case. An end-hole
catheter was placed in the stump, and low-dose urokinase was
administered overnight. (Images of thigh and knee [not shown]
revealed only small-vessel collateral flow.)
 | Media file 29:
Peripheral bypass thrombolysis, case 4. Day 1
follow-up image obtained after low-dose urokinase infusion
through an end-hole catheter. Close-up image demonstrates
recanalization of the bifurcation of the left common femoral
artery with flow into the lateral femoral circumflex artery. A
slender superficial femoral artery (SFA) is noted, and the tip
of the catheter is medially engaging a small bypass-graft
nipple. |
Peripheral bypass thrombolysis, case 4. Day 1
follow-up image obtained after low-dose urokinase infusion
through an end-hole catheter. Close-up image demonstrates
recanalization of the bifurcation of the left common femoral
artery with flow into the lateral femoral circumflex artery. A
slender superficial femoral artery (SFA) is noted, and the tip
of the catheter is medially engaging a small bypass-graft
nipple.
 | Media file 30:
Peripheral bypass thrombolysis, case 4. Day 1.
The occluded bypass is readily catheterized now that the
overnight lytic infusion softened the thrombus. Fluoroscopic
image shows a stagnant column of contrast agent, which
indicates distal occlusion. The position of the infusion
catheter is adjusted to allow retrograde flow to bathe the
proximal thrombus with urokinase. In the ideal case, the
catheter is placed so that most of the proximal thrombus is
lysed before the distal plug is dissolved. This way, the risk
of distal embolization is kept to a minimum. Similar results
may be achieved with simple catheter or coaxial infusion
systems. |
Peripheral bypass thrombolysis, case 4. Day 1.
The occluded bypass is readily catheterized now that the
overnight lytic infusion softened the thrombus. Fluoroscopic
image shows a stagnant column of contrast agent, which
indicates distal occlusion. The position of the infusion
catheter is adjusted to allow retrograde flow to bathe the
proximal thrombus with urokinase. In the ideal case, the
catheter is placed so that most of the proximal thrombus is
lysed before the distal plug is dissolved. This way, the risk
of distal embolization is kept to a minimum. Similar results
may be achieved with simple catheter or coaxial infusion
systems.
 | Media file 31:
Peripheral bypass thrombolysis, case 4. Day 2
follow-up image. Low-dose urokinase given through a simple
catheter infusion has resulted in complete lysis of the femoral
below-the-knee bypass graft. The etiology of the occlusion was
the poor outflow from the highly diseased tibial vascular bed.
Note the substantial retrograde popliteal artery flow needed to
supply the calf. Low-dose therapy is continued for another day
to improve calf-vessel patency. |
Peripheral bypass thrombolysis, case 4. Day 2
follow-up image. Low-dose urokinase given through a simple
catheter infusion has resulted in complete lysis of the femoral
below-the-knee bypass graft. The etiology of the occlusion was
the poor outflow from the highly diseased tibial vascular bed.
Note the substantial retrograde popliteal artery flow needed to
supply the calf. Low-dose therapy is continued for another day
to improve calf-vessel patency.
 | Media file 32:
Peripheral bypass thrombolysis, case 4. Day 3
follow-up image shows no improvement at the distal anastomosis
site. The slender tibioperoneal trunk visualized the day before
has reoccluded. Contributing factors are slow flow in these
severely diseased vessels and difficulty in maintaining
systemic anticoagulation. (The long-term patency would have
been poor in any case.) The absence of residual proximal
thrombus excludes embolization as a likely cause. Retrograde
popliteal flow is adequate. |
Peripheral bypass thrombolysis, case 4. Day 3
follow-up image shows no improvement at the distal anastomosis
site. The slender tibioperoneal trunk visualized the day before
has reoccluded. Contributing factors are slow flow in these
severely diseased vessels and difficulty in maintaining
systemic anticoagulation. (The long-term patency would have
been poor in any case.) The absence of residual proximal
thrombus excludes embolization as a likely cause. Retrograde
popliteal flow is adequate.
 | Media file 33:
Peripheral bypass thrombolysis, case 4. Day 3
angiogram of the distal calf shows diseased, reconstituted
anterior tibial run-off to the foot. Vascular surgical
evaluation revealed that the limb was no longer acutely
threatened. No notable additional improvement was expected, and
therapy was terminated. |
Peripheral bypass thrombolysis, case 4. Day 3
angiogram of the distal calf shows diseased, reconstituted
anterior tibial run-off to the foot. Vascular surgical
evaluation revealed that the limb was no longer acutely
threatened. No notable additional improvement was expected, and
therapy was terminated.
 | Media file 34:
Peripheral thrombolysis, case 5, part 1.
Thrombolysis of a native superficial femoral artery (SFA)
occlusion. No significant underlying stenosis was found
initially. Close-up anteroposterior (AP) image obtained high on
the right thigh demonstrates a subacute occlusion of the
superficial femoral artery (SFA). The residual nipple has a
small eccentric extension, which may indicate a dissection.
Caution with the initial catheterization is suggested.
(Findings on the contralateral angiogram [not shown] were
essentially normal.) |
Peripheral thrombolysis, case 5, part 1.
Thrombolysis of a native superficial femoral artery (SFA)
occlusion. No significant underlying stenosis was found
initially. Close-up anteroposterior (AP) image obtained high on
the right thigh demonstrates a subacute occlusion of the
superficial femoral artery (SFA). The residual nipple has a
small eccentric extension, which may indicate a dissection.
Caution with the initial catheterization is suggested.
(Findings on the contralateral angiogram [not shown] were
essentially normal.)
 | Media file 35:
Peripheral native arterial thrombolysis, case 5,
part 1. Close-up image shows typical reconstitution of the
above-the-knee popliteal artery at the adductor canal area.
Flow from several collateral sources causes the differential in
opacity of the contrast material. |
Peripheral native arterial thrombolysis, case 5,
part 1. Close-up image shows typical reconstitution of the
above-the-knee popliteal artery at the adductor canal area.
Flow from several collateral sources causes the differential in
opacity of the contrast material.
| Media file 36:
Peripheral thrombolysis, case 5, part 1.
Anteroposterior (AP) view of knees shows relatively
disease-free distal run-off. |
Peripheral thrombolysis, case 5, part 1.
Anteroposterior (AP) view of knees shows relatively
disease-free distal run-off.
 | Media file 37:
Peripheral thrombolysis, case 5, part 1. The
occlusion was traversed with relative ease, and a Mewissen
catheter was placed. Low-dose urokinase infusion was
administered through the catheter. Coaxial infusion was not
indicated, and a conventional 0.035-in. guidewire was used
instead of an infusion wire. |
Peripheral thrombolysis, case 5, part 1. The
occlusion was traversed with relative ease, and a Mewissen
catheter was placed. Low-dose urokinase infusion was
administered through the catheter. Coaxial infusion was not
indicated, and a conventional 0.035-in. guidewire was used
instead of an infusion wire.
| Media file 38:
Peripheral native arterial thrombolysis, case 5,
part 1. Day 1 follow-up angiogram. The guidewire was removed,
and contrast agent was injected through the Mewissen catheter.
The superficial femoral artery (SFA) is partially recanalized,
with good distal flow. No distal emboli were noted (images not
shown). |
Peripheral native arterial thrombolysis, case 5,
part 1. Day 1 follow-up angiogram. The guidewire was removed,
and contrast agent was injected through the Mewissen catheter.
The superficial femoral artery (SFA) is partially recanalized,
with good distal flow. No distal emboli were noted (images not
shown).
 | Media file 39:
Peripheral native arterial thrombolysis, case 5,
part 1. Day 2 (early morning) follow-up image shows an improved
luminal diameter, which is now sufficient to support antegrade
flow across it. The Mewissen catheter may now be removed and
replaced with an end-hole catheter for a proximal infusion.
Normal flow dynamics will transport the thrombolytic agent will
be transported across the thrombus. |
Peripheral native arterial thrombolysis, case 5,
part 1. Day 2 (early morning) follow-up image shows an improved
luminal diameter, which is now sufficient to support antegrade
flow across it. The Mewissen catheter may now be removed and
replaced with an end-hole catheter for a proximal infusion.
Normal flow dynamics will transport the thrombolytic agent will
be transported across the thrombus.
| Media file 40:
Peripheral native arterial thrombolysis, case 5,
part 1. Because antegrade flow is restored,
multiple–side-port infusion is no longer required. A
Mewissen catheter is replaced with an end-hole straight
catheter. The guidewire and Touhy-Borst adapter are no longer
needed, so nursing care in the ICU is simplified. The treatment
team elected to increase therapy to a high-dose urokinase
infusion for several hours and to recheck the patient in the
afternoon. |
Peripheral native arterial thrombolysis, case 5,
part 1. Because antegrade flow is restored,
multiple–side-port infusion is no longer required. A
Mewissen catheter is replaced with an end-hole straight
catheter. The guidewire and Touhy-Borst adapter are no longer
needed, so nursing care in the ICU is simplified. The treatment
team elected to increase therapy to a high-dose urokinase
infusion for several hours and to recheck the patient in the
afternoon.
 | Media file 41:
Peripheral native arterial thrombolysis, case 5,
part 1. Day 2 (afternoon) follow-up image shows interval
improvement in the flow and vascular lumen. Urokinase therapy
is reduced to a low-dose rate for overnight
infusion. |
Peripheral native arterial thrombolysis, case 5,
part 1. Day 2 (afternoon) follow-up image shows interval
improvement in the flow and vascular lumen. Urokinase therapy
is reduced to a low-dose rate for overnight
infusion.
 | Media file 42:
Peripheral native arterial thrombolysis, case 5,
part 1. Day 3 follow-up image shows dramatic improvement in the
vascular lumen with subtotal lysis of the occlusion in the
superficial femoral artery (SFA). |
Peripheral native arterial thrombolysis, case 5,
part 1. Day 3 follow-up image shows dramatic improvement in the
vascular lumen with subtotal lysis of the occlusion in the
superficial femoral artery (SFA).
 | Media file 43:
Peripheral native arterial thrombolysis, case 5,
part 1. Day 3 follow-up magnified close-up image of the mid
superficial femoral artery (SFA) shows minimal vascular
narrowing with a small, linear remnant of thrombus. Distal
run-off (not shown) demonstrated in-line flow to the foot.
Lysis was continued for a few hours, and treatment was then
terminated without further angiography. Because the stenosis
was less than 50% in severity, it was not treated at this
time. |
Peripheral native arterial thrombolysis, case 5,
part 1. Day 3 follow-up magnified close-up image of the mid
superficial femoral artery (SFA) shows minimal vascular
narrowing with a small, linear remnant of thrombus. Distal
run-off (not shown) demonstrated in-line flow to the foot.
Lysis was continued for a few hours, and treatment was then
terminated without further angiography. Because the stenosis
was less than 50% in severity, it was not treated at this
time.
| Media file 44:
Peripheral native arterial thrombolysis, case 5,
part 2. One-year follow-up angiogram demonstrates a
flow-limiting stenosis, which is consistent with progression of
disease in the same location as the residual stenosis
demonstrated on the final postthrombolytic image obtained a
year ago. The reason for the relatively rapid progression of
disease is unclear. Note the relative hypertrophy of the
profunda femoris branches feeding the calf. |
Peripheral native arterial thrombolysis, case 5,
part 2. One-year follow-up angiogram demonstrates a
flow-limiting stenosis, which is consistent with progression of
disease in the same location as the residual stenosis
demonstrated on the final postthrombolytic image obtained a
year ago. The reason for the relatively rapid progression of
disease is unclear. Note the relative hypertrophy of the
profunda femoris branches feeding the calf.
 | Media file 45:
Peripheral thrombolysis, case 5, part 2. A
non–flow-limiting but "ugly" dissection is noted after
angioplasty with a 5-mm balloon. |
Peripheral thrombolysis, case 5, part 2. A
non–flow-limiting but "ugly" dissection is noted after
angioplasty with a 5-mm balloon.
 | Media file 46:
Peripheral thrombolysis, case 5, part 2. Normal
lumen and flow is restored with a 5 mm x 8 cm Wallstent. Distal
outflow (not shown) was normal and unchanged from the previous
year. |
Peripheral thrombolysis, case 5, part 2. Normal
lumen and flow is restored with a 5 mm x 8 cm Wallstent. Distal
outflow (not shown) was normal and unchanged from the previous
year.
 | Media file 47:
Peripheral thrombolysis, case 6. Thrombolysis of
an acute thrombolytic occlusion in the popliteal artery. The
patient had severe cardiac dysfunction and atrial fibrillation
and presented with acute ischemia in the right lower limb 24 h
after receiving an inferior vena cava filter. A hypercoagulable
state was strongly suggested. Anteroposterior (AP) angiogram of
the knee shows acute occlusion in the middle of the popliteal
artery above the knee. Note the meniscus of the acute
thromboembolus, which raises the possibility of a cardiac
source. A paucity of collateral flow is noted, and distal
reconstitution is poor. These findings are typical of an acute
thromboembolic occlusion. |
Peripheral thrombolysis, case 6. Thrombolysis of
an acute thrombolytic occlusion in the popliteal artery. The
patient had severe cardiac dysfunction and atrial fibrillation
and presented with acute ischemia in the right lower limb 24 h
after receiving an inferior vena cava filter. A hypercoagulable
state was strongly suggested. Anteroposterior (AP) angiogram of
the knee shows acute occlusion in the middle of the popliteal
artery above the knee. Note the meniscus of the acute
thromboembolus, which raises the possibility of a cardiac
source. A paucity of collateral flow is noted, and distal
reconstitution is poor. These findings are typical of an acute
thromboembolic occlusion.
 | Media file 48:
Peripheral thrombolysis, case 6. Magnified view
of the upper thigh shows additional shower emboli in the
profunda femoris. Surgical morbidity and mortality rates are
very high in acute limb-threatening ischemia, particularly in
patients with poor cardiac function. In the absence of major
contraindications, the treatment of choice is thrombolysis.
Because of rest pain and underlying dementia, the patient was
uncooperative. Thrombolytic treatment was performed with
anesthesia during visits to the radiology department and with
heavy sedation in the ICU. These measures were required to
prevent the patient from self-injury and to allow the procedure
to proceed safely. Extra care must be given to monitoring
sedated patients for signs of intracerebral
hemorrhage. |
Peripheral thrombolysis, case 6. Magnified view
of the upper thigh shows additional shower emboli in the
profunda femoris. Surgical morbidity and mortality rates are
very high in acute limb-threatening ischemia, particularly in
patients with poor cardiac function. In the absence of major
contraindications, the treatment of choice is thrombolysis.
Because of rest pain and underlying dementia, the patient was
uncooperative. Thrombolytic treatment was performed with
anesthesia during visits to the radiology department and with
heavy sedation in the ICU. These measures were required to
prevent the patient from self-injury and to allow the procedure
to proceed safely. Extra care must be given to monitoring
sedated patients for signs of intracerebral
hemorrhage.
 | Media file 49:
Peripheral native arterial thrombolysis, case 6.
The popliteal artery occlusion is traversed with relative ease,
which is consistent with an acute occlusion. The tip of the
end-hole diagnostic catheter is in the popliteal artery below
the knee. Clinically significant intraluminal thrombus is
present, either from a shower phenomenon or from in situ
thrombosis from low flow and hypercoagulability. The
tibioperoneal trunk is occluded, but the anterior tibial artery
remains locally patent. |
Peripheral native arterial thrombolysis, case 6.
The popliteal artery occlusion is traversed with relative ease,
which is consistent with an acute occlusion. The tip of the
end-hole diagnostic catheter is in the popliteal artery below
the knee. Clinically significant intraluminal thrombus is
present, either from a shower phenomenon or from in situ
thrombosis from low flow and hypercoagulability. The
tibioperoneal trunk is occluded, but the anterior tibial artery
remains locally patent.
 | Media file 50:
Peripheral native arterial thrombolysis, case 6.
The infusion catheter (Mewissen) is placed. An injection of
contrast material demonstrates the extent of the thrombosis.
The proximal marker of the Mewissen catheter (poorly seen) is
placed above the level of the thrombus. A large thrombus is
seen in the tibioperoneal trunk. |
Peripheral native arterial thrombolysis, case 6.
The infusion catheter (Mewissen) is placed. An injection of
contrast material demonstrates the extent of the thrombosis.
The proximal marker of the Mewissen catheter (poorly seen) is
placed above the level of the thrombus. A large thrombus is
seen in the tibioperoneal trunk.
 | Media file 51:
Peripheral thrombolysis, case 6. A conventional
guidewire is placed within the Mewissen infusion catheter to
direct the flow of urokinase out of the side holes and into the
thrombus. The tip of the guidewire is in the anterior tibial
artery. There is no need for the added complexity and cost of
an inner infusion wire for coaxial infusion. Low-dose urokinase
is begun at a rate of 60,000 U/h with the systemic intravenous
administration of heparin. |
Peripheral thrombolysis, case 6. A conventional
guidewire is placed within the Mewissen infusion catheter to
direct the flow of urokinase out of the side holes and into the
thrombus. The tip of the guidewire is in the anterior tibial
artery. There is no need for the added complexity and cost of
an inner infusion wire for coaxial infusion. Low-dose urokinase
is begun at a rate of 60,000 U/h with the systemic intravenous
administration of heparin.
 | Media file 52:
Peripheral native arterial thrombolysis, case 6.
Day 1 follow-up image. Partial recanalization of the popliteal
artery is achieved after an overnight infusion of urokinase at
a rate of 60,000 U/h. Clinically significant residual thrombus
is present. |
Peripheral native arterial thrombolysis, case 6.
Day 1 follow-up image. Partial recanalization of the popliteal
artery is achieved after an overnight infusion of urokinase at
a rate of 60,000 U/h. Clinically significant residual thrombus
is present.
 | Media file 53:
Peripheral native arterial thrombolysis, case 6.
Fluoroscopic image of the proximal calf shows substantial
intraluminal thrombus in the anterior tibial and tibioperoneal
trunk distributions. |
Peripheral native arterial thrombolysis, case 6.
Fluoroscopic image of the proximal calf shows substantial
intraluminal thrombus in the anterior tibial and tibioperoneal
trunk distributions.
 | Media file 54:
Peripheral native arterial thrombolysis, case 6.
A 0.035-in. infusion wire is placed in the mid anterior tibial
artery, and a coaxial low-dose infusion is administered
overnight. |
Peripheral native arterial thrombolysis, case 6.
A 0.035-in. infusion wire is placed in the mid anterior tibial
artery, and a coaxial low-dose infusion is administered
overnight.
 | Media file 55:
Peripheral thrombolysis, case 6. Day 2 follow-up
image shows substantial lysis of the popliteal artery and
proximal run-off. Minimal residual thrombus is seen in the mid
popliteal artery. Irregularity of the proximal anterior tibial
artery represents stenosis and/or spasm. The posterior tibial
artery is still occluded, but the anterior tibial and peroneal
arteries are greatly improved. |
Peripheral thrombolysis, case 6. Day 2 follow-up
image shows substantial lysis of the popliteal artery and
proximal run-off. Minimal residual thrombus is seen in the mid
popliteal artery. Irregularity of the proximal anterior tibial
artery represents stenosis and/or spasm. The posterior tibial
artery is still occluded, but the anterior tibial and peroneal
arteries are greatly improved.
 | Media file 56:
Peripheral thrombolysis, case 6. Close-up image
of the mid anterior tibial artery shows a thrombus cast that
surrounded the infusion wire; this is now removed. A stenosis
is present just distal; this had impeded further guidewire
advancement on the previous day. This result illustrates the
merits of gentle guidewire manipulation in native vessels. An
additional day of lysis often softens the thrombus component of
plaque and eases the catheterization of hard
occlusions. |
Peripheral thrombolysis, case 6. Close-up image
of the mid anterior tibial artery shows a thrombus cast that
surrounded the infusion wire; this is now removed. A stenosis
is present just distal; this had impeded further guidewire
advancement on the previous day. This result illustrates the
merits of gentle guidewire manipulation in native vessels. An
additional day of lysis often softens the thrombus component of
plaque and eases the catheterization of hard
occlusions.
 | Media file 57:
Peripheral native arterial thrombolysis, case 6.
Close-up image of a distal anterior tibial artery occlusion.
Although the lesion has characteristics of chronic disease, the
team hopes further lysis will be beneficial. |
Peripheral native arterial thrombolysis, case 6.
Close-up image of a distal anterior tibial artery occlusion.
Although the lesion has characteristics of chronic disease, the
team hopes further lysis will be beneficial.
 | Media file 58:
Peripheral thrombolysis, case 6. Lateral view of
the foot demonstrates the segmental distal occlusion of the
anterior tibial artery. The perforating and communicating
branches of the peroneal artery reconstitute the distal
anterior and posterior tibial arteries, respectively. Proximal
occlusion of the plantar arch is bridged by collateral
flow. |
Peripheral thrombolysis, case 6. Lateral view of
the foot demonstrates the segmental distal occlusion of the
anterior tibial artery. The perforating and communicating
branches of the peroneal artery reconstitute the distal
anterior and posterior tibial arteries, respectively. Proximal
occlusion of the plantar arch is bridged by collateral
flow.
 | Media file 59:
Peripheral thrombolysis, case 6. Close-up image
of the collateral flow to the anterior and posterior tibial
arteries by the terminal branches of the peroneal
artery. |
Peripheral thrombolysis, case 6. Close-up image
of the collateral flow to the anterior and posterior tibial
arteries by the terminal branches of the peroneal
artery.
 | Media file 60:
Peripheral thrombolysis, case 6. A coaxial
infusion wire is placed just proximal to the distal anterior
tibial artery occlusion in the hope of restoring in-line
patency to the dorsalis pedis. Low-dose coaxial (split
infusion) is continued overnight with the patient under heavy
sedation. |
Peripheral thrombolysis, case 6. A coaxial
infusion wire is placed just proximal to the distal anterior
tibial artery occlusion in the hope of restoring in-line
patency to the dorsalis pedis. Low-dose coaxial (split
infusion) is continued overnight with the patient under heavy
sedation.
 | Media file 61:
Peripheral native arterial thrombolysis, case 6.
Day 3 follow-up image shows no substantial change in the
residual disease in the mid popliteal artery. Irregular plaque
or resilient thrombus may be present, preventing further
improvement. Follow-up images of the tibial run-off and foot
(not shown) failed to demonstrate any notable interval change
from the previous day's appearance. The limb was no longer
threatened, and therapy was terminated. |
Peripheral native arterial thrombolysis, case 6.
Day 3 follow-up image shows no substantial change in the
residual disease in the mid popliteal artery. Irregular plaque
or resilient thrombus may be present, preventing further
improvement. Follow-up images of the tibial run-off and foot
(not shown) failed to demonstrate any notable interval change
from the previous day's appearance. The limb was no longer
threatened, and therapy was terminated.
 | Media file 62:
Peripheral native arterial thrombolysis, case 7.
Thrombolysis of acute thromboembolic occlusion of the popliteal
artery. Patient with severe cardiac dysfunction (ejection
fraction, <30%) with acute symptoms of right lower-extremity
ischemia. Because the patient was a poor surgical candidate,
the only surgical option available was above-the-knee
amputation (AKA). Close-up angiogram of the adductor canal
region shows an abrupt cut-off of the above-the-knee popliteal
artery and poor collateral flow consistent with acute
occlusion. Distal images (not shown) demonstrated poor
reconstitution. A Mewissen multiple–side-hole catheter
was placed across the occlusion, and low-dose thrombolysis with
urokinase was begun at a rate of 60,000 U/h. |
Peripheral native arterial thrombolysis, case 7.
Thrombolysis of acute thromboembolic occlusion of the popliteal
artery. Patient with severe cardiac dysfunction (ejection
fraction, <30%) with acute symptoms of right lower-extremity
ischemia. Because the patient was a poor surgical candidate,
the only surgical option available was above-the-knee
amputation (AKA). Close-up angiogram of the adductor canal
region shows an abrupt cut-off of the above-the-knee popliteal
artery and poor collateral flow consistent with acute
occlusion. Distal images (not shown) demonstrated poor
reconstitution. A Mewissen multiple–side-hole catheter
was placed across the occlusion, and low-dose thrombolysis with
urokinase was begun at a rate of 60,000 U/h.
 | Media file 63:
Peripheral thrombolysis, case 7. Day 1,
follow-up 1. Image shows partial recanalization of the
popliteal artery with substantial residual
thrombus. |
Peripheral thrombolysis, case 7. Day 1,
follow-up 1. Image shows partial recanalization of the
popliteal artery with substantial residual
thrombus.
 | Media file 64:
Peripheral thrombolysis, case 7. Day 1,
follow-up 1. The distal popliteal artery tapers to an occlusion
of the named trifurcation vessels. Small, hypertrophied
collateral vessels are seen. |
Peripheral thrombolysis, case 7. Day 1,
follow-up 1. The distal popliteal artery tapers to an occlusion
of the named trifurcation vessels. Small, hypertrophied
collateral vessels are seen.
 | Media file 65:
Peripheral thrombolysis, case 7. Day 1,
follow-up 1. The position of the catheter is adjusted, and
high-dose urokinase is given for a few hours. The patient was
to return later in the day for reevaluation. Note the typical
appearance of arteriomegaly and the diabetic vessel-wall
calcification. |
Peripheral thrombolysis, case 7. Day 1,
follow-up 1. The position of the catheter is adjusted, and
high-dose urokinase is given for a few hours. The patient was
to return later in the day for reevaluation. Note the typical
appearance of arteriomegaly and the diabetic vessel-wall
calcification.
 | Media file 66:
Peripheral thrombolysis, case 7. Day 1,
follow-up 2. Subtotal recanalization of the popliteal artery is
noted. The trifurcation is still occluded proximally. The
anterior tibial artery is reconstituted after a focal occlusion
from hypertrophied collateral vessels. |
Peripheral thrombolysis, case 7. Day 1,
follow-up 2. Subtotal recanalization of the popliteal artery is
noted. The trifurcation is still occluded proximally. The
anterior tibial artery is reconstituted after a focal occlusion
from hypertrophied collateral vessels.
 | Media file 67:
Peripheral thrombolysis, case 7. Day 2
follow-up. Early angiogram demonstrates the reconstitution
pattern of the anterior tibial artery from 2 small collateral
branches of the anterior tibial artery. This finding is
essentially unchanged from the previous day's appearance.
Further improvement with additional thrombolysis is unlikely.
Angioplasty was possible, but the calcified and fragile
appearance of the arteries made this a relatively risky
option. |
Peripheral thrombolysis, case 7. Day 2
follow-up. Early angiogram demonstrates the reconstitution
pattern of the anterior tibial artery from 2 small collateral
branches of the anterior tibial artery. This finding is
essentially unchanged from the previous day's appearance.
Further improvement with additional thrombolysis is unlikely.
Angioplasty was possible, but the calcified and fragile
appearance of the arteries made this a relatively risky
option.
 | Media file 68:
Peripheral thrombolysis, case 7. Angiogram of
the mid calf shows slow flow in the anterior tibial artery. At
this time, the patient's vascular examination findings had
improved sufficiently to allow him to recover from a
below-the-knee amputation (BKA). Thrombolysis was terminated,
and the patient tolerated the amputation well. |
Peripheral thrombolysis, case 7. Angiogram of
the mid calf shows slow flow in the anterior tibial artery. At
this time, the patient's vascular examination findings had
improved sufficiently to allow him to recover from a
below-the-knee amputation (BKA). Thrombolysis was terminated,
and the patient tolerated the amputation well.
 | Media file 69:
Peripheral native arterial thrombolysis, case 8.
Thrombolysis of an occluded saccular popliteal artery aneurysm.
Diagnostic angiogram of the right leg shows an occlusion at the
adductor canal with curvilinear contrast enhancement consistent
with a small thrombosed aneurysm of the popliteal
artery. |
Peripheral native arterial thrombolysis, case 8.
Thrombolysis of an occluded saccular popliteal artery aneurysm.
Diagnostic angiogram of the right leg shows an occlusion at the
adductor canal with curvilinear contrast enhancement consistent
with a small thrombosed aneurysm of the popliteal
artery.
 | Media file 70:
Peripheral thrombolysis, case 8. Image shows
faint reconstitution of the mid above-the-knee popliteal artery
a short distance distal to the aneurysm. |
Peripheral thrombolysis, case 8. Image shows
faint reconstitution of the mid above-the-knee popliteal artery
a short distance distal to the aneurysm.
 | Media file 71:
Peripheral thrombolysis, case 8. A proximal
occlusion of the anterior tibial artery seems to be present,
but the proximal tibioperoneal trunk is intact. |
Peripheral thrombolysis, case 8. A proximal
occlusion of the anterior tibial artery seems to be present,
but the proximal tibioperoneal trunk is intact.
 | Media file 72:
Peripheral native arterial thrombolysis, case 8.
A small popliteal aneurysm is present on the left side, with
normal distal run-off. After consultation with a peripheral
vascular surgeon, the treatment team elects to perform
preoperative thrombolysis. The potential benefit is to restore
normal patency to the distal calf vessel. The potential risk is
a limb-threatening embolus occurring during lysis. Antegrade
access to the left superficial femoral artery (SFA) is
obtained, and a low-dose urokinase infusion is begun by using
the McNamara technique. |
Peripheral native arterial thrombolysis, case 8.
A small popliteal aneurysm is present on the left side, with
normal distal run-off. After consultation with a peripheral
vascular surgeon, the treatment team elects to perform
preoperative thrombolysis. The potential benefit is to restore
normal patency to the distal calf vessel. The potential risk is
a limb-threatening embolus occurring during lysis. Antegrade
access to the left superficial femoral artery (SFA) is
obtained, and a low-dose urokinase infusion is begun by using
the McNamara technique.
 | Media file 73:
Peripheral thrombolysis, case 8. Day 1 follow-up
angiogram demonstrates partial lysis of the thrombosed aneurysm
and reestablished antegrade flow. Early partial lysis of the
anterior tibial artery is noted. If the initial treatment had
been accomplished with a multiple–side-hole or coaxial
system, switching to a simple end-hole catheter (already in use
in this case) is appropriate. The low-dose urokinase infusion
was continued again overnight. |
Peripheral thrombolysis, case 8. Day 1 follow-up
angiogram demonstrates partial lysis of the thrombosed aneurysm
and reestablished antegrade flow. Early partial lysis of the
anterior tibial artery is noted. If the initial treatment had
been accomplished with a multiple–side-hole or coaxial
system, switching to a simple end-hole catheter (already in use
in this case) is appropriate. The low-dose urokinase infusion
was continued again overnight.
 | Media file 74:
Peripheral native arterial thrombolysis, case 8.
Day 2 follow-up image shows additional partial lysis of the
aneurysm with a slight reduction in the prominence of
collateral pathway flow. |
Peripheral native arterial thrombolysis, case 8.
Day 2 follow-up image shows additional partial lysis of the
aneurysm with a slight reduction in the prominence of
collateral pathway flow.
 | Media file 75:
Peripheral thrombolysis, case 8. Sluggish flow
is noted in the anterior tibial artery in comparison with that
of the peroneal artery. This finding indicates an outflow
lesion, presumably an embolic thrombus. The posterior tibial
artery is not seen. |
Peripheral thrombolysis, case 8. Sluggish flow
is noted in the anterior tibial artery in comparison with that
of the peroneal artery. This finding indicates an outflow
lesion, presumably an embolic thrombus. The posterior tibial
artery is not seen.
 | Media file 76:
Peripheral thrombolysis, case 8. Lateral ankle
angiogram shows reconstitution of the distal anterior and
posterior tibial arteries from peroneal
collaterals. |
Peripheral thrombolysis, case 8. Lateral ankle
angiogram shows reconstitution of the distal anterior and
posterior tibial arteries from peroneal
collaterals.
 | Media file 77:
Peripheral thrombolysis, case 8. Detail of the
peroneal artery collateral supply to the tibial arteries in the
ankle. Thrombolysis was continued overnight, this time with a
coaxial infusion with the distal infusion wire proximal to the
anterior tibial thrombus (not shown). |
Peripheral thrombolysis, case 8. Detail of the
peroneal artery collateral supply to the tibial arteries in the
ankle. Thrombolysis was continued overnight, this time with a
coaxial infusion with the distal infusion wire proximal to the
anterior tibial thrombus (not shown).
 | Media file 78:
Peripheral native arterial thrombolysis, case 8.
Day 3 follow-up image shows resolution of popliteal artery
thrombus, with excellent antegrade flow. |
Peripheral native arterial thrombolysis, case 8.
Day 3 follow-up image shows resolution of popliteal artery
thrombus, with excellent antegrade flow.
 | Media file 79:
Peripheral native arterial thrombolysis, case 8.
The anterior tibial artery shows the smooth lobulation of
spasm, which is not uncommon for patients without significant
atherosclerosis. No substantial further lysis was noted (image
not shown). The patient was at no risk of limb loss, and
treatment was terminated. He underwent uneventful aneurysm
repair. |
Peripheral native arterial thrombolysis, case 8.
The anterior tibial artery shows the smooth lobulation of
spasm, which is not uncommon for patients without significant
atherosclerosis. No substantial further lysis was noted (image
not shown). The patient was at no risk of limb loss, and
treatment was terminated. He underwent uneventful aneurysm
repair.
 | Media file 80:
Peripheral thrombolysis, case 9.
Thrombolysoangioplasty of right common iliac artery occlusion.
Oblique angiogram of the pelvis shows the smooth taper of a
chronic occlusion of the right common iliac
artery. |
Peripheral thrombolysis, case 9.
Thrombolysoangioplasty of right common iliac artery occlusion.
Oblique angiogram of the pelvis shows the smooth taper of a
chronic occlusion of the right common iliac
artery.
 | Media file 81:
Peripheral thrombolysis, case 9. Close-up image
of the chronic occlusion. The nipple is small, but it can be
engaged by using a selective catheter. |
Peripheral thrombolysis, case 9. Close-up image
of the chronic occlusion. The nipple is small, but it can be
engaged by using a selective catheter.
 | Media file 82:
Peripheral native arterial thrombolysis, case 9.
Delayed image shows the reconstitution of the right common
iliac at the bifurcation. The occlusion is
short. |
Peripheral native arterial thrombolysis, case 9.
Delayed image shows the reconstitution of the right common
iliac at the bifurcation. The occlusion is
short.
 | Media file 83:
Peripheral native arterial thrombolysis, case 9.
The lesion was traversed by means of an ipsilateral retrograde
approach. Then, 250,000 U of urokinase was administered by
using the pulse-spray technique though a Mewissen catheter. No
substantial improvement is noted. |
Peripheral native arterial thrombolysis, case 9.
The lesion was traversed by means of an ipsilateral retrograde
approach. Then, 250,000 U of urokinase was administered by
using the pulse-spray technique though a Mewissen catheter. No
substantial improvement is noted.
 | Media file 84:
Peripheral native arterial thrombolysis, case 9.
After angioplasty with balloons (8 mm x 3 cm) with a
kissing-balloon technique, patency is restored to the right
iliac system. The differential opacity in the right common
iliac artery suggests a non–flow-limiting residual
stenosis. This patient was treated before stents were available
and did well. |
Peripheral native arterial thrombolysis, case 9.
After angioplasty with balloons (8 mm x 3 cm) with a
kissing-balloon technique, patency is restored to the right
iliac system. The differential opacity in the right common
iliac artery suggests a non–flow-limiting residual
stenosis. This patient was treated before stents were available
and did well.
 | Media file 85:
Peripheral thrombolysis, case 10.
Thrombolysoangioplasty with stent placement in the occlusion in
the right common iliac artery. Oblique angiogram of the pelvis
demonstrates occlusion of the right common iliac artery and a
proximal stenosis of the left common iliac
artery. |
Peripheral thrombolysis, case 10.
Thrombolysoangioplasty with stent placement in the occlusion in
the right common iliac artery. Oblique angiogram of the pelvis
demonstrates occlusion of the right common iliac artery and a
proximal stenosis of the left common iliac
artery.
 | Media file 86:
Peripheral thrombolysis, case 10. Late
anteroposterior (AP) pelvic image demonstrates the
reconstitution of the distal right common iliac
artery. |
Peripheral thrombolysis, case 10. Late
anteroposterior (AP) pelvic image demonstrates the
reconstitution of the distal right common iliac
artery.
 | Media file 87:
Peripheral thrombolysis, case 10. The occlusion
extends up to the iliac ostium without a significant vessel
nipple for selective catheterization. A Motarjeme catheter is
reformed and placed just proximal to the right iliac artery. A
low-dose urokinase infusion is begun at a rate of 60,000
U/h. |
Peripheral thrombolysis, case 10. The occlusion
extends up to the iliac ostium without a significant vessel
nipple for selective catheterization. A Motarjeme catheter is
reformed and placed just proximal to the right iliac artery. A
low-dose urokinase infusion is begun at a rate of 60,000
U/h.
 | Media file 88:
Peripheral thrombolysis, case 10. Day 1
follow-up angiogram shows no significant interval change. The
premise is that this pretreatment eases catheterization
(reduces intimal dissection risk) and reduces the distal
embolization risk by lysing any thrombus associated with the
atheromatous stenosis. |
Peripheral thrombolysis, case 10. Day 1
follow-up angiogram shows no significant interval change. The
premise is that this pretreatment eases catheterization
(reduces intimal dissection risk) and reduces the distal
embolization risk by lysing any thrombus associated with the
atheromatous stenosis.
 | Media file 89:
Peripheral native arterial thrombolysis, case
10. The right occlusion in the common iliac artery was
traversed from a right-sided ipsilateral approach without
difficulty. The kissing-balloon technique was used to deploy
bilateral, large, single Palmaz stents to an 8-mm
diameter. |
Peripheral native arterial thrombolysis, case
10. The right occlusion in the common iliac artery was
traversed from a right-sided ipsilateral approach without
difficulty. The kissing-balloon technique was used to deploy
bilateral, large, single Palmaz stents to an 8-mm
diameter.
 | Media file 90:
Peripheral native arterial thrombolysis, case
10. Posttreatment angiogram shows no substantial residual
stenosis and good antegrade flow. |
Peripheral native arterial thrombolysis, case
10. Posttreatment angiogram shows no substantial residual
stenosis and good antegrade flow.
 | Media file 91:
Peripheral native arterial thrombolysis, case
11. Thrombolysoangioplasty of a left common iliac occlusion.
The patent distal bypass does not need treatment. Early oblique
angiogram of the pelvis shows chronic occlusion of the left
external iliac artery with compensatory hypertrophy of the
internal iliac system. |
Peripheral native arterial thrombolysis, case
11. Thrombolysoangioplasty of a left common iliac occlusion.
The patent distal bypass does not need treatment. Early oblique
angiogram of the pelvis shows chronic occlusion of the left
external iliac artery with compensatory hypertrophy of the
internal iliac system.
 | Media file 92:
Peripheral thrombolysis, case 11. Late oblique
image demonstrates segmental reconstitution of the left common
femoral artery. |
Peripheral thrombolysis, case 11. Late oblique
image demonstrates segmental reconstitution of the left common
femoral artery.
 | Media file 93:
Peripheral native arterial thrombolysis, case
11. Day 1 follow-up angiogram obtained after low-dose urokinase
infusion by using the McNamara technique. Antegrade flow is
restored to the left iliac system. Clinically significant
luminal irregularity remains. Treatment is continued for
another day to help in distinguishing the thrombus from
atheromatous plaque. |
Peripheral native arterial thrombolysis, case
11. Day 1 follow-up angiogram obtained after low-dose urokinase
infusion by using the McNamara technique. Antegrade flow is
restored to the left iliac system. Clinically significant
luminal irregularity remains. Treatment is continued for
another day to help in distinguishing the thrombus from
atheromatous plaque.
 | Media file 94:
Peripheral thrombolysis, case 11. Close-up image
shows lesions in the left internal and external iliac
arteries. |
Peripheral thrombolysis, case 11. Close-up image
shows lesions in the left internal and external iliac
arteries.
 | Media file 95:
Peripheral thrombolysis, case 11. Day 2
follow-up angiogram demonstrates partial
improvement. |
Peripheral thrombolysis, case 11. Day 2
follow-up angiogram demonstrates partial
improvement.
 | Media file 96:
Peripheral thrombolysis, case 11. After
angioplasty, further improvement is noted in the luminal
diameter and in the arterial flow to the left leg. The patient
recovered well. |
Peripheral thrombolysis, case 11. After
angioplasty, further improvement is noted in the luminal
diameter and in the arterial flow to the left leg. The patient
recovered well.
 | Media file 97:
Peripheral thrombolysis, case 12.
Thrombolysoangioplasty of a right external iliac artery
occlusion. Early oblique angiogram of the pelvis shows chronic
occlusion with hypertrophy of the internal iliac
artery. |
Peripheral thrombolysis, case 12.
Thrombolysoangioplasty of a right external iliac artery
occlusion. Early oblique angiogram of the pelvis shows chronic
occlusion with hypertrophy of the internal iliac
artery.
| Media file 98:
Peripheral thrombolysis, case 12. Late image
shows reconstitution of the right common iliac artery at the
level of the deep circumflex iliac branch. Low-dose urokinase
infusion was begun by using the McNamara
technique. |
Peripheral thrombolysis, case 12. Late image
shows reconstitution of the right common iliac artery at the
level of the deep circumflex iliac branch. Low-dose urokinase
infusion was begun by using the McNamara
technique.
 | Media file 99:
Peripheral native arterial thrombolysis, case
12. Day 1 follow-up angiogram shows restoration of antegrade
flow to the right leg, with lesions in the proximal and distal
external iliac arteries. The internal iliac artery obscures the
proximal lesion. The distal lesion looks irregular and suggests
residual thrombus. |
Peripheral native arterial thrombolysis, case
12. Day 1 follow-up angiogram shows restoration of antegrade
flow to the right leg, with lesions in the proximal and distal
external iliac arteries. The internal iliac artery obscures the
proximal lesion. The distal lesion looks irregular and suggests
residual thrombus.
| Media file 100:
Peripheral thrombolysis, case 12. Contralateral
oblique image shows that the stenosis in the proximal right
external iliac artery is smooth and circumferential. The distal
lesion is not seen in its ideal profile. Low-dose urokinase
infusion is continued by using the McNamara
technique. |
Peripheral thrombolysis, case 12. Contralateral
oblique image shows that the stenosis in the proximal right
external iliac artery is smooth and circumferential. The distal
lesion is not seen in its ideal profile. Low-dose urokinase
infusion is continued by using the McNamara
technique.
 | Media file 101:
Peripheral native arterial thrombolysis, case
12. Day 2 follow-up angiogram shows no notable interval change
from the previous day's appearance. |
Peripheral native arterial thrombolysis, case
12. Day 2 follow-up angiogram shows no notable interval change
from the previous day's appearance.
 | Media file 102:
Peripheral thrombolysis, case 12. Close-up
contralateral oblique image shows an eccentric stenosis of
approximately 60% in the distal right external iliac
artery. |
Peripheral thrombolysis, case 12. Close-up
contralateral oblique image shows an eccentric stenosis of
approximately 60% in the distal right external iliac
artery.
 | Media file 103:
Peripheral thrombolysis, case 12. Close-up
oblique image of the distal stenosis after angioplasty
demonstrates the appearance of an intimomedial split and good
antegrade flow. |
Peripheral thrombolysis, case 12. Close-up
oblique image of the distal stenosis after angioplasty
demonstrates the appearance of an intimomedial split and good
antegrade flow.
 | Media file 104:
Peripheral native arterial thrombolysis, case
12. Contralateral oblique image shows the intimomedial split
again. Antegrade flow is good, but a notable intraluminal
filling defect is seen. |
Peripheral native arterial thrombolysis, case
12. Contralateral oblique image shows the intimomedial split
again. Antegrade flow is good, but a notable intraluminal
filling defect is seen.
 | Media file 105:
Peripheral native arterial thrombolysis, case
12. In this patient, urokinase 250,000 U was administered by
using a pulse-spray technique, with no substantial interval
change. Note the fine intimomedial split of the proximal iliac
artery stenosis after angioplasty. Vascular stents were not
available. The patient did well. |
Peripheral native arterial thrombolysis, case
12. In this patient, urokinase 250,000 U was administered by
using a pulse-spray technique, with no substantial interval
change. Note the fine intimomedial split of the proximal iliac
artery stenosis after angioplasty. Vascular stents were not
available. The patient did well.
 | Media file 106:
Peripheral native arterial thrombolysis, case
13. Thrombolysoangioplasty with stent placement of a left iliac
occlusion with severe atherosclerosis. Pretreatment angiogram
demonstrates occlusion of the left common iliac artery. Early
reconstitution occurs by means of internal iliac artery
collateral flow. Moderate disease is noted in the right
external iliac artery. |
Peripheral native arterial thrombolysis, case
13. Thrombolysoangioplasty with stent placement of a left iliac
occlusion with severe atherosclerosis. Pretreatment angiogram
demonstrates occlusion of the left common iliac artery. Early
reconstitution occurs by means of internal iliac artery
collateral flow. Moderate disease is noted in the right
external iliac artery.
 | Media file 107:
Peripheral thrombolysis, case 13. Late image
shows reconstitution of the left external iliac artery.
Low-dose urokinase was administered by using the McNamara
technique. |
Peripheral thrombolysis, case 13. Late image
shows reconstitution of the left external iliac artery.
Low-dose urokinase was administered by using the McNamara
technique.
 | Media file 108:
Peripheral thrombolysis, case 13. Day 1
follow-up image demonstrates recanalization of the left iliac
system. A severe, coarse atheromatous change in the proximal
left iliac system is noted. An asymptomatic proximal right
common iliac artery stenosis is noted but not
treated. |
Peripheral thrombolysis, case 13. Day 1
follow-up image demonstrates recanalization of the left iliac
system. A severe, coarse atheromatous change in the proximal
left iliac system is noted. An asymptomatic proximal right
common iliac artery stenosis is noted but not
treated.
 | Media file 109:
Peripheral thrombolysis, case 13. Normal luminal
diameter and flow is restored after the deployment of 3 large
Palmaz stents mounted on 8-mm balloons (model P308). The
patient did well. |
Peripheral thrombolysis, case 13. Normal luminal
diameter and flow is restored after the deployment of 3 large
Palmaz stents mounted on 8-mm balloons (model P308). The
patient did well.
 | Media file 110:
Peripheral thrombolysis, case 14.
Thrombolysoangioplasty of occluded femoral-popliteal bypass.
Anteroposterior (AP) angiogram shows the residual nipple of the
thrombosed bypass. The superficial femoral artery (SFA) is
occluded, but the profunda femoris is
preserved. |
Peripheral thrombolysis, case 14.
Thrombolysoangioplasty of occluded femoral-popliteal bypass.
Anteroposterior (AP) angiogram shows the residual nipple of the
thrombosed bypass. The superficial femoral artery (SFA) is
occluded, but the profunda femoris is
preserved.
 | Media file 111:
Peripheral thrombolysis, case 14. The ostium of
the bypass is easily catheterized with a Motarjeme catheter.
Low-dose urokinase is infused by using the McNamara
technique. |
Peripheral thrombolysis, case 14. The ostium of
the bypass is easily catheterized with a Motarjeme catheter.
Low-dose urokinase is infused by using the McNamara
technique.
 | Media file 112:
Peripheral thrombolysis, case 14. Day 1
follow-up angiogram of the thigh shows restoration of flow and
subtotal resolution of the residual thrombus. |
Peripheral thrombolysis, case 14. Day 1
follow-up angiogram of the thigh shows restoration of flow and
subtotal resolution of the residual thrombus.
 | Media file 113:
Peripheral thrombolysis, case 14. Angiogram at
the knee shows a moderate-to-severe stenosis at the distal
anastomosis. Thrombolysis is continued
overnight. |
Peripheral thrombolysis, case 14. Angiogram at
the knee shows a moderate-to-severe stenosis at the distal
anastomosis. Thrombolysis is continued
overnight.
 | Media file 114:
Peripheral thrombolysis, case 14. Day 2
follow-up image shows resolution of proximal thrombus (not
shown) and no further distal improvement. |
Peripheral thrombolysis, case 14. Day 2
follow-up image shows resolution of proximal thrombus (not
shown) and no further distal improvement.
 | Media file 115:
Peripheral thrombolysis, case 14. Angiogram of
the proximal calf shows 1-vessel peroneal
run-off. |
Peripheral thrombolysis, case 14. Angiogram of
the proximal calf shows 1-vessel peroneal
run-off.
 | Media file 116:
Peripheral bypass thrombolysis, case 14. Distal
reconstitution of the anterior tibia supplies flow to the foot
by means of the dorsalis pedis (not shown). |
Peripheral bypass thrombolysis, case 14. Distal
reconstitution of the anterior tibia supplies flow to the foot
by means of the dorsalis pedis (not shown).
 | Media file 117:
Peripheral thrombolysis, case 14. Although the
above-the-knee popliteal artery perianastomotic stenosis is
only moderate, it is the most readily treatable lesion. It was
dilated successfully with a 5-mm balloon. |
Peripheral thrombolysis, case 14. Although the
above-the-knee popliteal artery perianastomotic stenosis is
only moderate, it is the most readily treatable lesion. It was
dilated successfully with a 5-mm balloon.
 | Media file 118:
Peripheral thrombolysis, case 14.
Postangioplastic appearance shows substantial improvement of
the distal bypass anastomosis. The patient did
well. |
Peripheral thrombolysis, case 14.
Postangioplastic appearance shows substantial improvement of
the distal bypass anastomosis. The patient did
well.
 | Media file 119:
Peripheral native arterial thrombolysis, case
15. Thrombolysoangioplasty and stent placement of highly
diseased left iliac artery. Oblique selective angiogram of the
left iliac system shows chronic occlusion of the external iliac
artery with reconstitution of the common femoral artery via the
diseased internal iliac artery. A moderate-sized nipple is
noted. Distal run-off angiogram (not shown) demonstrated a
diseased profunda femoris and occluded superficial femoral
artery (SFA) and reconstitution of a diseased above-the-knee
popliteal artery with diseased 2-vessel run-off to the foot by
means of the posterior tibial artery and peroneal
artery. |
Peripheral native arterial thrombolysis, case
15. Thrombolysoangioplasty and stent placement of highly
diseased left iliac artery. Oblique selective angiogram of the
left iliac system shows chronic occlusion of the external iliac
artery with reconstitution of the common femoral artery via the
diseased internal iliac artery. A moderate-sized nipple is
noted. Distal run-off angiogram (not shown) demonstrated a
diseased profunda femoris and occluded superficial femoral
artery (SFA) and reconstitution of a diseased above-the-knee
popliteal artery with diseased 2-vessel run-off to the foot by
means of the posterior tibial artery and peroneal
artery.
 | Media file 120:
Peripheral thrombolysis, case 15. The occlusion
is traversed with a guidewire, and a Mewissen catheter is
placed. The proximal port of the catheter is proximal to the
occlusion. A guidewire is used to occlude the end hole, and the
patient is treated with low-dose urokinase infusion
overnight. |
Peripheral thrombolysis, case 15. The occlusion
is traversed with a guidewire, and a Mewissen catheter is
placed. The proximal port of the catheter is proximal to the
occlusion. A guidewire is used to occlude the end hole, and the
patient is treated with low-dose urokinase infusion
overnight.
 | Media file 121:
Peripheral native arterial thrombolysis, case
15. Day 1 follow-up image shows no substantial
improvement. |
Peripheral native arterial thrombolysis, case
15. Day 1 follow-up image shows no substantial
improvement.
 | Media file 122:
Peripheral native arterial thrombolysis, case
15. Day 2 follow-up image obtained with a guidewire in the
catheter shows no definite interval change. Only a limited
injection of contrast material is possible without removing the
inner guidewire. |
Peripheral native arterial thrombolysis, case
15. Day 2 follow-up image obtained with a guidewire in the
catheter shows no definite interval change. Only a limited
injection of contrast material is possible without removing the
inner guidewire.
 | Media file 123:
Peripheral thrombolysis, case 15. Follow-up
angiogram obtained without the inner guidewire shows
substantial improvement from the pretreatment appearance.
Residual occlusion is present in the iliac
system. |
Peripheral thrombolysis, case 15. Follow-up
angiogram obtained without the inner guidewire shows
substantial improvement from the pretreatment appearance.
Residual occlusion is present in the iliac
system.
 | Media file 124:
Peripheral thrombolysis, case 15. Angiogram
performed with contrast material injected into the common
femoral artery via a Mewissen catheter within allows improved
opacification of the distal run-off compared with the
pretreatment iliac injection (not shown). The superficial
femoral artery (SFA) is occluded, and the profunda femoris is
highly diseased. |
Peripheral thrombolysis, case 15. Angiogram
performed with contrast material injected into the common
femoral artery via a Mewissen catheter within allows improved
opacification of the distal run-off compared with the
pretreatment iliac injection (not shown). The superficial
femoral artery (SFA) is occluded, and the profunda femoris is
highly diseased.
 | Media file 125:
Peripheral thrombolysis, case 15. Angiogram of
the mid thigh shows reconstitution of a diseased above-the-knee
popliteal artery. |
Peripheral thrombolysis, case 15. Angiogram of
the mid thigh shows reconstitution of a diseased above-the-knee
popliteal artery.
 | Media file 126:
Peripheral native arterial thrombolysis, case
15. Angiogram of the knee shows a highly diseased popliteal
artery with hypertrophied collateral branches bridging several
stenoses. |
Peripheral native arterial thrombolysis, case
15. Angiogram of the knee shows a highly diseased popliteal
artery with hypertrophied collateral branches bridging several
stenoses.
 | Media file 127:
Peripheral thrombolysis, case 15. A flexible
sheath is placed into the left iliac artery. |
Peripheral thrombolysis, case 15. A flexible
sheath is placed into the left iliac artery.
 | Media file 128:
Peripheral thrombolysis, case 15. Infusion
catheter is exchanged for a guidewire. Angiogram through the
sheath demonstrates the true lumen with improved
accuracy. |
Peripheral thrombolysis, case 15. Infusion
catheter is exchanged for a guidewire. Angiogram through the
sheath demonstrates the true lumen with improved
accuracy.
 | Media file 129:
Peripheral thrombolysis, case 15. Nonenhanced
image. |
Peripheral thrombolysis, case 15. Nonenhanced
image.
 | Media file 130:
Peripheral thrombolysis, case 15. Day 3
follow-up image demonstrates no further improvement with
possible redeposition of the thrombus. The lesion requires
definitive treatment at this time. |
Peripheral thrombolysis, case 15. Day 3
follow-up image demonstrates no further improvement with
possible redeposition of the thrombus. The lesion requires
definitive treatment at this time.
 | Media file 131:
Peripheral thrombolysis, case 15. End-hole
catheter is placed distal to the stenosis before stent
placement. |
Peripheral thrombolysis, case 15. End-hole
catheter is placed distal to the stenosis before stent
placement.
 | Media file 132:
Peripheral native arterial thrombolysis, case
15. A Wallstent is deployed across the external iliac artery
before balloon dilation to minimize the risk of distal
embolization. Substantial residual stenosis is
present. |
Peripheral native arterial thrombolysis, case
15. A Wallstent is deployed across the external iliac artery
before balloon dilation to minimize the risk of distal
embolization. Substantial residual stenosis is
present.
 | Media file 133:
Peripheral thrombolysis, case 15. The residual
stenosis is dilated in the Wallstent. |
Peripheral thrombolysis, case 15. The residual
stenosis is dilated in the Wallstent.
 | Media file 134:
Peripheral thrombolysis, case 15. Angiogram of
the proximal right iliac artery shows a now-significant common
iliac artery stenosis. Right iliac flow was too limited to
cause a significant pressure decrease before the external iliac
artery was recanalized and inline flow to the thigh is
restored. |
Peripheral thrombolysis, case 15. Angiogram of
the proximal right iliac artery shows a now-significant common
iliac artery stenosis. Right iliac flow was too limited to
cause a significant pressure decrease before the external iliac
artery was recanalized and inline flow to the thigh is
restored.
 | Media file 135:
Peripheral thrombolysis, case 15. Left common
iliac artery is treated with a Palmaz stent by using the
kissing-balloon technique. Posttreatment angiogram of the
pelvis showed no significant residual stenosis and markedly
improved flow. This case illustrates the rational for
thrombolysoangioplasty: Lysis of the thrombus allows a small
lesion to be treated with improved results. |
Peripheral thrombolysis, case 15. Left common
iliac artery is treated with a Palmaz stent by using the
kissing-balloon technique. Posttreatment angiogram of the
pelvis showed no significant residual stenosis and markedly
improved flow. This case illustrates the rational for
thrombolysoangioplasty: Lysis of the thrombus allows a small
lesion to be treated with improved results.
 | Media file 136:
Peripheral thrombolysis, case 16.
Thrombolysoangioplasty and stent treatment of left common and
external iliac occlusion. Angiogram of the pelvis shows the
occlusion with hypertrophied lumbar and internal iliac arteries
supplying collateral supply to the left leg. |
Peripheral thrombolysis, case 16.
Thrombolysoangioplasty and stent treatment of left common and
external iliac occlusion. Angiogram of the pelvis shows the
occlusion with hypertrophied lumbar and internal iliac arteries
supplying collateral supply to the left leg.
 | Media file 137:
Peripheral thrombolysis, case 16. Close-up image
demonstrates reconstitution of the left common and profunda
femoris arteries. |
Peripheral thrombolysis, case 16. Close-up image
demonstrates reconstitution of the left common and profunda
femoris arteries.
 | Media file 138:
Peripheral native arterial thrombolysis, case
16. Long occlusions are a challenge to traverse without
dissection. A diagnostic catheter is partly introduced through
the occlusion. An injection of contrast material shows the
residual lumen and provides a roadmap to the relatively normal
common femoral artery. |
Peripheral native arterial thrombolysis, case
16. Long occlusions are a challenge to traverse without
dissection. A diagnostic catheter is partly introduced through
the occlusion. An injection of contrast material shows the
residual lumen and provides a roadmap to the relatively normal
common femoral artery.
 | Media file 139:
Peripheral thrombolysis, case 16. The profunda
femoris is reached. |
Peripheral thrombolysis, case 16. The profunda
femoris is reached.
 | Media file 140:
Peripheral thrombolysis, case 16. The
superficial femoral artery (SFA) is occluded in the mid
thigh. |
Peripheral thrombolysis, case 16. The
superficial femoral artery (SFA) is occluded in the mid
thigh.
 | Media file 141:
Peripheral native arterial thrombolysis, case
16. Angiogram of the knee area shows relatively nondiseased
distal run-off. |
Peripheral native arterial thrombolysis, case
16. Angiogram of the knee area shows relatively nondiseased
distal run-off.
 | Media file 142:
Peripheral native arterial thrombolysis, case
16. A Mewissen catheter with a long infusion length is placed.
The infusion ports cover the entire occluded segment, obviating
coaxial infusion. A standard guidewire is required to occlude
the end hole. Occlusion of the superficial femoral artery (SFA)
provides protection of the lower leg from
embolization. |
Peripheral native arterial thrombolysis, case
16. A Mewissen catheter with a long infusion length is placed.
The infusion ports cover the entire occluded segment, obviating
coaxial infusion. A standard guidewire is required to occlude
the end hole. Occlusion of the superficial femoral artery (SFA)
provides protection of the lower leg from
embolization.
 | Media file 143:
Peripheral native arterial thrombolysis, case
16. Injection of contrast material shows a small residual lumen
in the iliac system. |
Peripheral native arterial thrombolysis, case
16. Injection of contrast material shows a small residual lumen
in the iliac system.
 | Media file 144:
Peripheral native arterial thrombolysis, case
16. Day 1 follow-up image shows antegrade flow through the
iliac system, with residual proximal stenosis. |
Peripheral native arterial thrombolysis, case
16. Day 1 follow-up image shows antegrade flow through the
iliac system, with residual proximal stenosis.
 | Media file 145:
Peripheral thrombolysis, case 16. The catheter
is placed in the distal aorta. Angiogram demonstrates a
high-grade narrowing of the left common iliac artery. Note the
extensive transpelvic collateral supply to the right side.
High-dose urokinase is infused for several hours to assess for
residual thrombus. |
Peripheral thrombolysis, case 16. The catheter
is placed in the distal aorta. Angiogram demonstrates a
high-grade narrowing of the left common iliac artery. Note the
extensive transpelvic collateral supply to the right side.
High-dose urokinase is infused for several hours to assess for
residual thrombus.
 | Media file 146:
Peripheral native arterial thrombolysis, case
16. Follow-up angiogram obtained later after Image 145 (not
shown) was unchanged. Ipsilateral access was obtained from the
left common femoral artery, and the left common iliac artery
stenosis was treated by using the kissing-balloon technique (to
8 mm). Note the waist on the left-side balloon. |
Peripheral native arterial thrombolysis, case
16. Follow-up angiogram obtained later after Image 145 (not
shown) was unchanged. Ipsilateral access was obtained from the
left common femoral artery, and the left common iliac artery
stenosis was treated by using the kissing-balloon technique (to
8 mm). Note the waist on the left-side balloon.
 | Media file 147:
Peripheral thrombolysis, case 16. Two
overlapping Palmaz stents are placed to yield a normal lumen
and flow. |
Peripheral thrombolysis, case 16. Two
overlapping Palmaz stents are placed to yield a normal lumen
and flow.
 | Media file 148:
Peripheral thrombolysis, case 17. Thrombolysis
of popliteal artery occlusion with follow-up. Angiogram of the
distal thigh shows segmental occlusion from the adductor canal
to the mid-distal above-the-knee popliteal artery. A moderate
number of collateral vessels are noted. The reconstituted
popliteal artery appears highly diseased. |
Peripheral thrombolysis, case 17. Thrombolysis
of popliteal artery occlusion with follow-up. Angiogram of the
distal thigh shows segmental occlusion from the adductor canal
to the mid-distal above-the-knee popliteal artery. A moderate
number of collateral vessels are noted. The reconstituted
popliteal artery appears highly diseased.
 | Media file 149:
Peripheral thrombolysis, case 17. Diseased
2-vessel calf run-off is noted, with poor flow. |
Peripheral thrombolysis, case 17. Diseased
2-vessel calf run-off is noted, with poor flow.
 | Media file 150:
Peripheral thrombolysis, case 17. Day 1
follow-up image with low-dose urokinase infusion by using the
McNamara technique restores antegrade flow to the lower leg.
Close-up image demonstrates an eccentric mid superficial
femoral artery (SFA) lesion, which may represent residual
thrombus. |
Peripheral thrombolysis, case 17. Day 1
follow-up image with low-dose urokinase infusion by using the
McNamara technique restores antegrade flow to the lower leg.
Close-up image demonstrates an eccentric mid superficial
femoral artery (SFA) lesion, which may represent residual
thrombus.
 | Media file 151:
Peripheral thrombolysis, case
17. |
Peripheral thrombolysis, case
17.
 | Media file 152:
Peripheral native arterial thrombolysis, case
17. Below-the-knee angiogram demonstrates a moderate-to-severe
focal stenosis of the popliteal artery. |
Peripheral native arterial thrombolysis, case
17. Below-the-knee angiogram demonstrates a moderate-to-severe
focal stenosis of the popliteal artery.
 | Media file 153:
Peripheral native arterial thrombolysis, case
17. Midcalf angiogram shows improved contrast enhancement,
flow, and vascular diameter. |
Peripheral native arterial thrombolysis, case
17. Midcalf angiogram shows improved contrast enhancement,
flow, and vascular diameter.
 | Media file 154:
Peripheral thrombolysis, case 17. Lateral
angiogram of the foot shows restoration of good flow to the
dorsalis pedis and plantar arch. (Day 1 images were obtained by
using a 9-in., 512 X 512 matrix, radiofrequency
suite.) |
Peripheral thrombolysis, case 17. Lateral
angiogram of the foot shows restoration of good flow to the
dorsalis pedis and plantar arch. (Day 1 images were obtained by
using a 9-in., 512 X 512 matrix, radiofrequency
suite.)
 | Media file 155:
Peripheral thrombolysis, case 17. Day 2
follow-up angiogram demonstrates no significant change in the
mid superficial femoral artery (SFA) lesion on the frontal view
(not shown). Right anterior oblique image shows the ulcerated
circumferential moderate-to-severe stenosis in
profile. |
Peripheral thrombolysis, case 17. Day 2
follow-up angiogram demonstrates no significant change in the
mid superficial femoral artery (SFA) lesion on the frontal view
(not shown). Right anterior oblique image shows the ulcerated
circumferential moderate-to-severe stenosis in
profile.
 | Media file 156:
Peripheral native arterial thrombolysis, case
17. The below-the-knee popliteal artery stenosis is unchanged
as well. The thrombolysis phase of treatment is complete. The
patient's problem was downgraded from a segmental occlusion to
focal stenoses, which are more successfully treated than the
other condition. |
Peripheral native arterial thrombolysis, case
17. The below-the-knee popliteal artery stenosis is unchanged
as well. The thrombolysis phase of treatment is complete. The
patient's problem was downgraded from a segmental occlusion to
focal stenoses, which are more successfully treated than the
other condition.
 | Media file 157:
Peripheral thrombolysis, case 17. Significant
luminal improvement is noted in the superficial femoral artery
(SFA) after dilation with a 5-mm angioplasty balloon. Mucosal
irregularity is not clinically significant and does not require
stent placement. |
Peripheral thrombolysis, case 17. Significant
luminal improvement is noted in the superficial femoral artery
(SFA) after dilation with a 5-mm angioplasty balloon. Mucosal
irregularity is not clinically significant and does not require
stent placement.
 | Media file 158:
Peripheral thrombolysis, case 17. The
below-the-knee popliteal artery stenosis is dilated with a 4-mm
angioplasty balloon. This roadmap-like image is obtained by
using the pretreatment angiogram as a superimposed reference
image during fluoroscopy. |
Peripheral thrombolysis, case 17. The
below-the-knee popliteal artery stenosis is dilated with a 4-mm
angioplasty balloon. This roadmap-like image is obtained by
using the pretreatment angiogram as a superimposed reference
image during fluoroscopy.
 | Media file 159:
Peripheral thrombolysis, case 17. Normal
postangioplasty appearance of a non–flow-limiting
intimomedial split. No stent is required. After hemostasis was
achieved, the patient was treated with systemic heparin therapy
overnight. |
Peripheral thrombolysis, case 17. Normal
postangioplasty appearance of a non–flow-limiting
intimomedial split. No stent is required. After hemostasis was
achieved, the patient was treated with systemic heparin therapy
overnight.
 | Media file 160:
Peripheral bypass thrombolysis, case 18.
Long-thrombolysis protocol (5-d) for occluded right
femoral-popliteal bypass. This patient has a history of several
vascular interventions. Angiogram of the pelvis demonstrates an
aortobifemoral bypass graft with a proximal end-to-side
anastomosis. Flow down the right limb of the bypass is slow.
The preserved internal iliac arteries are
hypertrophied. |
Peripheral bypass thrombolysis, case 18.
Long-thrombolysis protocol (5-d) for occluded right
femoral-popliteal bypass. This patient has a history of several
vascular interventions. Angiogram of the pelvis demonstrates an
aortobifemoral bypass graft with a proximal end-to-side
anastomosis. Flow down the right limb of the bypass is slow.
The preserved internal iliac arteries are
hypertrophied.
 | Media file 161:
Peripheral thrombolysis, case 18. The medial
femoral circumflex is the only remaining outflow vessel to the
leg. Close-up view shows the collateral supply to the right leg
and the complex appearance of the right common femoral
artery. |
Peripheral thrombolysis, case 18. The medial
femoral circumflex is the only remaining outflow vessel to the
leg. Close-up view shows the collateral supply to the right leg
and the complex appearance of the right common femoral
artery.
 | Media file 162:
Peripheral thrombolysis, case 18. Oblique view
shows the multiple nipples of the occluded outflow
branches. |
Peripheral thrombolysis, case 18. Oblique view
shows the multiple nipples of the occluded outflow
branches.
 | Media file 163:
Peripheral thrombolysis, case 18. The right
common femoral artery is catheterized with an end-hole
catheter. Low-dose urokinase infusion is begun by using the
McNamara technique. |
Peripheral thrombolysis, case 18. The right
common femoral artery is catheterized with an end-hole
catheter. Low-dose urokinase infusion is begun by using the
McNamara technique.
 | Media file 164:
Peripheral thrombolysis, case 18. Follow-up is
deferred until day 2 because of the severity of patient's
disease and the absence of complications. Slight improvement is
noted at the right common femoral area (not shown), and a
Simmons-3 catheter is placed in the now slightly elongated
stump. Catheter manipulation is complicated by the steep angles
of the aorto-bifemoral bypass graft anatomy. |
Peripheral thrombolysis, case 18. Follow-up is
deferred until day 2 because of the severity of patient's
disease and the absence of complications. Slight improvement is
noted at the right common femoral area (not shown), and a
Simmons-3 catheter is placed in the now slightly elongated
stump. Catheter manipulation is complicated by the steep angles
of the aorto-bifemoral bypass graft anatomy.
 | Media file 165:
Peripheral thrombolysis, case 18.Day 3 follow-up
image shows partial lysis with antegrade flow restored to a
femoral-popliteal bypass. Note that the bypass originates
medial to the still-occluded stump into which the catheter had
been placed the day before. |
Peripheral thrombolysis, case 18.Day 3 follow-up
image shows partial lysis with antegrade flow restored to a
femoral-popliteal bypass. Note that the bypass originates
medial to the still-occluded stump into which the catheter had
been placed the day before.
 | Media file 166:
Peripheral thrombolysis, case 18. The distal
femoral-popliteal anastomosis is widely patent with slow
outflow, which indicates distal disease. Note the retrograde
collateral flow supplying the upper thigh due to the
still-occluded descending branch of the profunda
femoris. |
Peripheral thrombolysis, case 18. The distal
femoral-popliteal anastomosis is widely patent with slow
outflow, which indicates distal disease. Note the retrograde
collateral flow supplying the upper thigh due to the
still-occluded descending branch of the profunda
femoris.
 | Media file 167:
Peripheral thrombolysis, case 18. The proximal
trifurcation vessels are occluded, with chronic hypertrophied
collateral vessels supplying the calf. |
Peripheral thrombolysis, case 18. The proximal
trifurcation vessels are occluded, with chronic hypertrophied
collateral vessels supplying the calf.
 | Media file 168:
Peripheral thrombolysis, case 18. Image shows
segmental reconstitution of the distal portion of the anterior
tibial artery, which acts as a bridging
collateral. |
Peripheral thrombolysis, case 18. Image shows
segmental reconstitution of the distal portion of the anterior
tibial artery, which acts as a bridging
collateral.
 | Media file 169:
Peripheral thrombolysis, case 18. Day 4
follow-up image shows minimally increased flow down the
femoral-popliteal bypass due to interval lysis of the proximal
graft thrombus (not shown). Slight lysis has occurred in the
popliteal artery, which now shows the meniscus of thrombus at
the level of the femoral condyles. |
Peripheral thrombolysis, case 18. Day 4
follow-up image shows minimally increased flow down the
femoral-popliteal bypass due to interval lysis of the proximal
graft thrombus (not shown). Slight lysis has occurred in the
popliteal artery, which now shows the meniscus of thrombus at
the level of the femoral condyles.
 | Media file 170:
Peripheral bypass thrombolysis, case 18. Blood
flow in the proximal calf through several recanalized and
collateral vessels is noted on day 4. |
Peripheral bypass thrombolysis, case 18. Blood
flow in the proximal calf through several recanalized and
collateral vessels is noted on day 4.
 | Media file 171:
Peripheral thrombolysis, case 18. Multiple small
vessels reconstitute the dorsalis pedis and the plantar
arch. |
Peripheral thrombolysis, case 18. Multiple small
vessels reconstitute the dorsalis pedis and the plantar
arch.
 | Media file 172:
Peripheral thrombolysis, case 18. The soft
popliteal thrombus is easily traversed with an infusion wire.
The infusion is changed to a coaxial infusion technique. The
infusion wire is withdrawn to the level of the tibial growth
plate to improve the delivery of urokinase to the thrombus (not
shown). |
Peripheral thrombolysis, case 18. The soft
popliteal thrombus is easily traversed with an infusion wire.
The infusion is changed to a coaxial infusion technique. The
infusion wire is withdrawn to the level of the tibial growth
plate to improve the delivery of urokinase to the thrombus (not
shown).
 | Media file 173:
Peripheral bypass thrombolysis, case 18. Day 5
follow-up image shows restoration of a more direct collateral
pathway to the anterior tibial artery region. Of some concern
is the appearance of tissue extravasation in the knee area.
This may represent an early sign of bleeding, which tends to
occur once the major intra-arterial thrombus burden is lysed.
No substantial change is noted distally (not shown). The right
leg was out of acute danger, and therapy was
terminated. |
Peripheral bypass thrombolysis, case 18. Day 5
follow-up image shows restoration of a more direct collateral
pathway to the anterior tibial artery region. Of some concern
is the appearance of tissue extravasation in the knee area.
This may represent an early sign of bleeding, which tends to
occur once the major intra-arterial thrombus burden is lysed.
No substantial change is noted distally (not shown). The right
leg was out of acute danger, and therapy was
terminated.
 | Media file 174:
Peripheral thrombolysis, case 19. Failed
thrombolysis (resilient plaque and/or thrombus). Close-up image
of the mid superficial femoral artery (SFA) shows a lobulated
and slightly angular intraluminal-appearing lesion suggestive
of thrombus. |
Peripheral thrombolysis, case 19. Failed
thrombolysis (resilient plaque and/or thrombus). Close-up image
of the mid superficial femoral artery (SFA) shows a lobulated
and slightly angular intraluminal-appearing lesion suggestive
of thrombus.
 | Media file 175:
Peripheral thrombolysis, case 19. Similar
lesions are noted in the mid popliteal artery. Note that
antegrade flow is maintained and allows treatment by means of
proximal infusion. A differential diagnosis of these lesions is
coarse atherosclerotic plaque. |
Peripheral thrombolysis, case 19. Similar
lesions are noted in the mid popliteal artery. Note that
antegrade flow is maintained and allows treatment by means of
proximal infusion. A differential diagnosis of these lesions is
coarse atherosclerotic plaque.
 | Media file 176:
Peripheral thrombolysis, case 19. Poor outflow
adds credibility to the presence of proximal thrombus. Low-dose
urokinase infusion is begun with infusion into the superficial
femoral artery (SFA). |
Peripheral thrombolysis, case 19. Poor outflow
adds credibility to the presence of proximal thrombus. Low-dose
urokinase infusion is begun with infusion into the superficial
femoral artery (SFA).
 | Media file 177:
Peripheral native arterial thrombolysis, case
19. Day 1 follow-up image shows no notable interval change in
the lesions in the superficial femoral artery (SFA) and
popliteal artery. Despite their appearance, they likely
represent irregular coarse atheromas. |
Peripheral native arterial thrombolysis, case
19. Day 1 follow-up image shows no notable interval change in
the lesions in the superficial femoral artery (SFA) and
popliteal artery. Despite their appearance, they likely
represent irregular coarse atheromas.
 | Media file 178:
Peripheral thrombolysis, case 19. Distal
angiogram shows lysis at the terminus of the popliteal artery,
which improves the outflow to the tibial vessels. Therapy was
terminated. |
Peripheral thrombolysis, case 19. Distal
angiogram shows lysis at the terminus of the popliteal artery,
which improves the outflow to the tibial vessels. Therapy was
terminated.
 | Media file 179:
Peripheral thrombolysis, case 20, part 1.
Profunda femoris thrombolysis, initial success. Initial
angiogram shows a patent aortobifemoral graft with a distal
eccentric kink or lesion on the left. A deep femoral nipple is
present, with residual patency of the medial femoral circumflex
branch. |
Peripheral thrombolysis, case 20, part 1.
Profunda femoris thrombolysis, initial success. Initial
angiogram shows a patent aortobifemoral graft with a distal
eccentric kink or lesion on the left. A deep femoral nipple is
present, with residual patency of the medial femoral circumflex
branch.
 | Media file 180:
Peripheral native arterial thrombolysis, case
20, part 1. Despite the steep angle of the aortobifemoral
bypass, the distal stump is catheterized. The distal occlusion
has a meniscus appearance, which suggests an acute-on-chronic
presentation. |
Peripheral native arterial thrombolysis, case
20, part 1. Despite the steep angle of the aortobifemoral
bypass, the distal stump is catheterized. The distal occlusion
has a meniscus appearance, which suggests an acute-on-chronic
presentation.
 | Media file 181:
Peripheral native arterial thrombolysis, case
20, part 1. Day 1 follow-up with low-dose urokinase infusion by
using the McNamara technique shows restoration of flow to the
major limbs of the profunda femoris. Clinically significant
residual intraluminal thrombus and an unusual narrowing of the
proximal segment of the main descending branch are
present. |
Peripheral native arterial thrombolysis, case
20, part 1. Day 1 follow-up with low-dose urokinase infusion by
using the McNamara technique shows restoration of flow to the
major limbs of the profunda femoris. Clinically significant
residual intraluminal thrombus and an unusual narrowing of the
proximal segment of the main descending branch are
present.
 | Media file 182:
Peripheral thrombolysis, case 20, part 1. Right
anterior oblique view shows a different aspect of the residual
thrombus. |
Peripheral thrombolysis, case 20, part 1. Right
anterior oblique view shows a different aspect of the residual
thrombus.
 | Media file 183:
Peripheral native arterial thrombolysis, case
20, part 1. Despite the proximal thrombus, the distal branches
of the profunda femoris are mostly intact with evidence of
small, distal shower emboli. |
Peripheral native arterial thrombolysis, case
20, part 1. Despite the proximal thrombus, the distal branches
of the profunda femoris are mostly intact with evidence of
small, distal shower emboli.
 | Media file 184:
Peripheral thrombolysis, case 20, part 1. A
short segment of the mid popliteal artery acts as a collateral
bridge to the calf. |
Peripheral thrombolysis, case 20, part 1. A
short segment of the mid popliteal artery acts as a collateral
bridge to the calf.
 | Media file 185:
Peripheral thrombolysis, case 20, part 1. Day 2
follow-up image shows near total resolution of profunda femoris
thrombus with minimal mural irregularity that possibly
represents residual resilient thrombus. |
Peripheral thrombolysis, case 20, part 1. Day 2
follow-up image shows near total resolution of profunda femoris
thrombus with minimal mural irregularity that possibly
represents residual resilient thrombus.
 | Media file 186:
Peripheral thrombolysis, case 20, part 1.
Angiogram of the mid calf shows highly diseased, partially
patent tibial vessels with many collaterals extending to the
ankle. Therapy was terminated. The expected long-term patency
is poor. |
Peripheral thrombolysis, case 20, part 1.
Angiogram of the mid calf shows highly diseased, partially
patent tibial vessels with many collaterals extending to the
ankle. Therapy was terminated. The expected long-term patency
is poor.
 | Media file 187:
Peripheral thrombolysis, case 20, part 2. Failed
thrombolysis at 6 months. Patient presents 6 months after the
initial thrombolysis with similar symptoms. Fluoroscopic image
demonstrates a similar occlusion of the profunda femoris. An
infusion wire is placed instead of a catheter because of the
steep angle of the aorto-bifemoral graft. A low-dose urokinase
infusion is begun. |
Peripheral thrombolysis, case 20, part 2. Failed
thrombolysis at 6 months. Patient presents 6 months after the
initial thrombolysis with similar symptoms. Fluoroscopic image
demonstrates a similar occlusion of the profunda femoris. An
infusion wire is placed instead of a catheter because of the
steep angle of the aorto-bifemoral graft. A low-dose urokinase
infusion is begun.
 | Media file 188:
Peripheral native arterial thrombolysis, case
20, part 2. Day 1 follow-up shows minimal improvement of the
profunda femoris. Because of the low expectation of durable
clinical benefit and because the patient is deemed a poor
candidate for further therapy, thrombolysis is terminated, and
the patient eventually underwent an above-the-knee amputation
of the left leg. |
Peripheral native arterial thrombolysis, case
20, part 2. Day 1 follow-up shows minimal improvement of the
profunda femoris. Because of the low expectation of durable
clinical benefit and because the patient is deemed a poor
candidate for further therapy, thrombolysis is terminated, and
the patient eventually underwent an above-the-knee amputation
of the left leg.
 | Media file 189:
Peripheral bypass thrombolysis, case 21, part 1.
Failed lysis of a venous femoral-popliteal bypass due to venous
sclerosis. The patient had a complex vascular history and
presented with subacute symptoms of right lower-extremity
arterial insufficiency. Oblique view of the pelvis shows
diffuse bilateral iliac disease with the hood of thrombosed
right venous femoral-popliteal bypass. |
Peripheral bypass thrombolysis, case 21, part 1.
Failed lysis of a venous femoral-popliteal bypass due to venous
sclerosis. The patient had a complex vascular history and
presented with subacute symptoms of right lower-extremity
arterial insufficiency. Oblique view of the pelvis shows
diffuse bilateral iliac disease with the hood of thrombosed
right venous femoral-popliteal bypass.
 | Media file 190:
Peripheral bypass thrombolysis, case 21, part 1.
Close-up image of the aortic bifurcation shows partial
protrusion of a left common iliac artery stent into the aortic
lumen. This complicates contralateral catheterization. An
end-hole catheter is placed into the right common femoral
artery above the bypass hood (not shown). Low-dose urokinase
infusion is begun. |
Peripheral bypass thrombolysis, case 21, part 1.
Close-up image of the aortic bifurcation shows partial
protrusion of a left common iliac artery stent into the aortic
lumen. This complicates contralateral catheterization. An
end-hole catheter is placed into the right common femoral
artery above the bypass hood (not shown). Low-dose urokinase
infusion is begun.
 | Media file 191:
Peripheral thrombolysis, case 21, part 1. Day 1
(morning) follow-up image shows no angiographic difference from
the previous day. |
Peripheral thrombolysis, case 21, part 1. Day 1
(morning) follow-up image shows no angiographic difference from
the previous day.
 | Media file 192:
Peripheral thrombolysis, case 21, part 1. After
gentle probing with a hydrophilic guidewire, a catheter is
placed. |
Peripheral thrombolysis, case 21, part 1. After
gentle probing with a hydrophilic guidewire, a catheter is
placed.
 | Media file 193:
Peripheral thrombolysis, case 21, part 1. The
vein graft is narrow along its entire length and occludes below
the knee. The 5F (5/3 mm) catheter is used for comparison. The
diameter of the residual vein lumen is approximately 1 mm.
Low-dose urokinase is continued overnight from within the
bypass. |
Peripheral thrombolysis, case 21, part 1. The
vein graft is narrow along its entire length and occludes below
the knee. The 5F (5/3 mm) catheter is used for comparison. The
diameter of the residual vein lumen is approximately 1 mm.
Low-dose urokinase is continued overnight from within the
bypass.
 | Media file 194:
Peripheral thrombolysis, case 21, part 1. Day 2
follow-up image shows no change in the appearance of the
proximal thigh (not shown). A near-occlusive focal stenosis is
present in the middle portion of the venous
bypass. |
Peripheral thrombolysis, case 21, part 1. Day 2
follow-up image shows no change in the appearance of the
proximal thigh (not shown). A near-occlusive focal stenosis is
present in the middle portion of the venous
bypass.
 | Media file 195:
Peripheral bypass thrombolysis, case 21, part 1.
The distal anastomosis is patent, and slender 3-vessel run-off
is noted. Therapy is terminated. The patient undergoes a
polytetrafluoroethylene (PTFE, Gore-Tex) femoral-femoral and
femoral below-the-knee popliteal bypass. |
Peripheral bypass thrombolysis, case 21, part 1.
The distal anastomosis is patent, and slender 3-vessel run-off
is noted. Therapy is terminated. The patient undergoes a
polytetrafluoroethylene (PTFE, Gore-Tex) femoral-femoral and
femoral below-the-knee popliteal bypass.
 | Media file 196:
Peripheral thrombolysis, case 21, part 2.
Thrombolysis of early graft thrombosis. Patient returns 4 days
after his previous thrombolysis with acute right
lower-extremity ischemia. Angiogram shows a patent
femoral-femoral bypass and profunda femoris. A double-nipple
appearance is noted. Neither distal bypasses are
seen. |
Peripheral thrombolysis, case 21, part 2.
Thrombolysis of early graft thrombosis. Patient returns 4 days
after his previous thrombolysis with acute right
lower-extremity ischemia. Angiogram shows a patent
femoral-femoral bypass and profunda femoris. A double-nipple
appearance is noted. Neither distal bypasses are
seen.
 | Media file 197:
Peripheral bypass thrombolysis, case 21, part 2.
As is commonly seen in bypass graft failure, propagation of
thrombosis into the recipient native vascular bed is noted with
worsening ischemia compared with the prebypass condition. The
tibioperoneal trunk is acutely occluded, as are the posterior
tibial and peroneal arteries. |
Peripheral bypass thrombolysis, case 21, part 2.
As is commonly seen in bypass graft failure, propagation of
thrombosis into the recipient native vascular bed is noted with
worsening ischemia compared with the prebypass condition. The
tibioperoneal trunk is acutely occluded, as are the posterior
tibial and peroneal arteries.
 | Media file 198:
Peripheral thrombolysis, case 21, part 2.
Close-up image of the right ankle shows occlusion the distal
anterior tibial artery. The terminal branches of the peroneal
act as a bridge to a short segment of distal posterior tibial
artery. No vessel to the foot is seen. The patient's right leg
is acutely threatened at this time. |
Peripheral thrombolysis, case 21, part 2.
Close-up image of the right ankle shows occlusion the distal
anterior tibial artery. The terminal branches of the peroneal
act as a bridge to a short segment of distal posterior tibial
artery. No vessel to the foot is seen. The patient's right leg
is acutely threatened at this time.
 | Media file 199:
Peripheral thrombolysis, case 21, part 2. The
soft, acute thrombus is readily catheterized. Extensive
thrombus is seen in the polytetrafluoroethylene (PTFE) graft
with minimal outflow. |
Peripheral thrombolysis, case 21, part 2. The
soft, acute thrombus is readily catheterized. Extensive
thrombus is seen in the polytetrafluoroethylene (PTFE) graft
with minimal outflow.
| Media file 200:
Peripheral thrombolysis, case 21, part 2.
Because of the severity of the patient's acute ischemia, an
initial course of pulse-spray thrombolysis is administered
within the femoral-popliteal graft. Minimal change is noted
after the administration of 250,000 U. |
Peripheral thrombolysis, case 21, part 2.
Because of the severity of the patient's acute ischemia, an
initial course of pulse-spray thrombolysis is administered
within the femoral-popliteal graft. Minimal change is noted
after the administration of 250,000 U.
| Media file 201:
Peripheral thrombolysis, case 21, part 2. After
the initial pulse-spray course of urokinase, the patient's
vascular result was deemed stable enough for a low-dose
infusion. Coaxial infusion in the femoral-popliteal bypass was
begun with the proximal infusion port just above the origin of
the graft. The infusion wire was placed in the midportion of
the graft based on the fluoroscopic evaluation of flow of
contrast material through the wire. |
Peripheral thrombolysis, case 21, part 2. After
the initial pulse-spray course of urokinase, the patient's
vascular result was deemed stable enough for a low-dose
infusion. Coaxial infusion in the femoral-popliteal bypass was
begun with the proximal infusion port just above the origin of
the graft. The infusion wire was placed in the midportion of
the graft based on the fluoroscopic evaluation of flow of
contrast material through the wire.
 | Media file 202:
Peripheral thrombolysis, case 21, part 2. Day 1
(morning) follow-up shows subtotal lysis with the restoration
of antegrade flow. A small amount of adherent thrombus is
present in the midportion of the graft. The speed of lysis is
consistent with acute thrombus. |
Peripheral thrombolysis, case 21, part 2. Day 1
(morning) follow-up shows subtotal lysis with the restoration
of antegrade flow. A small amount of adherent thrombus is
present in the midportion of the graft. The speed of lysis is
consistent with acute thrombus.
 | Media file 203:
Peripheral thrombolysis, case 21, part 2.
Close-up image of a distal anastomosis of a below-the-knee
bypass shows a small amount of non–flow-limiting
thrombus. |
Peripheral thrombolysis, case 21, part 2.
Close-up image of a distal anastomosis of a below-the-knee
bypass shows a small amount of non–flow-limiting
thrombus.
 | Media file 204:
Peripheral thrombolysis, case 21, part 2.
Three-vessel run-off to the ankle and foot is noted. The
catheter was exchanged for an end-hole catheter, and high-dose
urokinase was infused proximal to the residual superficial
femoral artery (SFA) thrombus. |
Peripheral thrombolysis, case 21, part 2.
Three-vessel run-off to the ankle and foot is noted. The
catheter was exchanged for an end-hole catheter, and high-dose
urokinase was infused proximal to the residual superficial
femoral artery (SFA) thrombus.
 | Media file 205:
Peripheral thrombolysis, case 21, part 2. Day 1
(afternoon) follow-up image shows near-total resolution of
thrombus in the bypass with a small amount of adherent residual
material in the lower portion of the image. |
Peripheral thrombolysis, case 21, part 2. Day 1
(afternoon) follow-up image shows near-total resolution of
thrombus in the bypass with a small amount of adherent residual
material in the lower portion of the image.
 | Media file 206:
Peripheral thrombolysis, case 21, part 2. No
significant improvement is noted in the distal anastomotic
region. Therapy was terminated. |
Peripheral thrombolysis, case 21, part 2. No
significant improvement is noted in the distal anastomotic
region. Therapy was terminated.
 | Media file 207:
Peripheral thrombolysis, case 21, part 3.
Rethrombosis of femoral-popliteal bypass at 6 months.
Pretreatment image is essentially unchanged from previous
pretreatment study. |
Peripheral thrombolysis, case 21, part 3.
Rethrombosis of femoral-popliteal bypass at 6 months.
Pretreatment image is essentially unchanged from previous
pretreatment study.
 | Media file 208:
Peripheral bypass thrombolysis, case 22. Early
tPA experience after the withdrawal of urokinase from market in
the United States. The recipient below-the-knee popliteal
artery is patent, with anterior tibial run-off
preserved. |
Peripheral bypass thrombolysis, case 22. Early
tPA experience after the withdrawal of urokinase from market in
the United States. The recipient below-the-knee popliteal
artery is patent, with anterior tibial run-off
preserved.
 | Media file 209:
Peripheral bypass thrombolysis, case 22. Flow to
the ankle via the anterior tibial artery is sluggish. Bridging
flow to a small segment of the posterior tibial artery occurs
through the peroneal artery. |
Peripheral bypass thrombolysis, case 22. Flow to
the ankle via the anterior tibial artery is sluggish. Bridging
flow to a small segment of the posterior tibial artery occurs
through the peroneal artery.
 | Media file 210:
Peripheral thrombolysis, case 22. Image obtained
after an 80-second delay illustrates the severity of distal
arterial insufficiency. |
Peripheral thrombolysis, case 22. Image obtained
after an 80-second delay illustrates the severity of distal
arterial insufficiency.
 | Media file 211:
Peripheral bypass thrombolysis, case 22. A
Mewissen catheter is placed proximally for a coaxial low-dose
urokinase infusion. A proximal marker is above the upper extent
of the thrombosis. Patient is given tissue-type plasminogen
activator (tPA) at a rate of 0.48 mg/h as a substitute for
low-dose urokinase. Full heparinization was still given at this
time. At present, subtherapeutic heparin is
used. |
Peripheral bypass thrombolysis, case 22. A
Mewissen catheter is placed proximally for a coaxial low-dose
urokinase infusion. A proximal marker is above the upper extent
of the thrombosis. Patient is given tissue-type plasminogen
activator (tPA) at a rate of 0.48 mg/h as a substitute for
low-dose urokinase. Full heparinization was still given at this
time. At present, subtherapeutic heparin is
used.
 | Media file 212:
Peripheral bypass thrombolysis, case 22.
Infusion wire is seen in the column of stagnant contrast agent
in the femoral-popliteal graft. |
Peripheral bypass thrombolysis, case 22.
Infusion wire is seen in the column of stagnant contrast agent
in the femoral-popliteal graft.
 | Media file 213:
Peripheral thrombolysis, case 22. Day 1
(morning) follow-up image shows that antegrade flow is
restored. A small amount of residual irregularity and thrombus
is present in the proximal graft. |
Peripheral thrombolysis, case 22. Day 1
(morning) follow-up image shows that antegrade flow is
restored. A small amount of residual irregularity and thrombus
is present in the proximal graft.
 | Media file 214:
Peripheral thrombolysis, case 22. The
below-the-knee bypass anastomosis is free of thrombus. Only
anterior tibial run-off to the ankle and foot is
noted. |
Peripheral thrombolysis, case 22. The
below-the-knee bypass anastomosis is free of thrombus. Only
anterior tibial run-off to the ankle and foot is
noted.
 | Media file 215:
Peripheral thrombolysis, case 22. In-line flow
to the foot is present, except for a small flow-limiting
thrombus within the dorsalis pedis. |
Peripheral thrombolysis, case 22. In-line flow
to the foot is present, except for a small flow-limiting
thrombus within the dorsalis pedis.
 | Media file 216:
Peripheral bypass thrombolysis, case 22. The
infusion wire was advanced into the anterior tibial artery. As
an analog of high-dose urokinase, infusion rate for the
tissue-type plasminogen activator (tPA) was doubled to 0.96
mg/h for a few hours. |
Peripheral bypass thrombolysis, case 22. The
infusion wire was advanced into the anterior tibial artery. As
an analog of high-dose urokinase, infusion rate for the
tissue-type plasminogen activator (tPA) was doubled to 0.96
mg/h for a few hours.
 | Media file 217:
Peripheral thrombolysis, case 22. The patient
returned late in the afternoon. Subtotal resolution of thrombus
in the bypass graft is observed. Residual thrombus is
demonstrated. |
Peripheral thrombolysis, case 22. The patient
returned late in the afternoon. Subtotal resolution of thrombus
in the bypass graft is observed. Residual thrombus is
demonstrated.
 | Media file 218:
Peripheral thrombolysis, case 22. The distal
anastomosis is clear of thrombus, with a patent anterior tibial
artery and a slender tibioperoneal trunk. |
Peripheral thrombolysis, case 22. The distal
anastomosis is clear of thrombus, with a patent anterior tibial
artery and a slender tibioperoneal trunk.
 | Media file 219:
Peripheral thrombolysis, case 22. Three-vessel
run-off to the ankle is noted, with no residual thrombus in the
calf. |
Peripheral thrombolysis, case 22. Three-vessel
run-off to the ankle is noted, with no residual thrombus in the
calf.
 | Media file 220:
Peripheral bypass thrombolysis, case 22.
Excellent anterior tibial flow into the dorsalis pedis is
surprisingly observed, with retrograde reconstitution of the
plantar arch. The infusion was terminated. |
Peripheral bypass thrombolysis, case 22.
Excellent anterior tibial flow into the dorsalis pedis is
surprisingly observed, with retrograde reconstitution of the
plantar arch. The infusion was terminated.
 | Media file 221:
Peripheral bypass thrombolysis, case 23. Failed
long-thrombolysis protocol with tissue-type plasminogen
activator (tPA). Patient had undergone a previous left
femoral-popliteal bypass procedure and presented with
limb-threatening ischemia of the left lower extremity.
Angiogram shows occlusion of the left common femoral artery,
superficial femoral artery (SFA), and bypass graft. Note the
bulbous appearance of the distal iliac artery from the previous
surgery. |
Peripheral bypass thrombolysis, case 23. Failed
long-thrombolysis protocol with tissue-type plasminogen
activator (tPA). Patient had undergone a previous left
femoral-popliteal bypass procedure and presented with
limb-threatening ischemia of the left lower extremity.
Angiogram shows occlusion of the left common femoral artery,
superficial femoral artery (SFA), and bypass graft. Note the
bulbous appearance of the distal iliac artery from the previous
surgery.
 | Media file 222:
Peripheral thrombolysis, case 23. The profunda
femoris acts as a large bridging vessel to the lower leg. Early
filling of the collaterals to the popliteal artery is noted
(see Image 223). |
Peripheral thrombolysis, case 23. The profunda
femoris acts as a large bridging vessel to the lower leg. Early
filling of the collaterals to the popliteal artery is noted
(see Image 223).
 | Media file 223:
Peripheral bypass thrombolysis, case 23. The
popliteal artery looks relatively normal. Slow flow proceeds
out of the trifurcation vessels, and an ostial lesion is in the
anterior tibial artery. Note the relative prominence of the
collateral vessels that indicates distal tibial vascular
disease. |
Peripheral bypass thrombolysis, case 23. The
popliteal artery looks relatively normal. Slow flow proceeds
out of the trifurcation vessels, and an ostial lesion is in the
anterior tibial artery. Note the relative prominence of the
collateral vessels that indicates distal tibial vascular
disease.
 | Media file 224:
Peripheral thrombolysis, case 23. Flow in the
midtibial arteries is nearly stagnant. The angiographic
appearance suggests that surgery is a poor option for this
patient. Bypass is problematic without the presence of a viable
distal anastomotic target. |
Peripheral thrombolysis, case 23. Flow in the
midtibial arteries is nearly stagnant. The angiographic
appearance suggests that surgery is a poor option for this
patient. Bypass is problematic without the presence of a viable
distal anastomotic target.
 | Media file 225:
Peripheral thrombolysis, case 23. The common
femoral artery occlusion is traversed with a hydrophilic
guidewire and a diagnostic 5F catheter. Either an air bubble or
a thrombus is present in the profunda femoris, but this is of
no clinical concern. The bypass ostium is not
seen. |
Peripheral thrombolysis, case 23. The common
femoral artery occlusion is traversed with a hydrophilic
guidewire and a diagnostic 5F catheter. Either an air bubble or
a thrombus is present in the profunda femoris, but this is of
no clinical concern. The bypass ostium is not
seen.
 | Media file 226:
Peripheral bypass thrombolysis, case 23. A short
infusion-length (5-cm) Mewissen catheter is placed across the
common femoral artery. A standard guidewire is used to block
the end hole. Coaxial infusion is not required because the
profunda femoris is widely patent. As a rule, a 65-cm-long
catheter is adequate for placement to the level of the femoral
trochanters. A 100-cm catheter is typically sufficient to reach
the below-the-knee popliteal artery. Special-order, low-cost 5F
catheters as long as 130 cm are available from Cook
(Bloomington, IN). |
Peripheral bypass thrombolysis, case 23. A short
infusion-length (5-cm) Mewissen catheter is placed across the
common femoral artery. A standard guidewire is used to block
the end hole. Coaxial infusion is not required because the
profunda femoris is widely patent. As a rule, a 65-cm-long
catheter is adequate for placement to the level of the femoral
trochanters. A 100-cm catheter is typically sufficient to reach
the below-the-knee popliteal artery. Special-order, low-cost 5F
catheters as long as 130 cm are available from Cook
(Bloomington, IN).
 | Media file 227:
Peripheral thrombolysis, case 23. Day 1
follow-up image shows partial recanalization of the common
femoral artery into the profunda femoris. Early lysis of the
proximal femoral-popliteal bypass is noted. |
Peripheral thrombolysis, case 23. Day 1
follow-up image shows partial recanalization of the common
femoral artery into the profunda femoris. Early lysis of the
proximal femoral-popliteal bypass is noted.
 | Media file 228:
Peripheral thrombolysis, case 23. Day 2
follow-up image shows minimal change in the proximal profunda
femoris. Some further lysis of the femoral-popliteal bypass is
noted. |
Peripheral thrombolysis, case 23. Day 2
follow-up image shows minimal change in the proximal profunda
femoris. Some further lysis of the femoral-popliteal bypass is
noted.
 | Media file 229:
Peripheral thrombolysis, case 23. Flow in the
trifurcation vessels is improved. Collateral flow has improved
to the anterior tibial artery, but the ostial narrowing is
persistent. |
Peripheral thrombolysis, case 23. Flow in the
trifurcation vessels is improved. Collateral flow has improved
to the anterior tibial artery, but the ostial narrowing is
persistent.
 | Media file 230:
Peripheral bypass thrombolysis, case 23.
Three-vessel run-off to the ankle and foot is present. The
patient is out of immediate danger at this point. With partial
flow restored to the thigh though the profunda femoris,
attention is now directed to restoring flow to the lower
leg. |
Peripheral bypass thrombolysis, case 23.
Three-vessel run-off to the ankle and foot is present. The
patient is out of immediate danger at this point. With partial
flow restored to the thigh though the profunda femoris,
attention is now directed to restoring flow to the lower
leg.
 | Media file 231:
Peripheral bypass thrombolysis, case 23. The
femoral-popliteal bypass was readily catheterized. Fluoroscopic
image shows a stagnant column of contrast agent due to a distal
occlusion with intraluminal thrombus in the mostly patent
midportion of the graft. This is the typical appearance of a
partially lysed graft occlusion. By comparison, thrombus in the
midportion is generally less organized and more readily lysed
than the proximal and distal thrombus plugs. Tissue-type
plasminogen activator (tPA) is infused overnight by using the
coaxial technique. The infusion catheter is kept in a similar
position to direct treatment to the proximal graft and the
profunda femoris. An infusion wire is placed in the distal
femoral-popliteal graft. The amount used for low-dose tPA is
split evenly between the ports. |
Peripheral bypass thrombolysis, case 23. The
femoral-popliteal bypass was readily catheterized. Fluoroscopic
image shows a stagnant column of contrast agent due to a distal
occlusion with intraluminal thrombus in the mostly patent
midportion of the graft. This is the typical appearance of a
partially lysed graft occlusion. By comparison, thrombus in the
midportion is generally less organized and more readily lysed
than the proximal and distal thrombus plugs. Tissue-type
plasminogen activator (tPA) is infused overnight by using the
coaxial technique. The infusion catheter is kept in a similar
position to direct treatment to the proximal graft and the
profunda femoris. An infusion wire is placed in the distal
femoral-popliteal graft. The amount used for low-dose tPA is
split evenly between the ports.
 | Media file 232:
Peripheral thrombolysis, case 23. Day 3
follow-up image shows no significant interval change in the
profunda femoris or distal bypass graft appearance or flow (not
shown). Moderate narrowing of the proximal profunda femoris and
the bypass was still present distally. Fluoroscopic image shows
stagnant contrast material and residual thrombus just beyond
the infusion wire. |
Peripheral thrombolysis, case 23. Day 3
follow-up image shows no significant interval change in the
profunda femoris or distal bypass graft appearance or flow (not
shown). Moderate narrowing of the proximal profunda femoris and
the bypass was still present distally. Fluoroscopic image shows
stagnant contrast material and residual thrombus just beyond
the infusion wire.
 | Media file 233:
Peripheral bypass thrombolysis, case 23. The
distal anastomosis of the femoral-popliteal bypass is easily
traversed. The profunda femoris thrombus is resistant to
tissue-type plasminogen activator (tPA) lysis for unknown
reasons. Further proximally directed infusion was believed to
be of little value, and attention was directed toward the
remaining distal thrombus. Further lysis of the profunda
femoris should occur with the recirculation of tPA after the
first-pass circulation is completed. A Mewissen catheter
traverses the distal bypass anastomosis. |
Peripheral bypass thrombolysis, case 23. The
distal anastomosis of the femoral-popliteal bypass is easily
traversed. The profunda femoris thrombus is resistant to
tissue-type plasminogen activator (tPA) lysis for unknown
reasons. Further proximally directed infusion was believed to
be of little value, and attention was directed toward the
remaining distal thrombus. Further lysis of the profunda
femoris should occur with the recirculation of tPA after the
first-pass circulation is completed. A Mewissen catheter
traverses the distal bypass anastomosis.
 | Media file 234:
Peripheral thrombolysis, case 23. The patient
returns for follow-up on day 4. At this point, treatment is
likely to be incompletely successful, possibly because of a
hypercoagulable state. By this time, prophylactic antibiotics
had been started because of the age of the arterial puncture.
Left anterior oblique (20°) image shows the profunda
femoris thrombus at a slightly different angle. The
anteroposterior (AP) appearance was essentially unchanged (not
shown). |
Peripheral thrombolysis, case 23. The patient
returns for follow-up on day 4. At this point, treatment is
likely to be incompletely successful, possibly because of a
hypercoagulable state. By this time, prophylactic antibiotics
had been started because of the age of the arterial puncture.
Left anterior oblique (20°) image shows the profunda
femoris thrombus at a slightly different angle. The
anteroposterior (AP) appearance was essentially unchanged (not
shown).
 | Media file 235:
Peripheral thrombolysis, case 23. Image shows
incomplete lysis of the bypass graft. The anterior tibial
stenosis is unchanged. Vigorous 3-vessel run-off to the ankle
is present; this has not changed. The dorsalis pedis and
plantar arch are unchanged. The benefit of restoring arterial
patency in the calf and foot cannot be underestimated. This
lysis usually occurs without direct catheterization below the
knee and is typically seen after about 72 h of low-dose
therapy. |
Peripheral thrombolysis, case 23. Image shows
incomplete lysis of the bypass graft. The anterior tibial
stenosis is unchanged. Vigorous 3-vessel run-off to the ankle
is present; this has not changed. The dorsalis pedis and
plantar arch are unchanged. The benefit of restoring arterial
patency in the calf and foot cannot be underestimated. This
lysis usually occurs without direct catheterization below the
knee and is typically seen after about 72 h of low-dose
therapy.
 | Media file 236:
Peripheral thrombolysis, case 23. As a final
attempt at lysis, tissue-type plasminogen activator (tPA) is
infused at the common femoral artery to directly infuse the
profunda femoris and femoral-popliteal bypass. Despite 5 days
of therapy, a friable profunda thrombus persists. This and the
following image (see Image 237) were obtained during a
high-speed angiographic series demonstrating the motion of the
adherent thrombus due to blood flow. This is the early image.
Note the slow flow down the femoral-popliteal
bypass. |
Peripheral thrombolysis, case 23. As a final
attempt at lysis, tissue-type plasminogen activator (tPA) is
infused at the common femoral artery to directly infuse the
profunda femoris and femoral-popliteal bypass. Despite 5 days
of therapy, a friable profunda thrombus persists. This and the
following image (see Image 237) were obtained during a
high-speed angiographic series demonstrating the motion of the
adherent thrombus due to blood flow. This is the early image.
Note the slow flow down the femoral-popliteal
bypass.
 | Media file 237:
Peripheral bypass thrombolysis, case 23. Later
image shows the motion of the profunda femoris thrombus and
improved filling of the femoral-popliteal
bypass. |
Peripheral bypass thrombolysis, case 23. Later
image shows the motion of the profunda femoris thrombus and
improved filling of the femoral-popliteal
bypass.
 | Media file 238:
Peripheral thrombolysis, case 23. Persistent
flow-limiting thrombus is present in the femoral-popliteal
bypass. Why the tissue-type plasminogen activator (tPA) was
relatively ineffective in this patient is unclear. The
0.48-mg/h infusion rate should not have overpowered the
patient's system, and the laboratory results showed no evidence
of disseminated intravascular coagulation (DIC). Although not
tried by the present author, plasminogen and thrombin
inhibitors have been found to promote lysis with tPA but not
urokinase. |
Peripheral thrombolysis, case 23. Persistent
flow-limiting thrombus is present in the femoral-popliteal
bypass. Why the tissue-type plasminogen activator (tPA) was
relatively ineffective in this patient is unclear. The
0.48-mg/h infusion rate should not have overpowered the
patient's system, and the laboratory results showed no evidence
of disseminated intravascular coagulation (DIC). Although not
tried by the present author, plasminogen and thrombin
inhibitors have been found to promote lysis with tPA but not
urokinase.
 | Media file 239:
Peripheral native arterial thrombolysis, case
24. Failed thrombolysis with tissue-type plasminogen activator
(tPA). A 50-year-old woman presented with several months of
upper-extremity pain, which began suddenly around the time of a
blood donation. Patient was initially treated for nonvascular
etiologies of pain. She now presents with a cool distal
extremity with diminished peripheral pulses and chronic
limb-threatening ischemia. Diagnostic angiography showed an
unremarkable aortic arch, thoracic outlet, and subclavian
artery. The brachial artery was slender (not shown).Initial
angiogram of the proximal forearm shows thromboembolic
occlusion of the radial and common ulnar-interosseous trunk.
The reconstituted interosseous artery serves as a bridging
artery to the wrist. |
Peripheral native arterial thrombolysis, case
24. Failed thrombolysis with tissue-type plasminogen activator
(tPA). A 50-year-old woman presented with several months of
upper-extremity pain, which began suddenly around the time of a
blood donation. Patient was initially treated for nonvascular
etiologies of pain. She now presents with a cool distal
extremity with diminished peripheral pulses and chronic
limb-threatening ischemia. Diagnostic angiography showed an
unremarkable aortic arch, thoracic outlet, and subclavian
artery. The brachial artery was slender (not shown).Initial
angiogram of the proximal forearm shows thromboembolic
occlusion of the radial and common ulnar-interosseous trunk.
The reconstituted interosseous artery serves as a bridging
artery to the wrist.
 | Media file 240:
Peripheral native arterial thrombolysis, case
24. Initial angiogram of distal forearm and wrist shows
short-segment ulnar reconstitution at the wrist with poor flow.
Therapy with tissue-type plasminogen activator (tPA) is begun
at 0.5 mg/h given through an end-hole catheter in the brachial
artery proximal to the occlusion. Subtherapeutic heparin is
administered intravenously. |
Peripheral native arterial thrombolysis, case
24. Initial angiogram of distal forearm and wrist shows
short-segment ulnar reconstitution at the wrist with poor flow.
Therapy with tissue-type plasminogen activator (tPA) is begun
at 0.5 mg/h given through an end-hole catheter in the brachial
artery proximal to the occlusion. Subtherapeutic heparin is
administered intravenously.
 | Media file 241:
Peripheral native arterial thrombolysis, case
24. Day 0, 6-h follow-up. Image shows early improvement of the
brachial artery trifurcation region, with partial
recanalization of the interosseous artery. The team is
encouraged and continue therapy overnight. |
Peripheral native arterial thrombolysis, case
24. Day 0, 6-h follow-up. Image shows early improvement of the
brachial artery trifurcation region, with partial
recanalization of the interosseous artery. The team is
encouraged and continue therapy overnight.
 | Media file 242:
Peripheral native arterial thrombolysis, case
24. Day 1, 20-h follow-up. Angiogram of distal arm and proximal
forearm shows no improvement overnight, and the brachial
trifurcation region has rethrombosed. |
Peripheral native arterial thrombolysis, case
24. Day 1, 20-h follow-up. Angiogram of distal arm and proximal
forearm shows no improvement overnight, and the brachial
trifurcation region has rethrombosed.
 | Media file 243:
Peripheral native arterial thrombolysis, case
24. Angiogram of the distal forearm and wrist is
unchanged. |
Peripheral native arterial thrombolysis, case
24. Angiogram of the distal forearm and wrist is
unchanged.
 | Media file 244:
Peripheral native arterial thrombolysis, case
24. The team observes a failure to progress or improve. Because
of the patient's poor surgical options, thrombolysis is
continued. A multi–side-port infusion catheter is
placed into the ulnar artery in the forearm. The dosage of
tissue-type plasminogen activator (tPA) is increased to 1 mg/h.
Image shows the catheter after the injection of a small amount
of contrast agent to verify its function. |
Peripheral native arterial thrombolysis, case
24. The team observes a failure to progress or improve. Because
of the patient's poor surgical options, thrombolysis is
continued. A multi–side-port infusion catheter is
placed into the ulnar artery in the forearm. The dosage of
tissue-type plasminogen activator (tPA) is increased to 1 mg/h.
Image shows the catheter after the injection of a small amount
of contrast agent to verify its function.
 | Media file 245:
Peripheral native arterial thrombolysis, case
24. Day 2, 27-h follow-up. Patient's symptoms have not
improved. The infusion catheter is withdrawn into the brachial
artery to allow for angiography. Angiogram of the proximal
forearm shows partial recanalization due to the physical
effects of the infusion catheter. No further thrombolysis is
noted. |
Peripheral native arterial thrombolysis, case
24. Day 2, 27-h follow-up. Patient's symptoms have not
improved. The infusion catheter is withdrawn into the brachial
artery to allow for angiography. Angiogram of the proximal
forearm shows partial recanalization due to the physical
effects of the infusion catheter. No further thrombolysis is
noted.
 | Media file 246:
Peripheral native arterial thrombolysis, case
24. Angiogram of the distal forearm shows minimal interval
lysis of the radial and ulnar arteries. Flow to the wrist is
marginally improved. |
Peripheral native arterial thrombolysis, case
24. Angiogram of the distal forearm shows minimal interval
lysis of the radial and ulnar arteries. Flow to the wrist is
marginally improved.
 | Media file 247:
Peripheral native arterial thrombolysis, case
24. Angiogram of the hand shows poor flow beyond the palmar
arches. Poor digital arterial patency and flow is noted. After
consultation with a vascular surgeon, the treatment is
terminated, and the patient undergoes surgical thrombectomy.
Initial results are positive, with improved flow and warmth to
the hand. The patient unfortunately returns with recurrent
ischemia 10 days after surgery. Thrombolysis is requested.
Alternate thrombolytic agents are not available at the medical
center. Further therapy with tissue-type plasminogen activator
(tPA) is considered to be to be of little value to the patient.
The radiologist recommends that the patient be referred to a
tertiary care center for limb salvage. |
Peripheral native arterial thrombolysis, case
24. Angiogram of the hand shows poor flow beyond the palmar
arches. Poor digital arterial patency and flow is noted. After
consultation with a vascular surgeon, the treatment is
terminated, and the patient undergoes surgical thrombectomy.
Initial results are positive, with improved flow and warmth to
the hand. The patient unfortunately returns with recurrent
ischemia 10 days after surgery. Thrombolysis is requested.
Alternate thrombolytic agents are not available at the medical
center. Further therapy with tissue-type plasminogen activator
(tPA) is considered to be to be of little value to the patient.
The radiologist recommends that the patient be referred to a
tertiary care center for limb salvage.
 | Media file 248:
Peripheral native arterial thrombolysis, case
25. Failed thrombolysis due to a pseudoaneurysm of the v in a
patient with right lower-extremity arterial insufficiency.
Aortogram shows a small aortoiliac aneurysm extending to the
left common iliac artery. The inferior mesenteric artery and
right common iliac artery are occluded. |
Peripheral native arterial thrombolysis, case
25. Failed thrombolysis due to a pseudoaneurysm of the v in a
patient with right lower-extremity arterial insufficiency.
Aortogram shows a small aortoiliac aneurysm extending to the
left common iliac artery. The inferior mesenteric artery and
right common iliac artery are occluded.
 | Media file 249:
Peripheral native arterial thrombolysis, case
25. Oblique view of the pelvis shows the nipple of the right
common and external iliac arteries. Image obtained in the mid
arterial phase shows early reconstitution of the right common
iliac artery. Later image (not shown) showed a left-to-right
internal iliac artery collateral supply. Distal image of the
high thigh (not shown) showed residual patency of the profunda
femoris. |
Peripheral native arterial thrombolysis, case
25. Oblique view of the pelvis shows the nipple of the right
common and external iliac arteries. Image obtained in the mid
arterial phase shows early reconstitution of the right common
iliac artery. Later image (not shown) showed a left-to-right
internal iliac artery collateral supply. Distal image of the
high thigh (not shown) showed residual patency of the profunda
femoris.
 | Media file 250:
Peripheral native arterial thrombolysis, case
25. A hook catheter is placed in the ostium of the right common
iliac artery. Gentle probing of the occlusion with a
hydrophilic guidewire was unsuccessful; the guidewire test
failed. Fluoroscopic image obtained after catheter placement
shows a curvilinear opacity of contrast agent, which has
unclear meaning (see next image). |
Peripheral native arterial thrombolysis, case
25. A hook catheter is placed in the ostium of the right common
iliac artery. Gentle probing of the occlusion with a
hydrophilic guidewire was unsuccessful; the guidewire test
failed. Fluoroscopic image obtained after catheter placement
shows a curvilinear opacity of contrast agent, which has
unclear meaning (see next image).
 | Media file 251:
Peripheral native arterial thrombolysis, case
25. Day 1 follow-up image obtained after the administration of
tissue-type plasminogen activator (tPA) 0.48-mg/h with the
McNamara technique demonstrates partial lysis of the right
common iliac artery. Of interest is the recanalization of the
inferior mesenteric artery (IMA), which was exposed to tPA by
means of recirculation. Later image (not shown) demonstrated
collateral supply from the IMA to the internal iliac
artery. |
Peripheral native arterial thrombolysis, case
25. Day 1 follow-up image obtained after the administration of
tissue-type plasminogen activator (tPA) 0.48-mg/h with the
McNamara technique demonstrates partial lysis of the right
common iliac artery. Of interest is the recanalization of the
inferior mesenteric artery (IMA), which was exposed to tPA by
means of recirculation. Later image (not shown) demonstrated
collateral supply from the IMA to the internal iliac
artery.
 | Media file 252:
Peripheral native arterial thrombolysis, case
25. Day 1 follow-up close-up image of the injection into the
right common iliac artery demonstrates an eggshell calcium
opacity of unclear significance (see next
image). |
Peripheral native arterial thrombolysis, case
25. Day 1 follow-up close-up image of the injection into the
right common iliac artery demonstrates an eggshell calcium
opacity of unclear significance (see next
image).
 | Media file 253:
Peripheral native arterial thrombolysis, case
25. The occlusion was probed with a Simmons-2 catheter and a
hydrophilic catheter. The wire was easily passed for a short
distance, and then it became coiled in an unusual manner. The
injection of contrast material into the catheter demonstrates a
lobular opacity that is larger and more lateral than
expected. |
Peripheral native arterial thrombolysis, case
25. The occlusion was probed with a Simmons-2 catheter and a
hydrophilic catheter. The wire was easily passed for a short
distance, and then it became coiled in an unusual manner. The
injection of contrast material into the catheter demonstrates a
lobular opacity that is larger and more lateral than
expected.
 | Media file 254:
Peripheral native arterial thrombolysis, case
25. Angiogram demonstrates a 3 X 5-cm, oblong aneurysm or
pseudoaneurysm with a narrow neck that leads back to the
proximal right common iliac artery. This structure corresponds
to the eggshell calcification noted previously. CT images (not
shown) confirmed the findings. The patient had improved feeling
in the lower extremity as a result of the distal effects of the
tissue-type plasminogen activator (tPA). Because of the risk of
spontaneous rupture, thrombolysis was terminated. The patient
was referred for aorto-bifemoral bypass
grafting. |
Peripheral native arterial thrombolysis, case
25. Angiogram demonstrates a 3 X 5-cm, oblong aneurysm or
pseudoaneurysm with a narrow neck that leads back to the
proximal right common iliac artery. This structure corresponds
to the eggshell calcification noted previously. CT images (not
shown) confirmed the findings. The patient had improved feeling
in the lower extremity as a result of the distal effects of the
tissue-type plasminogen activator (tPA). Because of the risk of
spontaneous rupture, thrombolysis was terminated. The patient
was referred for aorto-bifemoral bypass
grafting.
 | Media file 255:
Peripheral native arterial thrombolysis, case
26. Minor complication of guidewire dissection of the femoral
artery. Obese patient with diabetes presents with a cold left
lower extremity. Angiogram of the pelvis shows acute occlusion
of the left external iliac artery. Hypertrophy of the left
internal iliac artery suggests an acute-on-chronic etiology.
With some effort, the occlusion was traversed into the profunda
femoris. Coaxial urokinase infusion was
initiated. |
Peripheral native arterial thrombolysis, case
26. Minor complication of guidewire dissection of the femoral
artery. Obese patient with diabetes presents with a cold left
lower extremity. Angiogram of the pelvis shows acute occlusion
of the left external iliac artery. Hypertrophy of the left
internal iliac artery suggests an acute-on-chronic etiology.
With some effort, the occlusion was traversed into the profunda
femoris. Coaxial urokinase infusion was
initiated.
 | Media file 256:
Peripheral native arterial thrombolysis, case
26. Day 1 follow-up image demonstrates partial recanalization.
The external iliac artery and profunda femoris are partially
reconstituted. The possibility of a common femoral artery
dissection cannot be excluded. The treatment team left the
catheter positions unchanged. The patient was doing
well. |
Peripheral native arterial thrombolysis, case
26. Day 1 follow-up image demonstrates partial recanalization.
The external iliac artery and profunda femoris are partially
reconstituted. The possibility of a common femoral artery
dissection cannot be excluded. The treatment team left the
catheter positions unchanged. The patient was doing
well.
 | Media file 257:
Peripheral native arterial thrombolysis, case
26. Day 2 follow-up image demonstrates improved profunda
femoris patency. The distal profunda opacification terminates
proximal to the tip of the infusion wire. |
Peripheral native arterial thrombolysis, case
26. Day 2 follow-up image demonstrates improved profunda
femoris patency. The distal profunda opacification terminates
proximal to the tip of the infusion wire.
 | Media file 258:
Peripheral native arterial thrombolysis, case
26. Close-up image shows the distal profunda femoris at
dissection. The infusion wire was withdrawn into the profunda
femoris lumen, and coaxial infusion continued. |
Peripheral native arterial thrombolysis, case
26. Close-up image shows the distal profunda femoris at
dissection. The infusion wire was withdrawn into the profunda
femoris lumen, and coaxial infusion continued.
 | Media file 259:
Peripheral native arterial thrombolysis, case
26. Proximal image shows an intraluminal defect suggestive of
the appearance of the common femoral artery at dissection. This
appearance will likely improve with a similar maneuver of
pulling the catheter back. |
Peripheral native arterial thrombolysis, case
26. Proximal image shows an intraluminal defect suggestive of
the appearance of the common femoral artery at dissection. This
appearance will likely improve with a similar maneuver of
pulling the catheter back.
 | Media file 260:
Peripheral native arterial thrombolysis, case
26. Day 3 follow-up image demonstrates dramatic improvement of
the distal profunda femoris. Treatment was continued, and the
patient did well. This case illustrates the disadvantage of
vigorous catheterization attempts in the native
arteries. |
Peripheral native arterial thrombolysis, case
26. Day 3 follow-up image demonstrates dramatic improvement of
the distal profunda femoris. Treatment was continued, and the
patient did well. This case illustrates the disadvantage of
vigorous catheterization attempts in the native
arteries.
 | Media file 261:
Peripheral bypass thrombolysis, case 27.
Complication of flush embolus in an adjacent artery. The
patient presented with left lower-extremity ischemia.
Fluoroscopy-controlled angiogram of the upper left thigh shows
postoperative prominence of the common femoral artery and
patency of the profunda femoris. The superficial femoral artery
(SFA) and the femoral-popliteal bypass are
occluded. |
Peripheral bypass thrombolysis, case 27.
Complication of flush embolus in an adjacent artery. The
patient presented with left lower-extremity ischemia.
Fluoroscopy-controlled angiogram of the upper left thigh shows
postoperative prominence of the common femoral artery and
patency of the profunda femoris. The superficial femoral artery
(SFA) and the femoral-popliteal bypass are
occluded.
 | Media file 262:
Peripheral bypass thrombolysis, case 27. The
occluded superficial femoral artery (SFA) is readily
catheterized with a 5F general-purpose straight catheter and
hydrophilic guidewire. After catheterization, the occlusion was
evaluated with an overvigorous manual injection of contrast
material. |
Peripheral bypass thrombolysis, case 27. The
occluded superficial femoral artery (SFA) is readily
catheterized with a 5F general-purpose straight catheter and
hydrophilic guidewire. After catheterization, the occlusion was
evaluated with an overvigorous manual injection of contrast
material.
 | Media file 263:
Peripheral bypass thrombolysis, case 27.
Fluoroscopic image obtained immediately after the injection of
contrast material shows occlusion of the profunda femoris with
contrast material outlining the femoral-popliteal thrombus.
This patient developed acute limb-threatening ischemia of the
entire leg, which was treated with aggressive thrombolytic
infusion of the profunda femoris. Attention to technical detail
helps in preventing possible treatment
failures. |
Peripheral bypass thrombolysis, case 27.
Fluoroscopic image obtained immediately after the injection of
contrast material shows occlusion of the profunda femoris with
contrast material outlining the femoral-popliteal thrombus.
This patient developed acute limb-threatening ischemia of the
entire leg, which was treated with aggressive thrombolytic
infusion of the profunda femoris. Attention to technical detail
helps in preventing possible treatment
failures.
 | Media file 264:
Peripheral native arterial thrombolysis, case
28. Major complication: intracerebral hemorrhage. This patient
presented in the late 1980s with symptoms of acute
limb-threatening ischemia of the distal left lower extremity.
Close-up image of the adductor canal shows an acute cut-off
with a paucity of collateral vessels, which is typical of acute
thromboembolic occlusive disease. |
Peripheral native arterial thrombolysis, case
28. Major complication: intracerebral hemorrhage. This patient
presented in the late 1980s with symptoms of acute
limb-threatening ischemia of the distal left lower extremity.
Close-up image of the adductor canal shows an acute cut-off
with a paucity of collateral vessels, which is typical of acute
thromboembolic occlusive disease.
 | Media file 265:
Peripheral native arterial thrombolysis, case
28. Close-up image of the left knee shows partial segmental
reconstitution of the popliteal artery, which acts as a bridge
to the calf. Distal run-off was not demonstrated on
conventional angiography. Standard treatment for this patient
would have been urokinase therapy. The patient's spiritual
beliefs did not allow administration of the albumin carrier
agent in the urokinase preparation. After consulting with
pharmacist, the treatment team offered tissue-type plasminogen
activator (tPA) as a protein-free alternative. This case
occurred before the current low-dose tPA regimens were
developed. The team explained the addition risks of tPA to the
patient and family, including the risks of intracranial
hemorrhage. Written informed consent was obtained. Treatment
with tPA was begun at the accepted standard rates at that
time. |
Peripheral native arterial thrombolysis, case
28. Close-up image of the left knee shows partial segmental
reconstitution of the popliteal artery, which acts as a bridge
to the calf. Distal run-off was not demonstrated on
conventional angiography. Standard treatment for this patient
would have been urokinase therapy. The patient's spiritual
beliefs did not allow administration of the albumin carrier
agent in the urokinase preparation. After consulting with
pharmacist, the treatment team offered tissue-type plasminogen
activator (tPA) as a protein-free alternative. This case
occurred before the current low-dose tPA regimens were
developed. The team explained the addition risks of tPA to the
patient and family, including the risks of intracranial
hemorrhage. Written informed consent was obtained. Treatment
with tPA was begun at the accepted standard rates at that
time.
 | Media file 266:
Peripheral native arterial thrombolysis, case
28. Less than 24 hours after therapy began, the patient's
mental status severely changed. CT images show a large, right
intracerebral hemorrhage with subfalcine herniation. Images
obtained at levels below this (not shown) demonstrated
compression of the basilar cisterns. Thrombolytic therapy was
terminated, and a neurologist and a neurosurgeon were
consulted. Despite all efforts, the patient's condition
responded poorly. Current evidence shows that the incidence of
such catastrophic events is greatly decreased when tissue-type
plasminogen activator (tPA) is used in small dosages, such as
0.24-0.96 mg/h. |
Peripheral native arterial thrombolysis, case
28. Less than 24 hours after therapy began, the patient's
mental status severely changed. CT images show a large, right
intracerebral hemorrhage with subfalcine herniation. Images
obtained at levels below this (not shown) demonstrated
compression of the basilar cisterns. Thrombolytic therapy was
terminated, and a neurologist and a neurosurgeon were
consulted. Despite all efforts, the patient's condition
responded poorly. Current evidence shows that the incidence of
such catastrophic events is greatly decreased when tissue-type
plasminogen activator (tPA) is used in small dosages, such as
0.24-0.96 mg/h.
 | Media file 267:
After thrombolysis, imaging suggests a slender,
adherent, floating thrombus that extends from the medial aspect
of the residual stenosis. The residual luminal narrowing has
the appearance of an underlying atherosclerotic
narrowing. |
After thrombolysis, imaging suggests a slender,
adherent, floating thrombus that extends from the medial aspect
of the residual stenosis. The residual luminal narrowing has
the appearance of an underlying atherosclerotic
narrowing.
 | Media file 268:
This image is a spot radiograph of the right
side (supply side) of the femoral-femoral bypass obtained with
the gentle manual injection of dilute contrast material. The
finding of note is remarkable extravasation of contrast agent
from the region of the catheterization. Retrograde filling
occurs to the right side and outlines an intraluminal
thrombus. |
This image is a spot radiograph of the right
side (supply side) of the femoral-femoral bypass obtained with
the gentle manual injection of dilute contrast material. The
finding of note is remarkable extravasation of contrast agent
from the region of the catheterization. Retrograde filling
occurs to the right side and outlines an intraluminal
thrombus.
Keywords
thrombolysis, thrombus, thrombosis, streptokinase, SK, urokinase, UK, tissue-type plasminogen activator, tissue plasminogen activator, tPA, t-PA, Fontaine classification, acute limb ischemia, chronic limb ischemia, thrombolysoangioplasty, TLA, acute limb-threatening ischemia, ALLI
