Systemische und regionale Fibrinolyse peripherer arterieller Verschlüsse

Zusammenfassung

Die fibrinolytische Therapie ist eine anerkannte risikoarme Methode zur Rekanalisation akuter peripherer arterieller Verschlüsse. Sie sollte bei Patienten mit Verschlüssen nativer Arterien oder Bypassgefäßen als regionale intrathrombische Lyse erfolgen, wenn keine vollständige Ischämie mit sensorischen und/oder motorischen Ausfällen zu sofortigen operativen Maßnahmen zwingt. Durch die mit der fibrinolytischen Therapie verbundene Angiographie und der schrittweisen Thrombusreduktion wird die Verschlussstrecke verkürzt und die Verschlussursache demaskiert, so dass anschließend eine interventionelle Behandlung oder eine kleinere operative Rekonstruktion elektiv durchgeführt werden kann. So zeigten drei prospektive, randomisierte Studien, dass die fibrinolytische Therapie im Vergleich zur Operation den Anteil der erhaltenen Extremitäten nach 6 bis 12 Monaten erhöht und die Mortalität reduziert. Der Übergang eines akuten Verschlusses in einen chronischen ist fließend, so kann die fibrinolytische Therapie auch bei Verschlüssen, die älter als sechs Monate sind, erfolgreich eingesetzt werden.

Summary

Catheter-based treatment of intraarterial thrombus can be used successfully as a treatment to recanalize acutely occluded native arteries or bypasses associated with acute limb ischaemia. It should be used if the ischaemia not already caused sensory and/or paralytic disorders that require urgent open surgical treatment. Advantages of pursuing immediate angiography in patients with acute limb ischaemia include delineation of the limb arterial anatomy with visualization of both inflow and runoff vessels and clearing intraarterial thrombus from the distal runoff vessels. Thus, final treatment can be planned electively as an intervention of open surgery. A metaanalysis comparing lysis and surgery that included three randomized trials and case series concluded that lysis improved 6 to 12 months limb salvage and reduced mortality compared with surgery. The transformation of an acute arterial occlusion into a chronic one is not clearly defined. Thus, fibrinolytic therapy can be successfully used for occlusions supposed to be older than six months.

Schlüsselwörter

Fibrinolyse - akute Ischämie - Urokinase - Gewebeplasminogenaktivator - periphere arterielle Verschlusskrankheit

Keywords

Thrombolysis - acute ischaemia - urokinasis - tissue plasminogenactivator - peripheral arterial disease

• Literatur

• 1 Auster M, Kadir S, Mitchell SE. et al. Iliac artery occlusion: management with intrathrombus streptokinase infusion and angioplasty. Radiology 1984; 153: 385-8.
• 2 Bertuch H, Pilger E, Stark G. et al. Selektive Fibrinolyse mit rekombinaten Gewebsplasminogenaktivator in Kombination mit Prostaglandin E1. VASA 1987; 27 (Suppl. 22) 240.
• 3 Braithwaite BD, Quinones-Baldrich WJ. Lower limb intraarterial thrombolysis as an adjunct to the management of arterial and graft occlusions. World J Surg 1996; 20: 649-54.
• 4 Breda van A, Katzen BT, Deutsch AS. Urokinase versus streptokinase in local thrombolysis. Radiology 1987; 165: 109-11.
• 5 Burkart DJ, Borsa JJ, Anthony JP. et al. Thrombolysis of acute peripheral arterial and venous occlusions with tenecteplase and eptifibatide: a pilot study. J Vasc Interv Radiol 2003; 14: 729-33.
• 6 Davidian MM, Powell A, Benenati JF. et al. Initial results of reteplase in the treatment of acute lower extremity arterial occlusions. J Vasc Interv Radiol 2000; 11: 289-94.
• 7 Diffin DC, Kandarpa K. Assessment of peripheral intraarterial thrombolysis versus surgical revascularization in acute lowerlimb ischemia: a review of limb-salvage and mortality statistics. J Vasc Interv Radiol 1996; 7: 57-63.
• 8 Drescher P, Crain MR, Rilling WS. Initial experience with the combination of reteplase and abciximab for thrombolytic therapy in peripheral arterial occlusive disease: a pilot study. J Vasc Interv Radiol 2002; 13: 37-43.
• 9 Duda SH, Tepe G, Luz O. et al. Peripheral artery occlusion: treatment with abciximab plus urokinase versus with urokinase alone--a randomized pilot trial (the PROMPT Study). Platelet Receptor Antibodies in Order to Manage Peripheral Artery Thrombosis. Radiology 2001; 221: 689-96.
• 10 Earnshaw JJ, Westby JC, Gregsont RHS. et al. Local thrombolytic therapy of acute peripheral arterial ischemia with tissue plasminogen activator: a dose-ranging study. Br J Surg 1988; 75: 1196-200.
• 11 Hess H, Ingrisch H, Mietaschk A. et al. Local lowdose thrombolytic therapy of peripheral arterial occlusions. N Engl J Med 1982; 307: 1627-30.
• 12 Hess H, Mietaschk A, Brückl R. Peripheral arterial occlusions: A 6-year experience with local lowdose thrombolytic therapy. Radiology 1987; 163: 753-8.
• 13 Hess H, Mietaschk A, von Bilderling P. et al. Peripheral arterial occlusions: Local low-dose thrombolytic therapy with recombinant tissue-type plasminogen activator. Eur J Vasc Endovasc Surg 1996; 12: 97-104.
• 14 Hirsch AT, Haskal ZJ, Hertzer NR. ACC/AHA guidelines for the management of patients with peripheral arterial disease. 2006 www.acc.org.
• 15 Jung EM, Lutz R, Rupp N. Niedrigdosierte Thrombolyse mit rt-PA bei langstreckigen peripheren arteriellen Verschlüssen. Interv Radiol 2000; 172: 1028-34.
• 16 Rocha-Singh KJ, Trokey J. Combined glycoprotein IIb/IIIa receptor inhibition and low-dose fibrinolysis for peripheral arterial thrombosis. Cathet Cardiovasc Intervent 2002; 55: 457-60.
• 17 Kröger K, Buss C, Rudofsky G. Retrospective analysis of rt-pa thrombolysis combined with PGE1in patients with peripheral arterial occlusions. Angiology 2000; 51: 377-84.
• 18 Lammer J, Pilger E, Justich E. et al. Fibrinolysis in chronic arteriosclerotic occlusions: Intrathrombotic injections of streptokinase. Radiology 1985; 157: 45-50.
• 19 Mahler F, Schneider E, Hess H. Steering Committee, Study on Local Thrombolysis.. Recombinant tissue plasminogen activator versus urokinase for local thrombolysis of femoropopliteal occlusions: a prospective, randomized multicenter trial. J Endovasc Ther 2001; 8: 638-47.
• 20 Meyerovitz MF, Goldhaber SZ, Reagan K. et al. Recombinant tissue-type plasminogen activator versus urokinase in peripheral arterial and graft occlusions: A randomised Trial. Radiology 1990; 175: 75-8.
• 21 Ouriel K, Veith FJ, Sasahara AA. A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. N Engl J Med 1998; 338: 1105-11.
• 22 Ouriel K, Shortell CK, DeWeese JA. et al. A comparison of thrombolytic therapy with operative revascularization in the initial treatment of acute peripheral arterial ischemia. J Vasc Surg 1994; 19: 1021-30.
• 23 Razavi MK, Wong H, Kee ST. et al. Initial clinical results of tenecteplase (TNK) in catheter-directed thrombolytic therapy. J EndovascTher 2002; 9: 593-8.
• 24 Schweizer J, Altmann E, Stößlein F. et al. Comparison of tissue plasminogen activator and urokinase in the local infiltration thrombolysis of peripheral arterial occlusions. Eur J Radiol 1996; 22: 129-32.
• 25 Semba CP, Murphy TP, Bakal CW. et al. Thrombolytic therapy with use of alteplase (rt-PA) in peripheral arteriel oclusive disease: review of the clinical literature. The advisory panel. J Vasc Interv Radiol 2000; 11: 149-61.
• 26 Sullivan KL, Gardiner GA, Shapiro MJ. et al. Acceleration of thrombolysis with a high-dose transthrombus bolus technique. Radiology 1989; 173: 805-8.
• 27 Tepe Tepe G, Luz O, Hahn U. et al. Pulsed spray lysis with reteplase in peripheral arterial occlusions--technique and initial results. Röfo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2000; 172: 780-4.
• 28 Terres W, Beythien C, Kupper W. et al. Effects of aspirin and prostaglandin E1 on in vitro thrombolysis with urokinase. Circulation 1989; 79: 1309-14.
• 29 Valji K, Roberts AC, Davis GB. et al. Pulsed-spray thrombolysis of arterial and bypass graft occlusions. Am J Roentgenol 1991; 156: 617-21.
• 30 Verstraete M. Thrombolysis in the management of lower limb peripheral arterial occlusion – A consensus document. Am J Cardiol 1998; 81: 207-18.
• 31 Weaver FA, Comerota AJ, Youngblood M. et al. and the STILE Investigators: Surgical revascularization versus thrombolysis for nonembolic lower extremity native artery occlusions: Results of a prospective randomised trial. J Vasc Surg 1996; 24: 513-23.
• 32 Wholey MH, Maynar MA, Wholey MH. et al. Comparison of thrombolytic therapy of lower-extremity acute, sub-acute and chronic arterial occlusions. Cathet Cardiovasc Diagn 1998; 44: 159-69.