Thrombolytic therapy for acute arterial occlusion.

The standard treatment of peripheral arterial occlusion has been operative, employing embolectomy, thrombectomy, or bypass grafting to restore blood flow to the compromised extremity. Intra-arterial thrombolysis has been advocated as an initial intervention designed to unmask the anatomic lesion responsible for the occlusive event, with a directed or endovascular modality thereafter. Four thrombolytic agents are in clinical use: streptokinase, urokinase, recombinant tissue plasminogen activator, and acylated plasminogen streptokinase activator complex. The agents differ with respect to efficacy of thrombolysis, fibrin specificity, and cost. At present, urokinase is the most widely used. Recent randomized clinical trials suggest a benefit of thrombolytic therapy in the initial management of acute peripheral arterial occlusion, with improved patient survival and similar amputation rates compared with immediate open intervention. Each modality has its place in specific patient subcategories; the determination of which patients are best served by a specific modality awaits the results of large clinical trials.