The practical implications of recent trials comparing thrombolytic therapy with surgery for lower extremity ischemia.

UNLABELLED: Catheter-based thrombolysis for lower extremity ischemia is a well-accepted and frequently used technique. Three prospective randomized trials, Rochester, STILE, and TOPAS, which compared thrombolytic therapy with traditional surgical revascularization for lower limb ischemia, have recently been published. METHODS: These three trials are reviewed with the intent of assessing the relative of value of thrombolytic therapy and surgical revascularization for lower limb ischemia. RESULTS: As an initial therapy, thrombolysis reduces the magnitude of any subsequent surgical procedure in approximately 40% to 60% of patients. However, recurrent ischemia is frequent, and the subsequent need for surgical revascularization is common for any native artery occlusion or chronic (> 14 days) bypass graft occlusion. In the patient with an acute bypass graft occlusion, the incidence of recurrent ischemia is less and limb salvage at 1 year is enhanced when treated initially by thrombolysis. A possible survival benefit after thrombolysis was suggested in the Rochester trial and in the STILE trial for diabetics with femoral-popliteal occlusions. CONCLUSIONS: Surgical revascularization remains the optimal therapy for most patients with lower limb ischemia. However, thrombolysis as an initial therapy does reduce the magnitude of any subsequent surgical procedure and provides improved limb salvage for patients with acute bypass graft occlusions.