Surgery versus thrombolysis for initial management of acute limb ischaemia.

BACKGROUND: Both peripheral arterial thrombolysis and surgery can be used in the management of peripheral arterial ischaemia. Much is known about the indications, risks, and benefits of thrombolysis. However, whether thrombolysis works better than surgery for initial management of acute limb ischaemia remains unknown. This is the second update of the review first published in 2002. OBJECTIVES: To determine whether thrombolysis or surgery is the more effective technique in the initial management of acute limb ischaemia due to thromboembolism. SEARCH METHODS: For this update, the Cochrane Vascular Information Specialist (CIS) searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE Ovid, Embase Ovid, CINAHL, AMED, and clinical trials registries up to 7 May 2018. SELECTION CRITERIA: All randomised controlled studies comparing thrombolysis and surgery for initial treatment of acute limb ischaemia. DATA COLLECTION AND ANALYSIS: We independently assessed trial quality and extracted data. Agreement was reached by consensus. We performed analyses using odds ratios (ORs) and 95% confidence intervals (CIs). MAIN RESULTS: We identified no new studies for this update. We included five trials with a total of 1292 participants; agents used for thrombolysis were recombinant tissue plasminogen activator and urokinase. Trials were generally of moderate methodological quality. The quality of evidence according to GRADE was generally low owing to risk of bias (lack of blinding), imprecision in estimates, and heterogeneity.Trial results showed no clear differences in limb salvage, amputation, or death at 30 days (odds ratio (OR) 1.02, 95% confidence interval (CI) 0.41 to 2.55, 4 studies, 636 participants; OR 0.97, 95% CI 0.51 to 1.85, 3 studies, 616 participants; OR 0.59, 95% CI 0.31 to 1.14, 4 studies, 636 participants, respectively), and we rated the evidence as low, low, and moderate quality, respectively. Trial results show no clear differences for any of the three outcomes at six months or one year between initial surgery and initial thrombolysis. A single study evaluated vessel patency, so no overall association could be determined (OR 0.46, 95% CI 0.08 to 2.76, 20 participants; very low-quality evidence). Evidence of increased risk of major haemorrhage (OR 3.22, 95% CI 1.79 to 5.78, 4 studies, 1070 participants; low-quality evidence) and distal embolisation (OR 31.68, 95% CI 6.23 to 161.07, 3 studies, 678 participants; very low-quality evidence) was associated with thrombolysis treatment at 30 days, and there was no clear difference in stroke (OR 5.33, 95% CI 0.95 to 30.11, 5 studies, 1180 participants; low-quality evidence). Participants treated by initial thrombolysis had a greater reduction in the level of intervention required, compared with a pre-intervention prediction, at 30 days (OR 9.06, 95% CI 4.95 to 16.56, 2 studies, 502 participants). None of the included studies evaluated time to thrombolysis as an outcome. AUTHORS' CONCLUSIONS: There is currently no evidence in favour of either initial thrombolysis or initial surgery as the preferred option in terms of limb salvage, amputation, or death at 30 days, six months, or one year. Low-quality evidence suggests that thrombolysis may be associated with higher risk of haemorrhagic complications and ongoing limb ischaemia (distal embolisation). The higher risk of complications must be balanced against risks of surgery in each individual case. Trial results show no statistical difference in stroke, but the confidence interval is very wide, making it difficult to interpret whether this finding is clinically important. We used GRADE criteria to assess the quality of the evidence as generally low. We downgraded quality owing to risk of bias, imprecision, and heterogeneity between included studies.

Fibrinolytic agents for peripheral arterial occlusion.

BACKGROUND: Peripheral arterial thrombolysis is used in the management of peripheral arterial ischaemia. Streptokinase was originally used but safety concerns led to a search for other agents. Urokinase and recombinant tissue plasminogen activator (rt-PA) have increasingly become established as first line agents for peripheral arterial thrombolysis. Potential advantages of these agents include improved safety, greater efficacy and a more rapid response. Recently drugs such as pro-urokinase, recombinant staphylokinase and alfimperase have been introduced. This is an update of a review first published in 2010. OBJECTIVES: To determine which fibrinolytic agents are most effective in peripheral arterial ischaemia. SEARCH METHODS: For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched March 2013) and CENTRAL (2013, Issue 3) for randomised controlled trials (RCTs) comparing fibrinolytic agents to treat peripheral arterial ischaemia. SELECTION CRITERIA: RCTs comparing fibrinolytic agents to treat peripheral arterial occlusion. DATA COLLECTION AND ANALYSIS: Data were analysed for the outcomes vessel patency, time to lysis, limb salvage, amputation, death, complications including major haemorrhage, stroke, and distal embolization. MAIN RESULTS: Five RCTs involving a total of 687 participants with a range of clinical indications were included. No new studies were included in this update. In one three-pronged study, vessel patency was greater with intra-arterial recombinant tissue plasminogen activator (rt-PA) than with intra-arterial streptokinase (P < 0.04) or intravenous rt-PA (P < 0.01). In participants with peripheral arterial occlusion there was no statistically significant difference in limb salvage at 30 days with either urokinase or rt-PA, though this may reflect the small numbers in the studies. Incidences of haemorrhagic complications varied with fibrinolytic regime but there was no statistically significant difference between intra-arterial urokinase and intra-arterial rt-PA. In the three-pronged study intravenous rt-PA and intra-arterial streptokinase were associated with a significantly higher risk of haemorrhagic complications than with intra-arterial rt-PA (P < 0.05). AUTHORS' CONCLUSIONS: There is some evidence to suggest that intra-arterial rt-PA is more effective than intra-arterial streptokinase or intravenous rt-PA in improving vessel patency in people with peripheral arterial occlusion. There was no evidence that rt-PA was more effective than urokinase for patients with peripheral arterial occlusion and some evidence that initial lysis may be more rapid with rt-PA, depending on the regime. Incidences of haemorrhagic complications were not statistically significantly greater with rt-PA than with other regimes. However, all of the findings come from small studies and a general paucity of results means that it is not possible to draw clear conclusions.

Surgery versus thrombolysis for initial management of acute limb ischaemia.

BACKGROUND: Peripheral arterial thrombolysis is technique used in the management of peripheral arterial ischaemia. Much is known about the indications, risks and benefits of thrombolysis. However, it is not known whether thrombolysis works better than surgery in the initial treatment of acute limb ischaemia. OBJECTIVES: To determine the preferred initial treatment, surgery or thrombolysis, for acute limb ischaemia. SEARCH METHODS: For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched March 2013) and CENTRAL (2013, Issue 2). SELECTION CRITERIA: All randomised studies comparing thrombolysis and surgery for the initial treatment of acute limb ischaemia. DATA COLLECTION AND ANALYSIS: Each author independently assessed trial quality and extracted data. Agreement was reached by consensus. MAIN RESULTS: Five trials with a total of 1283 participants were included. There was no significant difference in limb salvage or death at 30 days, six months or one year between initial surgery and initial thrombolysis. However, stroke was significantly more frequent at 30 days in thrombolysis participants (1.3%) compared to surgery participants (0%) (Odds ratio (OR) 6.41; 95% confidence interval (CI) 1.57 to 26.22). Major haemorrhage was more likely at 30 days in thrombolysis participants (8.8%) compared to surgery participants (3.3%) (OR 2.80; 95% CI 1.70 to 4.60); and distal embolization was more likely at 30 days in thrombolysis participants (12.4%) compared to surgery participants (0%) (OR 8.35; 95% CI 4.47 to 15.58).Participants treated by initial thrombolysis underwent a less severe degree of intervention (OR 5.37; 95% CI 3.99 to 7.22) and displayed equivalent overall survival compared to initial surgery (OR 0.87; 95% CI 0.61 to 1.25). AUTHORS' CONCLUSIONS: Universal initial treatment with either surgery or thrombolysis cannot be advocated on the available evidence. There is no overall difference in limb salvage or death at one year between initial surgery and initial thrombolysis. Thrombolysis may be associated with a higher risk of ongoing limb ischaemia and haemorrhagic complications including stroke. The higher risk of complications must be balanced against risks of surgery in each person.

Fibrinolytic agents for peripheral arterial occlusion.

BACKGROUND: Peripheral arterial thrombolysis is used in the management of peripheral arterial ischaemia. Streptokinase was originally used but safety concerns led to a search for other agents. Urokinase and recombinant tissue plasminogen activator (rt-PA) have increasingly become established as first line agents for peripheral arterial thrombolysis. Potential advantages of these agents include improved safety, greater efficacy and a more rapid response. Recently drugs such as pro-urokinase, recombinant staphylokinase and alfimperase have been introduced. OBJECTIVES: To determine which fibrinolytic agents are most effective in peripheral arterial ischaemia. SEARCH STRATEGY: The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched October 2009) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (last searched 2009, Issue 4) for randomised controlled trials (RCTs) comparing fibrinolytic agents to treat peripheral arterial ischaemia. SELECTION CRITERIA: RCTs comparing fibrinolytic agents to treat peripheral arterial occlusion. DATA COLLECTION AND ANALYSIS: Data were analysed for the outcomes vessel patency, time to lysis, limb salvage, amputation, death, complications including major haemorrhage, stroke, and distal embolization. MAIN RESULTS: Five RCTs involving a total of 687 patients with a range of clinical indications were included. In one three-pronged study, vessel patency was greater with intra-arterial recombinant tissue plasminogen activator (rt-PA) than with intra-arterial streptokinase (P < 0.04) or intravenous rt-PA (P < 0.01). In patients with peripheral arterial occlusion there was no statistically significant difference in limb salvage at 30 days with either urokinase or rt-PA, though this may reflect the small numbers in the studies. Incidences of haemorrhagic complications varied with fibrinolytic regime but there was no statistically significant difference between intra-arterial urokinase and intra-arterial rt-PA. In the three-pronged study intravenous rt-PA and intra-arterial streptokinase were associated with a significantly higher risk of haemorrhagic complications than with intra-arterial rt-PA (P < 0.05). AUTHORS' CONCLUSIONS: There is some evidence to suggest that intra-arterial rt-PA is more effective than intra-arterial streptokinase or intravenous rt-PA in improving vessel patency in people with peripheral arterial occlusion. There was no evidence that rt-PA was more effective than urokinase for patients with peripheral arterial occlusion and some evidence that initial lysis may be more rapid with rt-PA, depending on the regime. Incidences of haemorrhagic complications were not statistically significantly greater with rt-PA than with other regimes. However, all of the findings come from small studies and a general paucity of results means that it is not possible to draw clear conclusions.

Endovascular management of arterial conduit pseudoaneurysm after liver transplantation: a report of two cases.

We describe two cases of pseudoaneurysms in liver-transplant iliac artery conduits, which were successfully treated with endovascular stent grafting.

Hepatic artery pseudoaneurysm after liver transplantation: treatment with percutaneous thrombin injection.

Pseudoaneurysms of the hepatic artery are a rare complication of liver transplantation. Early diagnosis and treatment are essential to avoid life-threatening hemorrhage. Conventional treatment consists of surgical resection and vascular reconstruction or transarterial coil embolization. More recently, percutaneous thrombin injection has been successfully used in the treatment of femoral artery pseudoaneurysms. We describe a 70-year-old woman who had a hepatic artery pseudoaneurysm after orthotopic liver transplantation, which was successfully treated by percutaneous thrombin injection.

Routine chest radiography following imaging-guided placement of tunneled central lines: a waste of time, money, and radiation.

BACKGROUND: This study sought to evaluate routine chest radiography following placement of tunneled central lines using combined ultrasound and fluoroscopic guidance. MATERIALS AND METHODS: A prospective study of 150 consecutive patients who underwent placement of tunneled central lines in the vascular radiology suite. Ultrasound-guided vein puncture was performed with an 18-gauge needle in each case, and the access site was noted. Line position was confirmed by fluoroscopy. Following the procedure, 50 patients had both an on-table digital chest radiograph and a conventional chest radiograph. Subsequent patients had a digital radiograph and a fluoroscopic image grab. Final line tip position was scored, and complications were recorded. RESULTS: Line placement was optimal (95%) or acceptable (5%) in all patients. Line tip position could be satisfactorily evaluated on supine fluoroscopy. Mean fluoroscopic x-ray dose was 0.5 cGy/cm2. Digital chest x-ray dose was 9.0 cGy/cm2, and formal chest radiography dose was 12.0 cGy/cm2. The only complications were 2 carotid artery punctures without clinical sequelae. CONCLUSION: When lines are placed under imaging guidance with ultrasound to direct the venous puncture, complications are rare and are not likely to be clinically important. Conventional and digital chest radiographs do not contribute clinically relevant information but do add to the radiation dose, time, and expense of the procedure.

Percutaneous transsplenic access in the management of bleeding varices from chronic portal vein thrombosis.

Three patients with life-threatening variceal hemorrhage secondary to portal vein (PV) thrombosis underwent endovascular treatment via the transsplenic route. The indications, techniques, and early outcomes are described. Each patient had successful portal/splenic vein recanalization with or without transjugular intrahepatic portosystemic shunt (TIPS) creation and variceal embolization with conventional catheter and wire techniques. The transsplenic approach is a useful addition to the interventional armamentarium that can be used in cases refractory to endoscopic management and unsuitable for surgical shunt procedures or conventional TIPS procedures. Longer-term follow-up will be needed to establish the durability of these procedures.

Initial clinical experience using the Amplatzer Vascular Plug.

BACKGROUND AND PURPOSE: The Amplatzer Vascular Plug (AVP) is a self-expanding nitinol wire mesh vascular embolization device derived from the Amplatz septal occluder. We assessed the results of vascular embolization obtained using the AVP. METHODS: A retrospective review was carried out of 23 consecutive cases of vascular embolization using the AVP in a variety of different clinical settings. The AVP was chosen to have a diameter approximately 30-50% greater than the target vessel. The device was delivered via an appropriately sized guide catheter and was released when satisfactorily positioned. Additional embolic agents were used in some cases. RESULTS: All target vessels were successfully occluded with no device malpositioning or malfunction. In 14 (61%) patients the AVP was the sole embolic material. In the remaining patients additional agents were used, particularly in preoperative embolization of highly vascular renal tumors. The AVP does not cause instantaneous thrombosis and in high-flow situations thrombosis typically takes up to 15 min. CONCLUSION: The AVP is a safe, effective embolization device that provides a useful adjunct to the therapeutic armamentarium. It is particularly suited to the treatment of short high-flow vessels where coil migration and catheter dislodgment might occur. In the majority of cases no additional embolic agents are necessary but it may take up to 15 min for complete thrombosis to occur.

Renal stenting from the radial artery: a novel approach.

PURPOSE: To describe the technique and feasibility of renal artery angioplasty and stenting from the radial artery. METHODS: A series of 19 patients were evaluated for transradial renal artery intervention. Procedures were performed using carbon dioxide gas (CO2) as the preferred angiographic contrast agent. Intervention was performed through a 5 Fr radial artery sheath using low-profile balloons and balloon-expandable stents. RESULTS: Nineteen patients with 26 stenosed renal arteries were considered for treatment via the radial route. A negative Allen's test precluded radial puncture in two (11%). In one patient the descending aorta could not be catheterized. Stenting from the radial route was successful in 22 renal arteries in 16 patients. On an intention-to-treat basis 16 of the 19 (84%) were treatable from the radial route. In the 17 patients with radial access technical success was 94% (16 of 17) patients and 91% (21 of 23) of renal arteries. One patient experienced a cerebrovascular event during intervention. CONCLUSION: Transradial renal artery intervention is technically feasible using low-profile angioplasty balloons and stents. This route offers advantages in renal arteries with a caudal angulation and in patients with diseases or tortuous iliac arteries.

Carbon-dioxide-guided vascular interventions: technique and pitfalls.

PURPOSE: To evaluate the usefulness of carbon dioxide (CO2) angiography to guide vascular interventions. METHODS: A prospective study was carried out of 50 procedures (angioplasty, stenting, stent-grafting and embolization) using CO2 angiography. Indications for using CO2 were renal impairment, cardiac failure, previous reaction to conventional iodinated contrast, or likelihood of needing high doses of conventional contrast. CO2 was intended to be the sole contrast agent. The use of additional conventional contrast or gadolinium was recorded, as were procedural complications. Radiation dose was compared with similar procedures using conventional contrast. RESULTS: Angiographic quality was satisfactory in 44 (88%) procedures and CO2 guidance was all that was required; in 6 (12%) cases adjunctive use of conventional contrast or gadolinium was necessary. Contrast doses were significantly reduced and there was a trend toward decreased radiation doses with CO2. There were two significant complications but only one related to the use of CO2. CONCLUSION: CO2 angiography is well tolerated and can be successfully used to guide even complex vascular interventions. High-risk patients can be spared the risks of conventional contrast agents.

Persistent sciatic vessels, varicose veins, and lower limb hypertrophy: an unusual case or discrete clinical syndrome?

Persistent sciatic artery is a rare congenital anomaly with a high incidence rate of aneurysmal degeneration and risk of thromboembolization or rupture. Despite a number of recognized associations, the presence of coexistent venous anomalies is extremely rare. We present the case of a 27-year-old woman with atypical left-sided varicose veins and soft tissue hypertrophy. Imaging showed persistence of both sciatic artery and vein. Whether these anomalies are an incidental finding or represent a discrete clinical syndrome remains unclear. We emphasize that unusual distribution varicose veins may be associated with underlying persistent sciatic vessels and recommend formal duplex scan assessment for these anomalies.

Type II endoleaks: predictable, preventable, and sometimes treatable?

OBJECTIVE: The purpose of this study was to evaluate the effect of preoperative coil embolization of lumbar and inferior mesenteric arteries on the incidence of type II endoleak after endovascular abdominal aortic aneurysm repair. METHODS: The subjects were consecutive patients who underwent EVAR between January 1996 and January 2001. Patent aortic side branches were identified with preprocedural spiral computed tomographic scanning and calibrated angiography. Coil embolization was performed before EVAR. Patients were followed up with plain radiographs and ultrasound and dual phase spiral computed tomographic scans. Digital subtraction angiography was performed when endoleak was suspected. The outcome measures were the incidence of type II endoleaks and changes in maximum aortic sac diameter (Dmax). RESULTS: Forty patients underwent EVAR, with a median duration of follow-up of 24 months (range, 3 to 48 months). Before surgery, the inferior mesenteric artery was patent in 16 patients (45%) and the lumbar arteries in 21 patients (53%). Inferior mesenteric artery embolization was successful in 13 of 16 patients (81%). Lumbar embolization was attempted in 13 patients and was successful in eight (62%). During EVAR, successful sac exclusion was achieved in 38 patients (95%). None of the patients who underwent embolization before EVAR had type II endoleak develop, eight of 13 patients (62%) with patent lumbar arteries had endoleaks develop (P =.006), and three of these patients subsequently underwent successful coil embolization. Type II endoleak was associated with a 2.0-mm median increase in Dmax (P =.045). A 3.0-mm median reduction in Dmax was seen in the absence of type II endoleak (P =.002). CONCLUSION: Type II endoleaks are predictable, preventable, and sometimes treatable. Significant sac shrinkage occurs in the absence of lumbar endoleak but not in the presence of type II endoleak.