Efficacy versus Complications in Arterial Thrombolysis.

BACKGROUND: Acute peripheral arterial occlusions threaten life and limb. Thrombolysis is an established, minimally invasive alternative treatment for surgical thromboembolectomy. Yet, there is no consensus regarding an optimal thrombolysis protocol, and current knowledge is largely based on studies from the 1990s. This study reviews a contemporary cohort of patients treated with thrombolysis and aims to evaluate the treatment results and to identify possible predictors for outcome and (bleeding) complications. METHODS: The electronic health record data of all consecutive patients who underwent thrombolysis for acute limb ischemia due to thromboembolic lower extremity arterial occlusions between April 2006 and June 2012 were analyzed. End points were change in clinical stage of ischemia, incidence of bleeding complications, duration of thrombolysis, predictors of outcome and complications, and mortality and amputation-free rates after 30-day and 6-months follow-up. RESULTS: In total, 109 cases were included. Clinical improvement was observed in 79%. Amputation-free rates at 30 days and 6 months were 94% and 90%, respectively. The incidence of major bleeding complications was 13%. Median duration of thrombolysis was 27 (4-68) hr. Mortality rates at 30 days and 6 months were 7% and 16%, respectively; none bleeding related. In addition to age, popliteal artery occlusions and a progressed chronic vascular stage are predictive for a worse outcome. Age, female sex, and cardiac history were risk factors for bleeding. CONCLUSIONS: Treatment of peripheral arterial occlusions with high-dose thrombolysis on an intensive-care unit yields high clinical success rates, but major bleeding complications are often observed. Strict clinical observation remains essential since intensive monitoring of hemostatic parameters during thrombolysis does not predict bleeding complications.

Microbubbles and UltraSound-accelerated Thrombolysis (MUST) for peripheral arterial occlusions: protocol for a phase II single-arm trial.

INTRODUCTION: Acute peripheral arterial occlusions can be treated with intra-arterial catheter-directed thrombolysis as an alternative to surgical thromboembolectomy. Although less invasive, this treatment is time-consuming and carries a significant risk of haemorrhagic complications. Contrast-enhanced ultrasound using microbubbles could accelerate dissolution of thrombi by thrombolytic medications due to mechanical effects caused by oscillation; this could allow for lower dosages of thrombolytics and faster thrombolysis, thereby reducing the risk of haemorrhagic complications. In this study, the safety and practical applicability of this treatment will be investigated. METHODS AND ANALYSIS: A single-arm phase II trial will be performed in 20 patients with acute peripheral arterial occlusions eligible for thrombolytic treatment. Low-dose catheter-directed thrombolysis with urokinase will be used. The investigated treatment will be performed during the first hour of thrombolysis, consisting of intravenous infusion of 4 Luminity phials (6 mL in total, diluted with saline 0.9% to 40 mL total) of microbubbles with the use of local ultrasound at the site of occlusion. Primary end points are the incidence of complications and technical feasibility. Secondary end points are angiographic and clinical success, duration of thrombolytic infusion, treatment-related mortality, amputations, additional interventions and quality of life. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained in 2015 from the Medical Ethics Committee of the VU University Medical Center, Amsterdam, the Netherlands. A statement of consent for this study was given by the Dutch national competent authority. Data will be presented at national and international conferences and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBERS: Dutch National Trial Registry: NTR4731; European Clinical Trials Database of the European Medicines Agency: 2014-003469-10; Pre-results.

Thoracic sympathectomy for upper extremity ischemia.

INTRODUCTION: Thoracic sympathectomy is performed in the management of a variety of disorders of the upper extremity. To evaluate the contemporary results of thoracic sympathectomy for upper extremity ischemia a systematic review of the literature was conducted. EVIDENCE AQUISITION: We performed a PubMed, EMBASE and Cochrane search of the literature written in the English language from January 1975 to December 2015. All articles presenting original patient data regarding the effect of treatment on symptoms or on the healing of ulcers were eligible for inclusion. Individual analyses for Primary Raynaud's Disease (PRD) and Secondary Raynaud's Phenomenon (SRP) were performed. EVIDENCE SYNTHESIS: We included 6 prospective and 23 retrospective series with a total of 753 patients and 1026 affected limbs. Early beneficial effects of thoracic sympathectomy were noticed in 63-100% (median 94%) of all patients, in 73-100% (median 98%) of PRD patients and in 63-100% (median 94%) of SRP patients. The beneficial effect was noted to lessen over time. Long-term beneficial effects were reported in 13-100% (median 75%) of all patients, in 22-100% (median 58%) of PRD patients, and in 13-100% (median 79%) of SRD patients. Complete or improved ulcer healing was achieved in 33-100% and 25-67% respectively, of all patients. CONCLUSIONS: Thoracic sympathectomy can be beneficial in the treatment of upper extremity ischemia in select patients. Although the effect in patients with PRD will lessen over time, it may still reduce the severity of symptoms. In SRD, effects are more often long-lasting. In addition, thoracic sympathectomy may maximize tissue preservation or prevent amputation in cases of digital ulceration.

Arterio-ureteral fistula: 11 new cases of a wolf in sheep's clothing.

PURPOSE: We provide insight into the presentation, diagnostics, treatment, and accompanying clinical difficulties and complications of an arterio-ureteral fistula and add 11 patients with arterio-ureteral fistula to the 90 described in the literature. MATERIALS AND METHODS: A retrospective search was done for confirmed cases of arterio-ureteral fistula that were treated at 3 medical centers. RESULTS: A total of 11 cases of arterio-ureteral fistula were reviewed from 1980 to 2006. A history of major abdominal surgery had an essential role in 10 of the 11 cases, especially vascular intervention in 8. All patients presented with varying manifestations of hematuria. Ureteral contrast studies and nonprovocative angiography provided the most valuable diagnostic information with all 5 and 3 of 5 showing positive results, respectively. In 4 of 11 patients (36%) the diagnosis of arterio-ureteral fistula was only made during laparotomy. Ten patients were treated with a classic open surgical approach (vascular and urological) and in 1 endovascular stents were inserted. Two of 11 patients (18%) needed acute surgical intervention because of hemodynamic instability. The in hospital mortality rate was 9%. At a mean followup of 17 months 3 other patients (27%) had died of causes unrelated to the arterio-ureteral fistula. CONCLUSIONS: The diagnosis of arterio-ureteral fistula should be considered in patients with persistent hematuria who have a history of major abdominal vascular surgery even when diagnostic test results are negative for a fistula, because in 36% of our patients the diagnosis could only be made at operation. The in hospital morbidity and mortality rates are considerable and, therefore, a timely diagnosis and elective multidisciplinary treatment are preferred.

Repeated arterial thrombosis as a complication of carboplatin-based chemotherapy.

We describe a case of a 57-year-old woman with repeated acute arterial thrombosis of the femoral arteries following intravenous carboplatin-based combination chemotherapy for metastatic ovarian carcinoma. By extensive workup, no other known causes of arterial thrombosis were found. To our knowledge, this is the first case describing arterial thrombosis occurring as a complication of carboplatin therapy.