Catheter-Directed Thrombolysis for Acute Limb Ischemia. Hwan Jun Jae MD Seoul National University Hospital Seoul, Korea
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1 Catheter-Directed Thrombolysis for Acute Limb Ischemia Hwan Jun Jae MD Seoul National University Hospital Seoul, Korea
2 Disclosure Speaker name: Hwan Jun Jae... I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) X I do not have any potential conflict of interest
3 Acute Limb Ischemia Acute limb ischemia(ali) Sudden decrease in limb perfusion that threatens limb viability Treatment options Endovascular therapy Catheter directed thrombolysis Aspiration thrombectomy Mechanical thrombectomy PTA/Stent Surgery 3
4 Rutherford classification of acute limb ischemia as a guideline for intervention Assess limb viability and potential for salvage. Stage I,2 : Endovscular Tx. Limbs in need of immediate revascularization are best treated with surgery. Creager MA et al. NEJM 2012
5 Endovascular Revascularization Goal Restore blood flow as rapidly as possible with thrombolytics, mechanical devices, or both. Contraindication Nonviable limb Bypass graft with suspected infection Contraindication to thrombolysis recent intracranial hemorrhage recent major surgery active bleeding vascular brain neoplasm 5
6 Catheter-Directed Thrombolysis Techniques Micropuncture under US guidance. single needle puncture is important to minimize hemorrhagic complication at the puncture site Angiography to assess the inflow and outflow arteries and the nature and length of thrombosis. Cross the occlusion with a guidewire. 6
7 Catheter-Directed Thrombolysis Techniques Multi side-hole catheter direct delivery of the thrombolytic agent into the thrombus Low dose continuous infusion of thrombolytics Urokinase Alteplase Reteplase Tenecteplase Concomitant heparin to prevent the formation of pericatheter thrombus Subtherapeutic heparin is infused at 500 units/h through the side arm of the sheath - Check aptt, fibrinogen level every 8 hours 7
8 Catheter-Directed Thrombolysis: Outcomes Complete or partial thrombus resolution with a satisfactory clinical result after catheter-based thrombolysis: 75-92% Earnshaw JJ et al. JVS 2004 Razavi MK et al. JVIR 2003 Major hemorrhage: 6-9% including ICH in less than 3% Van Den Berg JC et al. JVS
9 F/69 Sudden Rt. Lower leg pain (3DA) Embolic occlusion of Rt. ATA and peroneal a. Delayed and limited perfusion in the Rt. foot
10 Multi side-hole catheter Overnight UK infusion UK 50,000 IU/hour Heparin 500 IU/hour Guidewire passage
11 In the next day, after overnight UK infusion Revascularization of Rt. ATA and peroneal a.
12 F/80 Coldness and pain in the Rt lower leg, since 3DA 12
13 Rt CIA near complete occlusion Thromboembolism, Rt Popliteal a. & tibioperoneal trunk 13
14 For rapid improvement of Rt. L/E perfusion Balloon expandable stent 8mm x 37mm 14
15 Popliteal a Tibioperoneal trunk Overnight UK infusion: 60,000 unit / hour
16 In the next day, after overnight UK infusion 16
17 F/74 Color change of Lt. L/E since 1DA Large LA thrombus with atrial fibrillation s/p MVR DM ESRD Aspiration pneumonia 17
18 Extensive Thromboembolism, Both L/E 18
19 CFA CFA SFA DFA SFA Extensive Thromboembolism, Both L/E 19
20 Distal perfusion was not good. RT < LT 20
21 Aspiration Thrombectomy 6 F curved sheath Aspiration thrombectomy with 6F envoy catheter UK thrombolysis Overnight UK infusion UK 80,000 unit/hr via catheter heparin 500 unit/hr via sheath 21
22 ATA Aspiration thrombectomy 22
23 UK infusion: 60,000 unit/hr 23
24 Residual thrombus In the popliteal a. Aspiration thrombectomy 24
25 Summary In patients with ALI, the revascularization strategy should be determined by local resources and patient factors. Catheter-directed thrombolysis is effective for ALI patients with salvageable limb. Aspiration thrombectomy or stenting can be useful as adjunctive therapy to thrombolysis.
26 Thank you for your attention! Seoul, Korea 26
27 Catheter-Directed Thrombolysis for Acute Limb Ischemia Hwan Jun Jae MD Seoul National University Hospital Seoul, Korea
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