Suggs W D, Cynamon J, Martin B, Sanchez L A, Wahl S I, Aronoff B, Veith F J
Division of Vascular Surgery, Montefiore Medical Center, New York, New York 10467, USA.
Am J Surg. 1999 Aug;178(2):103-6. doi: 10.1016/s0002-9610(99)00135-x.
Intra-arterial thrombolytic therapy is currently a therapeutic option for the treatment of acute limb ischemia. A recent large prospective randomized trial (TOPAS) comparing lytic therapy and operative intervention showed that both forms of treatment had similar results in terms of amputation-free survival. However, the exact role for lytic treatment is unclear.
Over a 4-year period we treated 60 cases of acute limb ischemia in 57 patients secondary to native artery occlusion with thrombolytic therapy with urokinase. All patients were evaluated at 1 week, 1 month, and then at 3-month intervals posttreatment. Follow-up evaluations included pulse examination, pulse volume recordings, and duplex examinations to confirm arterial patency. No patients were lost to follow-up with a range of 8 to 54 months (mean 26).
Of these 60 native arterial occlusions, complete lysis was achieved in 46 cases (76%). Of these 46 cases, 18 required lysis only, 19 cases (9 iliac, 7 superficial femoral artery (SFA), and 3 popliteal) required angioplasty of lesions uncovered by clot lysis, and 9 patients had lysis and angioplasty of iliac arteries followed by infrainguinal bypasses. Eight of the 57 patients (14%) who had been asymptomatic presented with symptoms limited to new onset claudication, all of which were successfully lysed. Cumulative patency for the 43 successful cases was 90% +/- 5% at 1 year and 75% +/- 4% at 2 years. The 1-year amputation-free survival for all native artery occlusions was 85% +/- 6%.
Thrombolysis with urokinase simplified the treatment of native arterial occlusion proving to be the sole therapy in 18 (29%) patients or a valuable adjunct by facilitating the angioplasty of arterial lesions and avoiding open surgery in 60% of patients treated. In addition, the correction of inflow lesions reduced the magnitude of required subsequent bypass procedures to achieve limb salvage. In conclusion, successful thrombolysis of native artery occlusion provided durable arterial patency and limb salvage, particularly in patients with new onset claudication.
动脉内溶栓治疗目前是治疗急性肢体缺血的一种治疗选择。最近一项比较溶栓治疗和手术干预的大型前瞻性随机试验（TOPAS）表明，两种治疗形式在无截肢生存率方面结果相似。然而，溶栓治疗的确切作用尚不清楚。
在4年期间，我们用尿激酶溶栓治疗了57例因天然动脉闭塞继发急性肢体缺血的患者，共60例。所有患者在治疗后1周、1个月，然后每隔3个月进行评估。随访评估包括脉搏检查、脉搏容积记录和双功超声检查以确认动脉通畅情况。无患者失访，随访时间为8至54个月（平均26个月）。
在这60例天然动脉闭塞中，46例（76%）实现了完全溶解。在这46例中，18例仅需溶栓，19例（9例髂动脉、7例股浅动脉（SFA）和3例腘动脉）需要对血栓溶解后暴露的病变进行血管成形术，9例患者进行了髂动脉溶栓和血管成形术，随后进行了腹股沟下旁路移植术。57例无症状患者中有8例（14%）出现症状，仅限于新发间歇性跛行，所有这些均成功溶解。43例成功病例的1年累积通畅率为90%±5%，2年时为75%±4%。所有天然动脉闭塞的1年无截肢生存率为85%±6%。
尿激酶溶栓简化了天然动脉闭塞的治疗，在18例（29%）患者中被证明是唯一的治疗方法，或者通过促进动脉病变的血管成形术并避免60%接受治疗患者的开放手术，是一种有价值的辅助治疗方法。此外，纠正流入道病变减少了为挽救肢体所需的后续旁路手术的规模。总之，天然动脉闭塞的成功溶栓提供了持久的动脉通畅和肢体挽救，特别是在新发间歇性跛行的患者中。
