Catheter-directed thrombolysis for acute limb ischaemia: An audit.

Abstract

Acute limb ischaemia (ALI) is commonly managed with surgical intervention but catheter-directed thrombolysis (CDT) is a proven treatment alternative. CDT as a treatment for ALI is not common and is dependent on local practice. All patients receiving urokinase infusions at our institution currently require a bed in the high-dependency unit (HDU). Administering the infusion requires significant nursing time and this can be accommodated in HDU where the nurse-to-patient ratio is higher than it is on general wards. To report the outcomes of the initial admission of patients who received CDT to manage ALI, and to give a cost estimate of their care. A retrospective audit was undertaken of all patients who received CDT with urokinase for the management of ALI over a four-year period. Success of thrombolysis was defined as a patient's survival with no need for any surgical intervention prior to discharge. Outcome measures included the requirement for further vascular procedures in the same admission, the complication rate, and the median urokinase dose and duration. Cost estimates were based on hospital pharmacy and administration data. Seventy-three patients (median age 66 years, range 27-93 years) were included in the audit. The median urokinase dose was 2.3 million units (range 0.9-5.0 million units) with a median duration of treatment of 26 hours (range 3-96 hours). Fifty-seven patients did not require any further intervention prior to discharge, 14 had further intervention, and two died (one from a brainstem haemorrhage and one who deteriorated despite thrombolysis). The total cost per CDT case at our institution is currently approximately AUD $4,500 and AUD $6,700 for a patient being treated in HDU for one and two days, respectively. If patients were treated on a general ward, the cost would be approximately AUD $2,600 and AUD $3,000, respectively. Rates of clinically acceptable clot lysis were high for patients treated with urokinase for ALI. Complication rates were comparable with published studies. Infusions can be required for prolonged periods of time and given the low complication rate, managing patients on a general ward rather than in the HDU is a feasible alternative and would reduce costs substantially.