SLR - March 2020 - Sara Mateen

Efficacy of Intra-Arterial Catheter-Directed Thrombolysis for Popliteal and Infrapopliteal Acute Limb Ischemia

Reference:
Lian, Wei Shuai, et al. Efficacy of Intra-Arterial Catheter-Directed Thrombolysis for Popliteal and Infrapopliteal Acute Limb Ischemia. Journal of Vascular Surgery 71.1 (2020): 141-148.

Scientific Literature Review

Reviewed By: Sara Mateen, DPM
Residency Program: Temple University Hospital – Philadelphia, PA

Podiatric Relevance: Limb salvage is a large percentage of podiatric practice, requiring podiatric surgeons to understand the etiology as well as work-up of vascular pathology. Podiatric surgeons also require a respectable relationship with vascular surgeons for multidisciplinary patient care. Acute limb ischemia is a time sensitive and fatal disease that requires immediate attention and it is important for podiatric surgeons to identify this disease if they are the first provider to encounter such an issue. This study reviews 28 patients (30 limbs) who underwent catheter directed thrombolysis (CDT) for treatment of popliteal and infra-popliteal acute limb ischemia.

Methods: This was a single center prospective observational study that evaluated 28 patients (30 limbs) between the ages of 18 and 80 years with acute (less than 14 days) thromboembolism of the popliteal and infra-popliteal arteries between March 2012 and December 2017. Limb conditions were evaluated and the severity was determined by the Rutherford classification. The modified Society for Vascular Surgery (SVS) runoff score and pedal runoff score were calculated before and after CDT with use of angiogram imaging. The SVS runoff score ranged from 0-19 and evaluated the patency as well as degree of stenosis with a maximum score of nine of the tibial vessels and popliteal vessel. SVS runoff score was then divided into three groups: good <5, compromised, 5-10; and poor, 10. Each patient was then treated with catheter directed thrombolysis per protocol.

Results: Overall, 31 patients (33 limbs) with below knee acute limb ischemia underwent CDT, however, six patients were lost to follow-up, with one deceased and two with major limb amputations at outside hospitals. Technical success was achieved in 25 (83.33 percent) of patients with improved clinical status in 93.33 percent of limbs. Primary patency was 76.67 percent at six months and 60.0 percent at 12 months. Limb salvage was 90 percent at six months and 76.67 percent at 12 months. The patency rate at six months and 12 months was 91.67 percent and 83.33 percent for the good runoff group, 80 percent and 60 percent for the compromised runoff group, and 50 percent and 25 percent for the poor runoff group, with significant higher patency rate of the good runoff compared to the poor runoff group. At 12 months, 16.67 percent of patients had major amputations and a mortality rate of 7.14 percent. Finally, re-intervention rate at six months and 12 months was 3.57 percent and 21.42 percent respectively.

Conclusions: Overall, catheter directed thrombolysis (CDT) is one of the most common techniques used for acute limb ischemia. A few limitations of this publication include small study size, no comparable variable, and it was a single center based study. This study concluded that CDT can be efficacious and safely administered for acute thromboembolic lesions of the popliteal and infra-popliteal arteries with overall good patency and limb salvage at six and 12 months.

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