Percutaneous intraarterial thrombolysis in the treatment of thrombosis of lower extremity arterial reconstructions

Abstract Vascular grafts may be salvaged with thrombolytic therapy after acute occlusion as an alternative to balloon catheter thrombectomy. From October 1987 to May 1990, 15 arterial bypasses to the lower extremity (infrainguinal saphenous vein [ n = 7] or expanded polytetrafluoroethylene [ n = 6], and Dacron aortofemoral bifurcation graft limbs [ n = 2]) were treated for 30 occlusions with intraarterial urokinase (390,000 IU to 5,808,000 IU) infused from 3 to 40 hours. The origins of 15 grafts occlusions were morphologic defects (intimal hyperplasia with anastomotic or conduit stricture), pseudoaneurysm, or progression of disease distal to the graft. Two occlusions were attributed to coagulation disorders. A cause could not be identified for 13 occlusions. Patency was initially restored to all grafts with use of thrombolytic therapy, however, adjunctive surgical thrombectomy to remove persistent thrombus from the graft or outflow vessels was required after six thrombolytic infusions. One graft in the series could not be salvaged leading to below-knee amputation. Graft defects were corrected by balloon angioplasty ( n = 7) or surgical revision of the conduit ( n = 8). Five significant hemorrhagic complications occurred from the catheter insertion site requiring four emergent surgical procedures and resulting in the death of a fifth patient from a myocardial infarction. This technique allows chemical thrombectomy of branch arteries distal to the graft and inaccessible to a balloon embolectomy catheter, and permits diagnosis of abnormal graft morphology that may be the cause of the graft occlusion. Graft reocclusion can be expected if technical defects in the arterial reconstruction are not revised or hypercoagulable states are not treated. (J VASC SURG 1991;13:646-51.)