Bath Jonathan, Kim Ryan J, Dombrovskiy Viktor Y, Vogel Todd R
1 Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, USA.
2 Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, USA.
Vascular. 2019 Feb;27(1):71-77. doi: 10.1177/1708538118797782. Epub 2018 Sep 7.
Acute limb ischemia is a common vascular emergency requiring immediate intervention. Thrombolysis has been widely utilized for acute limb ischemia; the purpose of this study is to analyze contemporary trends, outcomes and complications of thrombolysis for acute limb ischemia.
Patients were identified from the Nationwide Inpatient Sample (2003-2013) using ICD-9. Patients undergoing emergency thrombolysis for acute limb ischemia were evaluated. Three groups were analyzed: thrombolysis alone, thrombolysis and endovascular procedure (T+ENDO), and failed thrombolysis requiring open surgery (T+OPEN).
A total of 162,240 patients with acute limb ischemia were estimated: 33,615 patients (20.7%) underwent thrombolysis as the initial treatment. Mean age was 66.2 ± 34.9 years with 54% male. The utilization of thrombolysis increased significantly during the study period (16.8-24.2%, p < 0.0001). The most common group was thrombolysis and endovascular procedure (40.7%), followed by thrombolysis alone (34.1%), and T+OPEN (25.2%). Thrombolysis and endovascular procedure increased significantly over time (31.6-47.8%, p < 0.0001) whereas thrombolysis alone and T+OPEN significantly decreased (39.6-28.6% and 28.7-23.6%, respectively, p < 0.0001). Overall mortality was 4.9%; thrombolysis and endovascular procedure compared to thrombolysis alone and T-OPEN had a lower mortality rate (3.2% vs. 6.1% and 5.9%, p < 0001). The overall stroke rate was 1.9%; thrombolysis alone had the highest stroke rate (3.0%, p < 0.0001) with thrombolysis and endovascular procedure the lowest (1.2%) and T+OPEN 1.7%. The highest amputation rate was T+OPEN (11.6%, p < 0.001) compared to thrombolysis and endovascular procedure (5.1%) and thrombolysis alone (5.3%). T+OPEN had the highest incidence of cardiac (5.5%), respiratory (7.3%) and renal complications (12.5%), pneumonia (4.0%), and fasciotomy (16.8%) (all p < 0.0001).
Thrombolysis remains an effective treatment for acute limb ischemia with increased utilization over time. There was a significant increase in thrombolysis and endovascular procedure leading to improved outcomes. Thrombolysis alone carried the highest mortality and stroke rate, with T+OPEN associated with the highest amputation and complications. Although thrombolysis is effective, 25% of patients required an open procedure suggesting that patient selection for thrombolysis first instead of open surgery continues to be a clinical challenge.
急性肢体缺血是一种常见的血管急症，需要立即进行干预。溶栓已广泛应用于急性肢体缺血；本研究的目的是分析急性肢体缺血溶栓治疗的当代趋势、疗效及并发症。
利用国际疾病分类第九版（ICD-9）从全国住院患者样本（2003 - 2013年）中识别患者。对接受急性肢体缺血急诊溶栓治疗的患者进行评估。分析三组情况：单纯溶栓、溶栓联合血管内介入治疗（T+ENDO）以及溶栓失败后需行开放手术（T+OPEN）。
估计共有162,240例急性肢体缺血患者：33,615例患者（20.7%）接受溶栓作为初始治疗。平均年龄为66.2±34.9岁，男性占54%。在研究期间，溶栓治疗的使用率显著增加（16.8% - 24.2%，p<0.0001）。最常见的组是溶栓联合血管内介入治疗（40.7%），其次是单纯溶栓（34.1%），以及T+OPEN组（25.2%）。溶栓联合血管内介入治疗随时间显著增加（31.6% - 47.8%，p<0.0001），而单纯溶栓和T+OPEN组显著下降（分别为39.6% - 28.6%和28.7% - 23.6%，p<0.0001）。总体死亡率为4.9%；与单纯溶栓和T - OPEN相比，溶栓联合血管内介入治疗的死亡率较低（3.2% vs. 6.1%和5.9%，p<0.0001）。总体卒中率为1.9%；单纯溶栓的卒中率最高（3.0%，p<0.0001），溶栓联合血管内介入治疗最低（1.2%），T+OPEN为1.7%。截肢率最高的是T+OPEN组（11.6%，p<0.001），相比之下溶栓联合血管内介入治疗为（5.1%），单纯溶栓为（5.3%）。T+OPEN组心脏（5.5%）、呼吸（7.3%）和肾脏并发症（12.5%）、肺炎（4.0%）以及筋膜切开术（16.8%）的发生率最高（均p<0.0001）。
溶栓仍然是急性肢体缺血的有效治疗方法，且随着时间推移使用率增加。溶栓联合血管内介入治疗显著增加，从而改善了疗效。单纯溶栓的死亡率和卒中率最高，T+OPEN与最高的截肢率和并发症相关。尽管溶栓有效，但25%的患者需要进行开放手术，这表明选择首先进行溶栓而非开放手术的患者仍然是一项临床挑战。
