Section of Vascular Surgery, Department of Surgery, University of Kentucky Medical Center, Lexington, KY, USA -
J Cardiovasc Surg (Torino). 2023 Aug;64(4):389-395. doi: 10.23736/S0021-9509.23.12685-1. Epub 2023 May 31.
The purpose of this study was to review early experience with catheter directed thrombolysis in the setting of chronic juxtarenal aortic occlusion as an initial therapy to allow safe definitive management with placement of aorto-iliac endografts.
A retrospective review was performed of all patients with a diagnosis of chronic juxtarenal aortic occlusion treated by the author with initial catheter directed thrombolysis. In all, six patients (five males and one female, average age of 57 years) treated between 2019 and 2022 met criteria. Total duration of symptoms prior to thrombolysis ranged from 2 to 54 months (average 23 months.) Four patients (67%) had progressed to tissue loss 2 to 5 months prior to the initiation of thrombolysis (average 3.25 months). Radiographic confirmation of aortic occlusion on preoperative imaging was noted 7 to 846 days prior to the initiation of thrombolysis (average 190 days).
Five of six patients (83%) had near complete resolution of aorto-iliac thrombus after 12 to 72 hours of thrombolysis to reveal underlying stenoses. The remaining patient's thrombolysis therapy was cut short at 48 hours due to behavioral issues, but had enough clearing of juxtarenal thrombus to undergo placement of aorto-iliac endografts. There were no perioperative deaths, myocardial infarctions, strokes or major complications. Temporary laboratory abnormalities (coagulopathy and/or increase in serum creatinine) were seen in four patients (67%), but all resolved by discharge without clinical sequelae. The primary patency is 100% at early follow-up of up to 15 months.
In the setting of chronic juxtarenal aortic occlusions, thrombolysis can provide effective clearing of the juxtarenal aortic thrombus to allow safe definitive therapy with aorto-iliac endografts. The approach deserves consideration in patients at high risk for open reconstruction.
本研究的目的是回顾慢性肾下主动脉闭塞患者中导管定向溶栓的早期经验，作为初始治疗方法，以安全地进行主动脉-髂内血管内移植物的确定性治疗。
对作者采用初始导管定向溶栓治疗的所有慢性肾下主动脉闭塞患者进行回顾性分析。共有 6 名患者（5 名男性，1 名女性，平均年龄 57 岁）符合条件，治疗时间为 2019 年至 2022 年。溶栓前症状持续时间从 2 个月至 54 个月不等（平均 23 个月）。4 名患者（67%）在溶栓前 2 至 5 个月出现组织坏死进展（平均 3.25 个月）。术前影像学检查证实主动脉闭塞，从开始溶栓前 7 天至 846 天不等（平均 190 天）。
6 名患者中的 5 名（83%）在溶栓后 12 至 72 小时内几乎完全清除了主髂动脉血栓，显示出潜在的狭窄。其余患者的溶栓治疗因行为问题在 48 小时内中断，但肾下血栓清除足够，可进行主动脉-髂内血管内移植物的植入。没有围手术期死亡、心肌梗死、中风或重大并发症。4 名患者（67%）出现暂时的实验室异常（凝血障碍和/或血清肌酐升高），但所有患者在出院时均得到解决，无临床后遗症。在早期随访中（长达 15 个月），主要通畅率为 100%。
在慢性肾下主动脉闭塞的情况下，溶栓可以有效清除肾下主动脉血栓，从而安全地进行主动脉-髂内血管内移植物的确定性治疗。该方法值得在高危开放重建患者中考虑。
