Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands.
Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands.
Eur J Vasc Endovasc Surg. 2019 Oct;58(4):564-569. doi: 10.1016/j.ejvs.2019.02.028. Epub 2019 Aug 3.
Catheter directed thrombolysis (CDT) for acute arterial occlusions of the lower extremities is associated with a risk of major bleeding complications. Strict monitoring of vital functions is advised for timely adjustment or discontinuation of thrombolytic treatment. Nevertheless, current evidence on the optimal application of CDT and use of monitoring during CDT is limited. In this study the different standard operating procedures (SOPs) for CDT in Dutch hospitals were compared against a national guideline in a nationwide analysis.
SOPs, landmark studies, and national and international guidelines for CDT for acute lower extremity arterial occlusions were compared. The protocols of 34 Dutch medical centres where CDT is performed were assessed. Parameters included contraindications to CDT, co-administration of heparin, thrombolytic agent administration, angiographic control, and patient monitoring.
Thirty-four SOPs were included, covering 94% of medical centres performing CDT in the Netherlands. None of the SOPs had identical contraindications and a strong divergence in relative and absolute grading was found. Heparin and urokinase dosages differed by a factor of five. In 18% of the SOPs heparin co-administration was not mentioned. Angiographic control varied between once every 6 h to once every 24 h. In 76% of the SOPs plasma fibrinogen levels were used for CDT dose adjustments. However, plasma fibrinogen level threshold values for treatment adjustments varied between 2.0 g/L and 0.5 g/L.
The SOPs for CDT for acute arterial occlusions of the lower extremities differ greatly on five major operating aspects among medical centres in the Netherlands. None of the SOPs exactly conforms to current national or international guidelines. This study provides direction on how to increase homogeneity in guideline recommendations and to improve guideline adherence in CDT.
下肢急性动脉闭塞的导管定向溶栓（CDT）有发生大出血并发症的风险。建议对生命体征进行严格监测，以便及时调整或停止溶栓治疗。然而，目前关于 CDT 的最佳应用和 CDT 期间监测的证据有限。在这项研究中，通过全国性分析，将荷兰各家医院的 CDT 不同标准操作流程（SOP）与国家指南进行了比较。
比较了 CDT 急性下肢动脉闭塞的 SOP、标志性研究以及国家和国际指南。评估了 34 家荷兰医疗中心进行 CDT 的方案。纳入的参数包括 CDT 的禁忌证、肝素的联合使用、溶栓药物的使用、血管造影控制以及患者监测。
纳入了 34 项 SOP，涵盖了荷兰 94%行 CDT 的医疗中心。没有一项 SOP 的禁忌证完全相同，相对和绝对分级差异很大。肝素和尿激酶的剂量相差五倍。在 18%的 SOP 中未提及肝素联合使用。血管造影控制在每 6 小时和每 24 小时之间不等。在 76%的 SOP 中，血浆纤维蛋白原水平用于 CDT 剂量调整。然而，用于治疗调整的血浆纤维蛋白原水平阈值在 2.0g/L 和 0.5g/L 之间变化。
荷兰各家医疗中心的 CDT 治疗急性动脉闭塞的 SOP 在五个主要操作方面差异很大。没有一项 SOP 完全符合当前的国家或国际指南。本研究为如何增加指南推荐的一致性以及提高 CDT 对指南的依从性提供了方向。
