Therapeutic application of contrast-enhanced ultrasound and low-dose urokinase for thrombolysis in a porcine model of acute peripheral arterial occlusion.
BACKGROUND
The addition of local ultrasound (US) with a contrast agent to standard intra-arterial thrombolysis can accelerate the thrombolytic treatment of stroke and myocardial infarction. The contrast agent consists of microsized gas-filled bubbles that collapse when exposed to US, causing destabilization of the clot and making the clot surface more susceptible to fibrinolytics. In this study, we investigated the effect of additional US and microbubbles on standard low-dose intra-arterial thrombolysis in a porcine model of extensive peripheral arterial occlusion.


METHODS
Extensive arterial thrombosis was induced in 10 pigs in the 4-cm external iliac artery by clamping and injection of 100 IU of bovine thrombin. A transcutaneous laser Doppler flow probe and an ultrasonic perivascular flow probe assessed microcirculation and arterial flow respectively. The urokinase-only (UK) group (n = 4) received standard thrombolytic therapy: intra-arterial bolus injection of 500,000 IU, followed by a continuous low-dose urokinase (50,000 IU/h) infusion through an intra-arterial catheter and local intermittent application of US, 1 second on, 5 seconds off, to visualize vascular patency during the first hour of therapy and to ensure microbubbles replenished the proximal portion of the occluded artery. The urokinase plus microbubbles (UK+) group (n = 6) received the same urokinase therapy with a concomitant intravenous infusion of microbubbles and local intermittent application of US. The contrast infusion protocol consisted of a bolus of two vials of 5 mL in the first 15 minutes and then three times 5 mL slowly hand-injected continuously during the next 45 min. After 3 hours of therapy, the animals were euthanized, and thrombi were harvested and weighed. All organs were cut in thin slices and macroscopically inspected for potential (hemorrhagic) adverse events, and tissue samples were taken.


RESULTS
Median thrombus weights were 1.1 g (range, 0.8-1.3 g) in the UK+ group vs 1.6 g (range, 1.3-1.9 g) in the UK group (P = .01). Arterial blood flow increased in four of six pigs in the UK+ group by a mean 61% vs in one of four in the UK group, with 1%. Microcirculation and lower limb arterial pressure levels improved after the start of therapy in the UK+ group, contrary to a trend of decline in the UK group. No signs of bleeding complications were observed in either group.


CONCLUSIONS
In this experimental pilot study, the addition of contrast-enhanced US accelerated the thrombolytic effect of low-dose intra-arterial thrombolysis in peripheral arterial occlusions. Further clinical studies are warranted.
Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands; Department of Physiology, VU University Medical Center, Amsterdam, The Netherlands.
Harm P
HP
Ebben
Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
Johanna H
JH
Nederhoed
Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands.
Jeroen
J
Slikkerveer
Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands.
Otto
O
Kamp
Department of Physiology, VU University Medical Center, Amsterdam, The Netherlands.
Geert W J M
GW
Tangelder
Department of Physiology, VU University Medical Center, Amsterdam, The Netherlands.
René J P
RJ
Musters
Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
Willem
W
Wisselink
Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands; Department of Physiology, VU University Medical Center, Amsterdam, The Netherlands. Electronic address: k.yeung@vumc.nl.
Kak K
KK
Yeung
D000208:Acute Disease; D000818:Animals; D001157:Arterial Occlusive Diseases / Q000628:therapy*; D003287:Contrast Media; D004195:Disease Models, Animal; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005740:Gases; D058729:Peripheral Arterial Disease / Q000628:therapy*; D010865:Pilot Projects; D013552:Swine; D015912:Thrombolytic Therapy; D014463:Ultrasonography; D014568:Urokinase-Type Plasminogen Activator / Q000627:therapeutic use*
D003287:Contrast Media; D005343:Fibrinolytic Agents; D005740:Gases; D014568:Urokinase-Type Plasminogen Activator