Endovascular Treatment of Acute Limb Ischemia: Review of Current Plasminogen Activators and Mechanical Thrombectomy Devices

Abstract

Acute limb ischemia occurs in 15% to 20% of patients with chronic peripheral arterial disease. Off-label use of tissue plasminogen activators is the most common approach for patients with ischemic limbs that can wait 24 to 48 hours to restore flow. In the past decade, mechanical thrombectomy devices that use aspiration, maceration, or ultrasound waves have been developed to allow more rapid restoration of flow. Combination therapy with both mechanical and pharmacologic thrombolysis has become commonplace without randomized data to support its use. This article reviews acute limb ischemia and data regarding pharmacologic and mechanical thrombolysis.

Keywords

thrombolysis mechanical thrombectomy acute limb ischemia tPA plasminogen activators

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References

Aquino R. , Johnnides C. , Makaroun M. , et al. Natural history of claudication: long-term serial follow-up study of 1244 claudicants. J Vasc Surg. 2001 ;34:962-970.

Ouriel K. , Shortell CK , DeWeese JA , et al. A comparison of thrombolytic therapy with operative revascularization in the initial treatment of acute peripheral arterial ischemia. J Vasc Surg. 1994;19:1021-1030.

Norgren L. , Hiatt WR , Dormandy JA , et al., Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1): S1-S75.

Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity. The STILE trial. Ann Surg. 1994;220:251-266.

Ouriel K. , Veith FJ , Sasahara AA A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. Thrombolysis or Peripheral Arterial Surgery (TOPAS) Investigators. N Engl J Med. 1998;338:1105-1111.

Ouriel K. , Veith FJ , Sasahara AA Thrombolysis or peripheral arterial surgery: phase I results. TOPAS Investigators [see comments]. J Vasc Surg. 1996;23:64-73.

Giugliano RP , McCabe CH , Antman EM , et al. Lower-dose heparin with fibrinolysis is associated with lower rates of intracranial hemorrhage. Am Heart J. 2001;141:742-750.

Semba CP , Murphy TP , Bakal CW , Calis KA , Matalon TA Thrombolytic therapy with use of alteplase (rt-PA) in peripheral arterial occlusive disease: review of the clinical literature. The Advisory Panel. J Vasc Interv Radiol. 2000;11(2pt1):149-161.

Kasirajan K. , Haskal ZJ , Ouriel K. The use of mechanical thrombectomy devices in the management of acute peripheral arterial occlusive disease. J Vasc Interv Radiol. 2001;12:405-411.

10.

Haskal ZJ Mechanical thrombectomy devices for the treatment of peripheral arterial occlusions . Rev Cardiovasc Med. 2002;3(suppl 2):S45-S52.

11.

Silva JA , Ramee SR , Collins TJ , et al. Rheolytic thrombectomy in the treatment of acute limb-threatening ischemia: immediate results and six-month follow-up of the multi-center AngioJet registry. Possis Peripheral AngioJet Study AngioJet Investigators. Cathet Cardiovasc Diagn. 1998;45: 386-393.

12.

Zhu DW The potential mechanisms of bradyarrhythmias associated with AngioJet thrombectomy . J Invasive Cardiol. 2008;20(8supplA):2A-4A.

13.

Stahr P. , Rupprecht HJ , Voigtländer T. , et al. A new thrombectomy catheter device (AngioJet) for the disruption of thrombi: an in vitro study. Catheter Cardiovasc Interv . 1999;47: 381-389.

14.

Francis CW , Suchkova VN Ultrasound and thrombolysis. Vasc Med. 2001 ;6:181-187.

15.

Francis CW , Blinc A. , Lee S. , Cox C. Ultrasound accelerates transport of recombinant tissue plasminogen activator into clots. Ultrasound Med Biol. 1995;21:419-424.

16.

Suchkova V. , Carstensen EL , Francis CW Ultrasound enhancement of fibrinolysis at frequencies of 27 to 100 kHz. Ultrasound Med Biol. 2002;28:377-382.