Influence of Intraoperative Intra-arterial Thrombolysis on Long-term Clinical Outcomes in Patients With Acute Popliteal Artery Aneurysm Thrombosis

Abstract

Introduction: Acute lower limb ischemia (ALI) after popliteal artery aneurysm (PAA) thrombosis represents a challenging problem. In the last edition in 2017 from European Society for Cardiology specific recommendations for PAA treatment are lacking [1]. Generally for Rutherford grade II ischemia surgery is recommended. Intraoperative intra-arterial fibrinolytic therapy has been proposed as an adjunct to surgical procedure[ 2].The aim of this research was to investigate outcomes of intraoperative intra-arterial thrombolysis in the treatment of acute PAA thrombosis Rutherford grade IIa and IIb in terms of major adverse limb event (MALE), overall survival and intrahospital complications, especially those associated with bleeding. Methods: A total of 156 patients (Rutherford grade IIa and IIb) with acute PAA thrombosis were admitted between January 1st 2009 and January 1st 2015. We divided PAA patients in two groups, those who underwent (20 patients) and those who didn't undergo additional treatment with intraoperative intra-arterial thrombolysis (136 patients). By using covariables from baseline and angiographic characteristics, a propensity score was calculated for each patient. Each patient who underwent intraoperative thrombolysis was matched to 4 patients from non-thrombolysis group. Thus, comparable patient cohorts (20 in thrombolysis and 80 in non-thrombolysis group) were identified for further analysis. Primary end-point was MALE and secondary all-cause mortality. Results: Patients in thrombolysis group received less frequent fasciotomy (20% vs 56.25%, p=0.02), and had longer hospital stay (10.60 vs 7.04, p< 0.01). Same group had more common wound/hematoma related intervention (25% vs 8%, p=0.13) less common MALE events (0% vs 11.25%, p=0.19), but these differences weren't statistically significant. There were no cases of intrahospital death nor major hemorrhage in both groups. After median follow-up of 49 months, the estimated MALE rate was significantly lower in thrombolysis group (30% vs 65%) (χ 2 =11.50, DF=1, P< 0.01, log rank test). On the other hand, after same follow-up, patients in thrombolysis group had significantly lower mortality rate (20% vs 42.65%) (χ 2 =4.87, DF=1, P=0.03, log rank test). Conclusion: Vascunet and Swedish registry for popliteal artery aneurysm showed 30-day amputation rate of 6.5% and 3.3% respectively [3]. Mainly to address this critical issue arose the strategy of initial thrombolytic treatment for ALI associated with PAA thrombosis. Catheter directed intraaterial thrombolysis prior to surgery can achieve extremity revascularization and reestablish patency of small runoff vessels, providing more favorable conditions for open surgical or endovascular repair to follow in semi- urgent, or elective manner [4]. Systematic review published by Kropman et al. showed that the limb salvage rate was not different with preoperative thrombolysis when compared to the patients who did not undergo thrombolysis [5]. In this research we found that intraoperative intra-arterial thrombolysis in treatment of acute PAA thrombosis showed a significant reduction in terms of MALE events and even improves overall survival. No significant differences have been shown between groups in bleeding complications, except loco-regional. Disclosure: Nothing to disclose