Intra-arterial streptokinase therapy to relieve acute limb ischemia.

One hundred two patients with acute lower limb ischemia were treated with intra-arterial streptokinase. Thirty-seven patients had occluded vascular grafts and sixty-five had had no previous vascular surgery. Eighty-six limbs were acutely threatened. Intra-arterial streptokinase was given as an initial loading dose with a lower maintenance dose given afterward. The mean duration of therapy was 59 hours and hematologic monitoring was meticulous. Indications for intra-arterial streptokinase therapy were contraindication to surgery, anticipation of technically difficult surgery, and multiple occlusions that required separate surgical approaches. Seventy-two legs were saved (71%) and 30 amputated. Morbidity was low and only 1 of the 11 deaths was attributable to streptokinase. No leg was lost that would otherwise have been saved by straightforward surgery and no leg was lost that had not been previously threatened. In 46 patients for whom emergency femorotibial bypass would have been necessary, 35 legs (76%) were saved. Forty-three patients had vascular reconstruction immediately after streptokinase therapy was stopped, to bypass occlusive lesions that had been demonstrated by the thrombolytic therapy in 28 patients, and because streptokinase had produced no response in 15 patients. The advantages of intra-arterial streptokinase in the management of the acutely ischemic leg are that the leg may be saved without surgery, that surgery is not precluded, that the patient can be made as fit as possible for surgery during the streptokinase infusion, and that streptokinase can facilitate surgery by delineating underlying vascular pathologic conditions and clearing distal runoff vessels.