Sicard G A, Schier J J, Totty W G, Gilula L A, Walker W B, Etheredge E E, Anderson C B
J Vasc Surg. 1985 Jan;2(1):65-78.
To evaluate the role of selective intra-arterial low-dose thrombolytic therapy (SILDT) as an alternative to the surgical management of acute arterial occlusion, the hospital records of 40 patients who underwent 43 SILDT treatments with either streptokinase (36) or urokinase (7) between December 1979 and March 1984 were reviewed. Twenty-eight patients underwent 30 treatments (group 1) for native arterial occlusion and 12 patients underwent 13 treatments (group 2) for prosthetic or autogenous graft occlusions. Therapy was deemed successful if subsequent surgical therapy was obviated. In group 1, SILDT was successful in 13 of 28 (45%) patients with 12 of 25 lower extremity occlusions and one of three upper extremity occlusions. Successful lysis in the native artery occlusion group fell into three categories: five patients were successfully treated for arterial thrombosis complicating percutaneous transluminal angioplasty (PTA); four patients required PTA after complete lysis revealed an underlying arterial stenosis; and only three required no further therapy after SILDT. SILDT failed in all three patients with the aortoiliac occlusions. Eleven patients with femoral artery occlusions and unsuccessful SILDT required six bypass procedures, three amputations, one embolectomy, and one PTA. In group 2 only 3 of 14 treatments (21%) were successful. Bypass revision was not possible in 11 patients and all required amputation. Systemic fibrinolysis was seen in 20 (59%) of 34 patients with available data. Neither fibrinogen levels nor fibrin degradation products predicted the occurrence of complications. Minor complications occurred in 18 of 43 (43%) treatments; small hematomas at the catheter entry site were most common. Minor complications occurred in 20 of 43 treatments (44%) and included severe local hemorrhage (four), distant bleeding (three), pulmonary embolism (four), myocardial infarction (three), unmasking of an aortoduodenal fistula (one), and clot migration requiring emergency thrombectomy (four). SILDT is most effective in acute arterial thrombosis complicating arteriography or percutaneous angioplasty. It may play a role in the patient in whom thrombolysis can reveal an underlying stenosis amenable to percutaneous angioplasty. This experience shows SILDT to be of limited value in the management of prosthetic autogenous graft occlusions. Finally, thrombolytic therapy is associated with significant morbidity and mortality rates and requires cautious monitoring to detect arterial thrombus migration, worsening tissue ischemia, venous thromboembolism, intracerebral hemorrhage, and local or systemic bleeding.
为评估选择性动脉内低剂量溶栓疗法（SILDT）作为急性动脉闭塞手术治疗替代方法的作用，我们回顾了1979年12月至1984年3月期间40例接受了43次SILDT治疗的患者的医院记录，这些患者使用链激酶（36例）或尿激酶（7例）进行治疗。28例患者接受了30次治疗（第1组）用于原发性动脉闭塞，12例患者接受了13次治疗（第2组）用于人工血管或自体移植物闭塞。如果避免了后续的手术治疗，则认为治疗成功。在第1组中，28例患者中有13例（45%）治疗成功，其中25例下肢闭塞患者中有12例成功，3例上肢闭塞患者中有1例成功。原发性动脉闭塞组的成功溶栓分为三类：5例患者成功治疗了经皮腔内血管成形术（PTA）并发的动脉血栓形成；4例患者在完全溶栓后发现潜在动脉狭窄，需要进行PTA；只有3例患者在SILDT后无需进一步治疗。所有3例主动脉髂动脉闭塞患者的SILDT均失败。11例股动脉闭塞且SILDT失败的患者需要进行6次搭桥手术、3次截肢、1次栓子切除术和1次PTA。在第2组中，14次治疗中只有3次（21%）成功。11例患者无法进行搭桥修复，均需要截肢。在有可用数据的34例患者中，20例（59%）出现了全身性纤溶。纤维蛋白原水平和纤维蛋白降解产物均不能预测并发症的发生。43次治疗中有18次（43%）出现轻微并发症；导管穿刺部位小血肿最为常见。43次治疗中有20次（44%）出现轻微并发症，包括严重局部出血（4例）、远处出血（3例）、肺栓塞（4例）、心肌梗死（3例）、主动脉十二指肠瘘暴露（1例）以及血栓迁移需要紧急血栓切除术（4例）。SILDT在动脉造影或经皮血管成形术并发的急性动脉血栓形成中最有效。它可能在溶栓能发现适合经皮血管成形术的潜在狭窄的患者中发挥作用。该经验表明SILDT在人工血管自体移植物闭塞的治疗中价值有限。最后，溶栓治疗与显著的发病率和死亡率相关，需要谨慎监测以检测动脉血栓迁移、组织缺血恶化、静脉血栓栓塞、脑出血以及局部或全身出血。
