Thrombolysis for native arterial occlusions of the lower extremities: clinical outcome and cost.

INTRODUCTION: Intra-arterial thrombolysis is commonly used as the initial treatment of acute or subacute lower extremity ischemia. METHODS: To evaluate the efficacy and cost of thrombolysis, we retrospectively analyzed 100 consecutive cases (87 patients) in which intra-arterial lysis (urokinase) was used as the initial treatment for native arterial lower extremity occlusive disease. The mean age of patients was 67 years, 57% of the patients were male, and preexisting peripheral vascular disease was present in 74%. Presenting symptoms were limb-threatening ischemia (53%) and claudication (47%). Acute symptoms (< 2 weeks' duration) were present in 48%. RESULTS: The 30-day morbidity rate was 31%, and four patients died. Complications were significant bleeding (23%), ischemic stroke (1%), and renal failure with (2%) and without (2%) dialysis. Concomitant angioplasty was performed in 63%. Complete or significant lysis as demonstrated with angiography was achieved in 75% of iliac, 58% of femoropopliteal, and 41% of crural vessels (P <.001). Within 30 days of lysis, 9% of patients underwent major amputation and 20% surgical revascularization (in 3 patients the extent of revascularization was lessened by the lytic therapy). Amputation-free survival was 83% and 75% at 6 months and 2 years, respectively. Relief of ischemia (defined as relief of claudication or limb salvage without major surgical intervention) was achieved in only 70% and 43% of patients at 30 days and 2 years, respectively (Kaplan-Meier analysis; mean follow-up, 31 months). Patients with aortoiliac disease had significantly better outcomes than those with infrainguinal disease (P =.03). Duration or type of presenting symptoms did not predict outcome. The cost of the initial hospitalization per patient for thrombolysis was $18,490. CONCLUSION: Thrombolysis can be as or more costly than surgery and is associated with a suboptimal outcome in a significant number of patients. These data lead us to caution against a uniform policy of initial thrombolysis for patients who present with lower extremity ischemia.

A biomechanical analysis of an engineered cell-scaffold implant for cartilage repair.

This study evaluated the biomechanical and physical properties of newly formed cartilage engineered from isolated chondrocytes in combination with matrix components. Four groups of constructs were studied. Group A consisted of lyophilized articular cartilage chips mixed with a cell-fibrinogen solution and thrombin to obtain constructs made of fibrin glue, chondrocytes, and cartilage chips. Group B constructs were prepared using fibrin glue and cartilage chips without cells. Group C contained chondrocytes in fibrin glue without chips, and group D comprised constructs of fibrin glue alone. Specimens were implanted in the subcutaneous tissue of nude mice for 9 weeks. At necropsy the specimens were examined grossly, physically, biomechanically, and histologically. The original, preimplantation mass of the constructs was retained only in experimental group A. Histological analysis of specimens in experimental groups A and C demonstrated the presence of newly formed cartilaginous matrix, whereas only fibrotic tissue was observed in control groups B and D. Biomechanical analysis demonstrated higher mean values of equilibrium modulus in the experimental samples of group A with respect to all control groups. This study demonstrated that adding lyophilized cartilage chips to a fibrin glue-engineered cartilage construct maintains the biomechanical properties and the original mass after medium-/long-term in vivo transplantation.