Poredos P, Videcnik V
Department of Angiology, University Medical Centre, Ljubljana, Slovenia.
Wien Klin Wochenschr. 1999 Jan 15;111(1):21-5.
Local thrombolytic treatment of peripheral arterial occlusions, which has been accepted as a therapeutic alternative to surgical treatment, is not always successful. One of the reasons for unsuccessful thrombolytic treatment might be a low concentration of plasminogen in the thrombus or insufficient activation of the thrombolytic system. Therefore the purpose of this study was to determine whether the success of local treatment of peripheral arterial occlusions of lower extremities with streptokinase could be improved by enriching the thrombus with exogenous plasminogen and furthermore, if the therapeutic success depends on a systemic fibrinolytic effect. In a prospective randomized study two groups of patients with acute and subacute arterial occlusions of the lower limbs (Stage III, IV) were treated with a continuous infusion of local low dose of streptokinase (SK). The first group (45 patients, mean age 73 years) was treated with SK only (3750 IU/hour) (SK group). While the patients in the second group (43 patients, mean age 72 years) received exogenous lys-plasminogen (7.5 mg) before application of SK in thrombi (SK-Plg group). The treatment was successful in 69% (31 out of 45 patients) of the SK group and in 77% (33 out of 43 patients) of the SK-Plg group. Although lysis of thrombi was observed more frequently in the SK-Plg group than in the SK-group, the clinical outcome was comparable between groups. In successfully treated patients from the SK-Plg group the duration of treatment was significantly shorter than in the SK group (33 +/- 8 hr vs. 53 +/- 11 hr, p < 0.01). A significant decrease of fibrinogen concentration as an indicator of activation of fibrinolysis was not observed in the majority of treated patients. On the other hand, in successfully treated patients of both groups, the following was observed: 24 hour after the beginning of treatment, euglobulin clot lysis times were shortened to half of baselines values, and the plasminogen concentration was also significantly reduced (to 55% of the baseline value). In unsuccessfully treated patients no significant changes in fibrinolytic parameters were observed. The results of our study indicated that enrichment of the thrombus with exogenous plasminogen does not significantly improve the percentage of successful recanalization of peripheral arteries with a local low dose of SK, but significantly shortens the duration of treatment up to reperfusion. The study also showed that in local thrombolysis for the treatment of arterial occlusion a certain degree of systemic activation of the fibrinolytic system is essential for successful dissolution of the thrombi.
外周动脉闭塞的局部溶栓治疗已被公认为手术治疗的替代疗法，但并非总能成功。溶栓治疗失败的原因之一可能是血栓中纤溶酶原浓度低或溶栓系统激活不足。因此，本研究的目的是确定通过向血栓中添加外源性纤溶酶原是否可以提高链激酶局部治疗下肢外周动脉闭塞的成功率，此外，治疗成功是否取决于全身纤溶作用。在一项前瞻性随机研究中，两组急性和亚急性下肢动脉闭塞（III期、IV期）患者接受了局部低剂量链激酶（SK）的持续输注治疗。第一组（45例患者，平均年龄73岁）仅接受SK治疗（3750 IU/小时）（SK组）。而第二组（43例患者，平均年龄72岁）在血栓部位应用SK前接受外源性赖氨酸纤溶酶原（7.5 mg）（SK-Plg组）。SK组69%（45例患者中的31例）治疗成功，SK-Plg组77%（43例患者中的33例）治疗成功。虽然SK-Plg组血栓溶解的观察频率高于SK组，但两组的临床结果相当。在SK-Plg组成功治疗的患者中，治疗持续时间明显短于SK组（33±8小时对53±11小时，p<0.01）。在大多数接受治疗的患者中，未观察到作为纤溶激活指标的纤维蛋白原浓度显著降低。另一方面，在两组成功治疗的患者中，观察到以下情况：治疗开始后24小时，优球蛋白凝块溶解时间缩短至基线值的一半，纤溶酶原浓度也显著降低（降至基线值的55%）。在治疗失败的患者中，未观察到纤溶参数有显著变化。我们的研究结果表明，用外源性纤溶酶原富集血栓并不能显著提高局部低剂量SK治疗外周动脉再通成功的百分比，但可显著缩短直至再灌注的治疗持续时间。该研究还表明，在局部溶栓治疗动脉闭塞时，纤溶系统一定程度的全身激活对于血栓的成功溶解至关重要。
