Thrombolysis for native arterial occlusions of the lower extremities: clinical outcome and cost.
BACKGROUND
Intra-arterial thrombolysis is commonly used as the initial treatment of acute or subacute lower extremity ischemia.


METHODS
To evaluate the efficacy and cost of thrombolysis, we retrospectively analyzed 100 consecutive cases (87 patients) in which intra-arterial lysis (urokinase) was used as the initial treatment for native arterial lower extremity occlusive disease. The mean age of patients was 67 years, 57% of the patients were male, and preexisting peripheral vascular disease was present in 74%. Presenting symptoms were limb-threatening ischemia (53%) and claudication (47%). Acute symptoms (< 2 weeks' duration) were present in 48%.


RESULTS
The 30-day morbidity rate was 31%, and four patients died. Complications were significant bleeding (23%), ischemic stroke (1%), and renal failure with (2%) and without (2%) dialysis. Concomitant angioplasty was performed in 63%. Complete or significant lysis as demonstrated with angiography was achieved in 75% of iliac, 58% of femoropopliteal, and 41% of crural vessels (P <.001). Within 30 days of lysis, 9% of patients underwent major amputation and 20% surgical revascularization (in 3 patients the extent of revascularization was lessened by the lytic therapy). Amputation-free survival was 83% and 75% at 6 months and 2 years, respectively. Relief of ischemia (defined as relief of claudication or limb salvage without major surgical intervention) was achieved in only 70% and 43% of patients at 30 days and 2 years, respectively (Kaplan-Meier analysis; mean follow-up, 31 months). Patients with aortoiliac disease had significantly better outcomes than those with infrainguinal disease (P =.03). Duration or type of presenting symptoms did not predict outcome. The cost of the initial hospitalization per patient for thrombolysis was $18,490.


CONCLUSIONS
Thrombolysis can be as or more costly than surgery and is associated with a suboptimal outcome in a significant number of patients. These data lead us to caution against a uniform policy of initial thrombolysis for patients who present with lower extremity ischemia.
Korn
P
P
Divisions of Vascular Surgery and Interventional Radiology, New York Presbyterian Hospital, Weill Medical College of Cornell University, NY 10021, USA.
Khilnani
N M
NM
Fellers
J C
JC
Lee
T Y
TY
Winchester
P A
PA
Bush
H L
HL
Kent
K C
KC
D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D000792:Angiography; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000401:mortality; D003362:Cost-Benefit Analysis; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000187:drug effects; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D017721:Hospital Costs; D006801:Humans; D007383:Intermittent Claudication; D007511:Ischemia / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000401:mortality; D007866:Leg / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D016491:Peripheral Vascular Diseases / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000401:mortality; D011237:Predictive Value of Tests; D011336:Probability; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015996:Survival Rate; D015912:Thrombolytic Therapy / Q000191:economics* / Q000379:methods*; D016896:Treatment Outcome; D014568:Urokinase-Type Plasminogen Activator / Q000008:administration & dosage*
D005343:Fibrinolytic Agents; D014568:Urokinase-Type Plasminogen Activator