Department of Surgical Sciences, Section of Vascular Surgery, Uppsala, and Lund University, Department of Clinical Sciences Malmö, Malmö, Sweden.
Br J Surg. 2014 Aug;101(9):1105-12. doi: 10.1002/bjs.9579. Epub 2014 Jun 25.
Thrombolysis is a common treatment for acute leg ischaemia. The purpose of this study was to evaluate different thrombolytic treatment strategies, and risk factors for complications.
This was a retrospective analysis of prospective databases from two vascular centres. One centre used a higher dose of heparin and recombinant tissue plasminogen activator (rtPA).
Some 749 procedures in 644 patients of median age 73 years were studied; 353 (47·1 per cent) of the procedures were done in women. The aetiology of ischaemia was graft occlusion in 38·8 per cent, acute arterial thrombosis in 32·2 per cent, embolus in 22·3 per cent and popliteal aneurysm in 6·7 per cent. Concomitant heparin infusion was used in 63·2 per cent. The mean dose of rtPA administered was 21·0 mg, with a mean duration of 25·2 h. Technical success was achieved in 80·2 per cent. Major amputation and death within 30 days occurred in 13·1 and 4·4 per cent respectively. Bleeding complications occurred in 227 treatments (30·3 per cent). Blood transfusion was needed in 104 (13·9 per cent). Three patients (0·4 per cent of procedures) had intracranial bleeding; all were fatal. Amputation-free survival was 83·6 per cent at 30 days at both centres. In multivariable analysis, preoperative severe ischaemia with motor deficit was the only independent risk factor for major bleeding (odds ratio (OR) 2·98; P <0·001). Independent risk factors for fasciotomy were severe ischaemia (OR 2·94) and centre (OR 6·50). Embolic occlusion was protective for major amputation at less than 30 days (OR 0·30; P = 0·003). Independent risk factors for death within 30 days were cerebrovascular disease (OR 3·82) and renal insufficiency (OR 3·86).
Both treatment strategies were successful in achieving revascularization with acceptable complication rates. Continuous heparin infusion during intra-arterial thrombolysis appeared to offer no advantage.
溶栓是治疗急性下肢缺血的常用方法。本研究旨在评估不同的溶栓治疗策略和并发症的危险因素。
这是对两个血管中心前瞻性数据库的回顾性分析。一个中心使用了更高剂量的肝素和重组组织型纤溶酶原激活剂（rtPA）。
研究了 644 名中位年龄为 73 岁的患者的 749 例手术，其中 353 例（47.1%）为女性。缺血的病因是移植血管闭塞占 38.8%，急性动脉血栓形成占 32.2%，栓塞占 22.3%，腘动脉瘤占 6.7%。同时使用肝素输注的占 63.2%。给予的 rtPA 平均剂量为 21.0mg，平均持续时间为 25.2h。技术成功率为 80.2%。30 天内主要截肢和死亡的发生率分别为 13.1%和 4.4%。227 例（30.3%）发生出血并发症。104 例（13.9%）需要输血。3 例（0.4%的手术）发生颅内出血，均为致命性。两个中心 30 天时的无截肢生存率分别为 83.6%。多变量分析显示，术前严重缺血伴运动障碍是大出血的唯一独立危险因素（比值比（OR）2.98；P<0.001）。筋膜切开术的独立危险因素是严重缺血（OR 2.94）和中心（OR 6.50）。栓塞闭塞是 30 天内主要截肢的保护因素（OR 0.30；P=0.003）。30 天内死亡的独立危险因素是脑血管疾病（OR 3.82）和肾功能不全（OR 3.86）。
两种治疗策略均成功实现了血管再通，并发症发生率可接受。动脉内溶栓期间持续肝素输注似乎没有优势。
