title: Catheter-Directed Intraarterial Thrombolysis as Part of a Multidisciplinary Management Protocol of Frostbite Injury.
abstract: OBJECTIVE
  To evaluate intraarterial catheter-directed thrombolysis for prediction and prevention of delayed surgical amputation as part of multidisciplinary management of frostbite injury.
  
  
  METHODS
  A retrospective review was performed of 13 patients (11 men, 2 women; median age, 33.4 y; range, 8-62 y) at risk of tissue loss secondary to frostbite injury and treated with catheter-directed tissue plasminogen activator (t-PA) thrombolysis. Amputation data were assessed on follow-up (mean, 23 mo; range, 9-83 mo). Angiographic findings were classified into complete, partial, and no angiographic response and assessed for association with follow-up amputation rates. Correlation between amputation outcome and duration of cold exposure (mean, 23 h; range, 5-96 h), time between exposure and rewarming therapy (mean, 25.5 h; range, 7-95 h), and time between exposure and t-PA thrombolysis (mean, 32 h; range, 12-96 h) was assessed. Complications were recorded.
  
  
  RESULTS
  Of 127 digits at risk on baseline angiography that were treated with catheter-directed thrombolysis, complete recovery was seen in 106 (83.4%). Total mean t-PA dose per extremity was 27.5 mg (range, 12-48 mg) over a mean period of 34 hours (range, 12-72 h). Patients with complete angiographic response (8 patients; 79.5% of digits) did not require amputations; 4 of 5 patients (80%) with partial angiographic response (20.5% of digits) underwent amputation (P = .007). There was no significant correlation between amputation rates and duration of cold exposure (P = .9), time to rewarming therapy (P = .88), and time to thrombolysis (P = .56). Femoral access site bleeding in 2 patients was managed conservatively. One patient underwent surgical exploration for brachial artery hematoma.
  
  
  CONCLUSIONS
  Intraarterial catheter-directed thrombolysis should be included in initial management of frostbite injury, as it may prevent delayed amputations. The degree of angiographic response to thrombolysis can potentially predict amputation outcomes.
authors.affiliation: Division of Vascular and Interventional Radiology, Department of Radiology, University Hospitals and Case Western Reserve University School of Medicine, 11100 Euclid Avenue, BSH 5056, Cleveland, OH 44106. Electronic address: siddharth.tavri@gmail.com.
authors.forename: Sidhartha
authors.initials: S
authors.lastname: Tavri
authors.affiliation: Division of Interventional Radiology, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
authors.forename: Suvranu
authors.initials: S
authors.lastname: Ganguli
authors.affiliation: Division of Interventional Radiology, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
authors.forename: Roy G
authors.initials: RG
authors.lastname: Bryan
authors.affiliation: Department of Radiology, and Division of Burns, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Goverman
authors.affiliation: Division of Interventional Radiology, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
authors.forename: Raymond
authors.initials: R
authors.lastname: Liu
authors.affiliation: Division of Interventional Radiology, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
authors.forename: Zubin
authors.initials: Z
authors.lastname: Irani
authors.affiliation: Division of Interventional Radiology, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
authors.forename: T Gregory
authors.initials: TG
authors.lastname: Walker
mesh_terms: D000293:Adolescent; D000328:Adult; D000671:Amputation, Surgical; D015901:Angiography, Digital Subtraction; D002406:Catheterization, Peripheral / Q000009:adverse effects; D002648:Child; D003131:Combined Modality Therapy; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D005385:Fingers / Q000098:blood supply*; D005627:Frostbite / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D007261:Infusions, Intra-Arterial; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D015641:Radiography, Interventional; D012189:Retrospective Studies; D017694:Rewarming; D012307:Risk Factors; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000379:methods*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects; D014034:Toes / Q000098:blood supply*; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator