Acute Leg Ischemia Research Articles

Value of POSSUM physiology scoring to assess outcome after intra-arterial thrombolysis for acute leg ischaemia (short note).

Value of POSSUM physiology scoring to assess outcome after intra-arterial thrombolysis for acute leg ischaemia (short note).

Demography and etiology of acute leg ischemia.

Acute leg ischemia arguably is the most challenging condition that a vascular surgeon has to manage. Patients have widely different presentations, there are several available treatment options, and, yet, despite best efforts, the outcome remains poor. An understanding of the changes in population demographics in affluent western societies, set in an historical context, enables choices about therapy. A vascular unit serving a community including half a million people can expect to treat approximately 75 patients with acute leg ischemia per year. It is vital that a team approach is used to decide management because endovascular treatment with peripheral thrombolysis is increasingly important. The distinction between etiology of thrombosis or embolism remains important, although the diagnosis can never be conclusive. The severity of arterial ischemia is a more important determinant of outcome; optimal management, therefore, begins with stratification according to the severity of ischemia on admission to the hospital. Subsequent care lends itself to organization by care-pathway or guidelines that take into account the available local facilities.

Acute aortic dissection with critical stenoses of the true lumen treated by transluminal stent-graft placement and findings one year after treatment

Clinical summary. A 54-year-old woman with a sudden onset of back pain was admitted to a satellite hospital of Mie University. Contrast-enhanced computed tomography (CT) revealed a DeBakey type IIIb, Stanford type B acute aortic dissection. The patient was treated medically. Nineteen days after admission, she had acute renal failure (blood urea nitrogen, 54 mg/dL; creatinine, 3.8 mg/dL) and left leg ischemia. CT disclosed severe stenosis of the true lumen at the level of the left renal artery. She was referred to Mie University Hospital for evaluation and treatment of acute aortic dissection. Her left femoral pulse was not palpable. The patient immediately underwent digital subtraction angiography (DSA), which showed that the intimal tear was located in the midportion of the descending thoracic aorta and that stenoses of the true lumen were located at the level of the diaphragm and distal to the level of the left renal artery. The left external iliac artery also had a critical stenosis. The true lumen of the right iliac artery was completely obliterated. However, the right leg was perfused by blood flow through the false lumen (Fig 1, A). Emergency transluminal stent-graft placement was subsequently performed. The stent graft was constructed of a selfexpanding, Gianturco stainless steel Z stent (Cook Critical Care, Inc, Bloomington, Ind) covered with a balloon-expandStanford type B acute aortic dissection is mainly treated medically. However, emergency surgery for type B dissection with rupture, impending rupture, end-organ ischemia, or some combination thereof is mandatory. Surgical outcomes are poor for patients with an acute type B aortic dissection with endorgan ischemia. Recently, transluminal stent-graft placement became an alternative for the treatment of aortic dissection.1,2 However, transluminal stent-graft placement for stenosis of the true lumen is not common, and the fate of a narrowed true lumen is not clear after stent-graft treatment. We report the case of a patient with acute type B aortic dissection with critical stenoses of the true lumen treated by transluminal stentgraft placement. We also discuss the effects on a narrowed true lumen 1 year after the treatment. ACUTE AORTIC DISSECTION WITH CRITICAL STENOSES OF THE TRUE LUMEN TREATED BY TRANSLUMINAL STENT-GRAFT PLACEMENT AND FINDINGS ONE YEAR AFTER TREATMENT

Outcome analysis of over 1000 episodes of limb ischaemia treated by peripheral thrombolysis

Abstract Background In the past 10 years, 13 hospitals with an interest in peripheral arterial thrombolysis have collected information on 1064 episodes of thrombolysis used to treat some 933 patients. The aim of the database was to identify clinical factors at the time of admission to hospital and relate them to the patients' outcome. Methods After verification of the database, a regression analysis was done in three stages: univariate analysis, logistic regression including the initial success of thrombolysis, and logistic regression analysis excluding initial success. The endpoints were amputation-free survival (AFS), survival but with amputation, and death. Statistical analysis was performed with SPSS software (SPSS, Chicago, Illinois, USA). Results The overall AFS was 72·9 per cent; 12·6 per cent of events resulted in amputation and 12·9 per cent of patients died. Univariate analysis showed that patients receiving warfarin had a survival advantage, whereas those with diabetes and ischaemia that caused sensory loss were significantly more likely to require amputation. Logistic regression analysis confirmed the above effects of diabetes and ischaemia. Major haemorrhage occurred in 8 per cent of events, but there was a significantly increased risk if the patient had a history of peripheral vascular disease (P = 0·007) or presented with graft thrombosis (P = 0·001). Stroke occurred in 2·4 per cent of events; a greater incidence occurred in patients with a duration of ischaemia of less than 8 h. Conclusion Further detailed analysis of this large and unique database should help clinicians to refine the indications for peripheral thrombolysis in the management of acute leg ischaemia.

Vascular surgical society of great britain and ireland: two-year follow-up after acute thromboembolic lower limb ischaemia: the importance of continuing warfarin treatment

BACKGROUND: The Vascular Surgical Society carried out an audit of follow-up after acute thromboembolic lower limb ischaemia. METHODS: The audit of acute lower limb ischaemia was done between 1 January and 31 March 1996 and included 474 patients. This report describes a 2-year follow-up of patients with a diagnosis of thrombosis or embolism who survived 30 days. Details were obtained for 214 (75 per cent) of 287 patients: half (107) were men, and the age range was 21-96 (mean 74) years. RESULTS: Amputation of the leg affected initially had been required (after 30 days) in 12 per cent. Further acute leg ischaemia had occurred in 11 per cent, and 9 per cent had undergone arterial reconstruction (11), angioplasty (seven) or thrombolysis (two). Major medical events were reported in 31 per cent and 35 per cent had died during the 2-year period. After the episode of acute ischaemia, warfarin was started in 57 per cent of patients, but was continued in only 43 per cent. Reasons for stopping were seldom known, nor was duration of treatment (range 1-22 (median 6) months in reported cases). Significantly more patients who were not on warfarin suffered recurrent acute limb ischaemia (19 versus 3 per cent; P < 0.01). No significant association was found between recurrent acute ischaemia and initial diagnosis of embolism, thrombosis or atrial fibrillation (but numbers of recurrences in each group were small). CONCLUSION: The incidence of recurrent acute thromboembolic limb ischaemia up to 2 years was significantly lower in patients treated with warfarin. Warfarin treatment is often stopped for no clear reason, especially in the elderly. Explicit advice about long-term warfarin therapy should be given when these patients are discharged from hospital.

Femoral Anastomotic Aneurysms: Pathogenic Factors, Clinical Presentations and Treatment. A Study of 142 Cases

In this study, the files of 112 patients with a total of 142 femoral anastomotic aneurysms were reviewed. Eighty-five patients (76%) were initially operated upon for obstructive aorto-iliac disease, while the remaining 27 (24%) had abdominal aortic aneurysms repaired. The majority of the patients (104/112) were male and their mean age was 64.5 years (range 45–88). Ninety-three per cent of the subjects were smokers prior to the first operation and 43% continued to smoke at the time of their femoral anastomotic aneurysms operation. The mean delay between the initial surgery and the repair of the femoral anastomotic aneurysms was 74.5 months (range 1–228). The diagnosis was made because of a painless pulsatile mass (91/142). acute leg ischaemia (27/142), a painful pulsatile mass (12/142). haemorrhage (10/142), pseudo-post-phlebitic oedema (1/142) and microemboli of the toes (1/142). The operative mortality was 2.7% (3/112) of which two-thirds were patients with infected grafts. Two subgroups were distinguished: 10 patients with an infected femoral anastomotic aneurysm and 12 patients with recurrent femoral anastomotic aneurysms, 11 with a single recurrence and one with a double recurrence. In the infected group, the time to development of anastomotic aneurysm was shorter than for the group with non-infected femoral anastomotic aneurysms (41 versus 74.5 months) and the operative mortality was 20% (2/10). One patient developed a recurrent femoral anastomotic aneurysm and another was lost to follow-up. Two subsequent deaths occurred, which were unrelated to the femoral anastomotic aneurysms. In the group of recurrent femoral anastomotic aneurysms one patient was lost to follow-up and two patients died, but not as a result of recurrent femoral anastomotic aneurysms. A total of 122 cases underwent interposition of a new prosthetic segment between the proximal prosthesis and the distal artery (89 at the common femoral, 21 at the femoral profundis, eight at the superficial femoral and four at an existing femoro-popliteal graft).

Femoral anastomotic aneurysms: pathogenic factors, clinical presentations and treatment. A study of 142 cases

In this study, the files of 112 patients with a total of 142 femoral anastomotic aneurysms were reviewed. Eighty-five patients (76%) were initially operated upon for obstructive aorto-iliac disease, while the remaining 27 (24%) had abdominal aortic aneurysms repaired. The majority of the patients (104/112) were male and their mean age was 64.5 years (range 45–88). Ninety-three per cent of the subjects were smokers prior to the first operation and 43% continued to smoke at the time of their femoral anastomotic aneurysms operation. The mean delay between the initial surgery and the repair of the femoral anastomotic aneurysms was 74.5 months (range 1–228). The diagnosis was made because of a painless pulsatile mass (91/142), acute leg ischaemia (27/142), a painful pulsatile mass (12/142), haemorrhage (10/142), pseudo-post-phlebitic oedema (1/142) and microemboli of the toes (1/142). The operative mortality was 2.7% (3/112) of which two-thirds were patients with infected grafts. Two subgroups were distinguished: 10 patients with an infected femoral anastomotic aneurysm and 12 patients with recurrent femoral anastomotic aneurysms, 11 with a single recurrence and one with a double recurrence. In the infected group, the time to development of anastomotic aneurysm was shorter than for the group with non-infected femoral anastomotic aneurysms (41 versus 74.5 months) and the operative mortality was 20% (2/10). One patient developed a recurrent femoral anastomotic aneurysm and another was lost to follow-up. Two subsequent deaths occurred, which were unrelated to the femoral anastomotic aneurysms. In the group of recurrent femoral anastomotic aneurysms one patient was lost to follow-up and two patients died, but not as a result of recurrent femoral anastomotic aneurysms. A total of 122 cases underwent interposition of a new prosthetic segment between the proximal prosthesis and the distal artery (89 at the common femoral, 21 at the femoral profundis, eight at the superficial femoral and four at an existing femoro-popliteal graft).

Emergent endovascular treatment for leg ischemia complicating acute aortic dissection

We describe a patient with acute aortic dissection involving the right iliac artery and causing right lower leg ischemia that was successfully treated by Wallstent placement. Emergent endovascular treatment may be the treatment of choice in the patient with acute leg ischemia caused by the involvement of the iliac artery by aortic dissection.

Prospective randomized trial of high-dose bolus versus low-dose tissue plasminogen activator infusion in the management of acute limb ischaemia

Accelerated thrombolysis with high-dose bolus tissue plasminogen activator (tPA) may enable patients with more severe acute leg ischaemia to be treated without recourse to surgery. This study was a randomized comparison of two thrombolytic regimens. One hundred patients with acute leg ischaemia of less than 30 days' duration were randomized to receive either high-dose bolus tPA (three doses of 5 mg over 30 min, then 3.5 mg/h for up to 4 h, then 0.5-1.0 mg/h) or conventional low-dose tPA (0.5-1.0 mg/h). The groups were well matched for age, cardiovascular risk factors, duration and severity of ischaemia, site, cause and length of arterial occlusion. The median duration of infusion in the high-dose group was 4.0 (range 0.25-46) h compared with 20 (range 2-46) h for low-dose infusion (P < 0.0001). Successful thrombolysis was achieved in 45 of 49 high-dose and 39 of 44 low-dose infusions but significantly more adjunctive procedures were required following high-dose bolus infusion (26 versus 16 patients) (P = 0.002). Thirty days after treatment was commenced, limb salvage was achieved in 39 of 49 patients in the high-dose group compared with 37 of 44 who had a low-dose infusion of tPA. Six and two patients respectively required amputation. Four patients in the high-dose group and five in the low-dose group died. Three patients in each group suffered a major haemorrhage and one in the low-dose group had a stroke. High-dose bolus therapy significantly accelerated thrombolysis with tPA without compromising outcome. Some 50 per cent of patients were treated within 4 h enabling thrombolysis to be used as primary therapy for patients with acute critical ischaemia.

Acute leg ischaemia in Gloucestershire

Acute leg ischaemia is both life threatening and limb threatening. This audit was designed to determine the incidence and outcome of acute leg ischaemia in a single county. Using multisource data collection for a 1-year interval in 1994 all patients with acute leg ischaemia were identified prospectively using hospital and general practice records in the county of Gloucestershire, population 540,000. Seventy-seven patients with 84 events of acute leg ischaemia were identified, giving an incidence of one per 7000 per year rising to one per 6000 per year when bypass graft occlusions were included. All but four patients were treated in hospital. Sixteen of 80 hospital events involved conservative treatment; after 30 days nine patients had died and two required amputation. The remaining five patients had borderline ischaemic rest pain and accepted their symptoms without intervention. Sixty-four of 80 events were managed by either primary surgery and angioplasty (n = 31) or thrombolysis (n = 33). The 30-day outcome in patients treated actively was: limb salvage in 50 (78 per cent), amputation in four (6 per cent) and death in ten (16 per cent). In Gloucestershire almost all cases of acute leg ischaemia are managed by, or discussed with vascular surgeons. A flexible integrated policy of surgery and peripheral thrombolysis has resulted in a limb salvage rate of 78 per cent in patients suitable for active treatment.

Results of 100 cases of pulse-spray thrombolysis for acute and subacute leg ischaemia

Pulse-spray thrombolysis is a rapid technique for the treatment of limb ischaemia of recent onset. Early results have been published but the longer term results are not known. This study consisted of a series of 100 legs with acute and subacute ischaemia treated using this method with a follow-up interval of up to 3 years. Eighty-three limbs were classified as Fontaine grade III or IV and 42 had a sensory or motor deficit. Sixty-seven limbs were treated with pulse spray alone and 33 had an additional low-dose infusion. In 71 cases an additional catheter-directed intervention was required. Median duration of lysis was 135 (range 35-1540) min and median dose of recombinant tissue plasminogen activator used was 18 (range 4-61) mg. Complete radiological patency was achieved in 79 limbs and the ankle:brachial pressure index improved from a median of 0 (range 0-0.8) to 0.8 (range 0-1.5) (P < 0.0001). At 30 days ten patients had died, eight needed amputation and a further 11 had rethrombosed. Cumulative limb salvage rate at 30 months was 79 per cent (standard error 8) and the estimated cumulative patency rate for successful cases was 72 per cent (standard error 10). The incidence of major bleeding was 7 per cent and of minor bleeding 24 per cent. There were no haemorrhagic strokes but three thrombotic strokes occurred within 30 days of thrombolysis. Pulse-spray thrombolysis achieves rapid and safe revascularization of acute and subacute leg ischaemia.

Unusual complication seven years after succussful aortic recoarctation repair with a dacron graft: Acute thromboembolic leg ischemia caused by a mobile thrombus at the distal suture line

Unusual complication seven years after succussful aortic recoarctation repair with a dacron graft: Acute thromboembolic leg ischemia caused by a mobile thrombus at the distal suture line

Acute leg ischaemia as a presentation of hyperleukocytosis syndrome in acute myeloid leukaemia

Acute leg ischaemia as a presentation of hyperleukocytosis syndrome in acute myeloid leukaemia

Early outcome and intermediate follow-up of vascular stents in the femoral and popliteal arteries without long-term anticoagulation.

The role of arterial stenting in the treatment of femoral and popliteal arterial disease is controversial and has been hampered by recommendations for patients to be given anticoagulants (oral warfarin) for several months or more. This study was undertaken to evaluate the immediate and midterm outcomes of vascular stents implanted percutaneously in the femoral and popliteal arteries, without long-term anticoagulation. Over a 3-year period, 32 patients admitted to a vascular surgery service had arterial stents implanted in the femoral (n = 22) or popliteal (n = 10) artery for the following indications: recurrent stenosis after angioplasty (n = 13), suboptimal result after angioplasty of occluded (n = 12) or calcified stenotic arteries (n = 2), percutaneous transluminal angioplasty-induced thrombosis or dissection (n = 5). Access to the artery was gained by percutaneous insertion of a hemostatic sheath into the ipsilateral common femoral artery. Systemic heparin was given at the time of stent insertion, and patients were prescribed daily low-dose aspirin. Successful stent implantation was achieved in 31 of the 32 patients. Acute thrombosis (< 30 days) occurred in two patients. There was no incidence of false aneurysm formation, acute leg ischemia, or vessel perforation. All patients were monitored by Doppler scanning index and duplex scanning within 24 hours, and thereafter at 3- to 6-month intervals. The mean ankle-brachial systolic pressure index improved from 0.60 (before treatment) to 0.88 (3 to 6 months after stenting). Stent occlusion has occurred in six patients; two stents were successfully salvaged with urokinase infusion. In follow-up to date (range 3 to 33 months) the primary patency rate by life-table analysis was 75% at 18 months, whereas the secondary patency rate was 89% at the same interval. Restenosis (> 50% lumen diameter) was detected by duplex ultrasonography in seven of 25 patent stents (28%) at a mean interval of 9.5 months (range 4 to 15 months); of these, four patients remained clinically symptom-free despite the ultrasound findings. We conclude that vascular stents can be implanted into the femoropopliteal arteries with few complications and with acceptable early and intermediate patency rates, without the need for long-term anticoagulation. Restenosis is not prevented by stents, and the main value of stenting at this site appears to be in salvaging acute complications of percutaneous transluminal angioplasty, or to correct suboptimal results after recanalization of occluded arteries.

The value of interventional techniques in the management of symptomatic leg ischaemia complicating transfemoral cardiac procedures

During a 4 year study period, 3169 coronary arteriograms and 733 coronary angioplasties were carried out at this institution using the percutaneous femoral approach. Seven (0.18%) patients developed symptomatic ischaemia in the leg of the transfemoral access, two (0.06%) after coronary arteriography, four (0.55%) after coronary angioplasty, and one after intraaortic balloon pump insertion for complications during coronary arteriography. Of the three patients with acute leg ischaemia within 24 h of the cardiac procedure, two required emergency surgery and the other was managed by systemic heparinization. Four patients developed intermittent claudication on mobilization after the procedure but referral for angiography was after an interval of 6 days to 12 months. One patient was treated by intra-arterial thrombolysis and three by percutaneous transluminal angioplasty. On follow-up, at 12-36 (mean 20) months, only one patient (who had been treated surgically) had residual symptoms of ischaemia in the leg of the transfemoral access. We conclude that interventional techniques have a useful role to play in the management of symptomatic leg ischaemia complicating transfemoral cardiac procedures.

Acute leg ischaemia as a manifestation of the hyperleukocytosis syndrome in acute myeloid leukaemia

American Journal of HematologyVolume 46, Issue 2 p. 167-167 Letters and CorrespondenceFree Access Acute leg ischaemia as a manifestation of the hyperleukocytosis syndrome in acute myeloid leukaemia Janine Campbell, Janine Campbell Department of Medicine, Monash University, Box Hill Hospital, Melbourne, AustraliaSearch for more papers by this authorChristina A. Mitchell, Christina A. Mitchell Department of Medicine, Monash University, Box Hill Hospital, Melbourne, AustraliaSearch for more papers by this author Janine Campbell, Janine Campbell Department of Medicine, Monash University, Box Hill Hospital, Melbourne, AustraliaSearch for more papers by this authorChristina A. Mitchell, Christina A. Mitchell Department of Medicine, Monash University, Box Hill Hospital, Melbourne, AustraliaSearch for more papers by this author First published: June 1994 https://doi.org/10.1002/ajh.2830460234Citations: 14AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume46, Issue2June 1994Pages 167-167 ReferencesRelatedInformation

Popliteal artery aneurysms: Current management and outcome

Thrombosis of popliteal artery aneurysms can produce limb-threatening ischemia. In this setting we have found preoperative thrombolytic therapy to be beneficial. Thirty-three patients with 54 popliteal artery aneurysms were studied (mean follow-up 62 months). Twenty-one patients (62%) had bilateral popliteal artery aneurysms, and 20 patients (61%) had extrapopliteal arterial aneurysms. Thirty-three (61%) aneurysms had symptoms of compression or ischemia, and 21 (39%) aneurysms had thrombosis. A trend toward thrombosis for larger aneurysms was noted (p < 0.068). Forty-five aneurysms were treated with bypass grafting. Five-year graft patency and limb salvage rates were 71% and 90%, respectively. Factors favoring graft patency and limb salvage included presence of two- or three-vessel runoff compared with patients with single- or no-vessel runoff (p < 0.025 graft patency; p < 0.003 limb salvage) and presence of a patent aneurysm (p < 0.005 graft patency and limb salvage). Seven patients diagnosed with thrombosis of their aneurysm and all runoff vessels were treated with preoperative thrombolytic therapy. Complete clearing of thrombus from these arteries was achieved in six of these patients (and from two of these runoff vessels in the remaining patient). These patients had better graft patency (p < 0.005) and limb salvage (p < 0.01) than comparable patients treated with emergency operations. Six amputations were performed in the follow-up interval, none of which were performed in patients having undergone thrombolytic therapy. It is concluded that popliteal aneurysms are managed best by elective repair of patent aneurysms with good runoff. In that difficult situation of the thrombosed popliteal artery aneurysm associated with acute leg ischemia, thrombolytic therapy safely and effectively provides patients with a more favorable alternative than emergency surgery.

Intraoperative catheter thrombolysis as an adjunct to surgical revascularisation for infrainguinal limb-threatening ischaemia

The objective of this study was to assess the benefits of intraoperative thrombolysis (IOL) on patients with acute leg ischaemia. This study was conducted in the Department of Cardiovascular Surgery, Inselspital, Berne, Switzerland. IOL was prospectively assessed in 25 patients with infrainguinal limb-threatening ischaemia due to acute thrombosis of atherosclerotic lesions and aneurysms (44%), occluded grafts (32%), arterial injuries (12%), delayed embolism (8%) and trash foot (8%). Three hundred and seventy-five thousand units of urokinase were delivered over 30 min with inflow occlusion to the profunda femoral artery in 8%, to the calf arteries via exposed trifurcation in 88% and to the pedal arch via exposed posterior tibial artery at the ankle in 8% of the patients. This was followed by graft thrombectomy in 24%, femoropopliteal bypass in 60%, intraoperative percutaneous transluminal angioplasty in 12% and vein patch angioplasty in 16%. Chief outcome measures were: postoperative morbidity; mortality; patency and limb salvage up to a maximum of 2 years. Postoperative bleeding complications occurred in two patients (8%) and consisted of two wound haematomas. Four patients died within 30 days after IOL, but no death could be attributed to IOL. All remaining patients were followed with a mean follow-up time of 10.9 months. The patency and limb salvage rate remained stable at 71 and 86% after 6 and 2 months, respectively. Conclusions were that IOL followed by surgical inflow restoration is a straightforward procedure for limb-threatening ischaemia with rewarding results regarding side effects, patency and limb salvage.

Acute lower extremity ischemia after cardiac surgery

A retrospective review during a 5-year period (1987 to 1992) was conducted of all patients manifesting leg ischemia after major cardiac surgery. There were 7,620 procedures performed, and 65 (0.85%) patients (mean age: 65 years) were identified with acute ischemia. Diagnosis was made by physical examination, during which a cool pulseless extremity without pedal Doppler signals was noted in 63 of 65 patients (97%). An intra-aortic balloon pump (IABP) was inserted in 56 patients (86%). Treatment regimens included medical management (17), IABP removal (4), IABP removal and thromboembolectomy (24), thromboembolectomy and endarterectomy with patch angioplasty (10), femoral-femoral bypass (17), other bypasses (6), fasciotomy (10), and amputation (16). Morbidity was 92% and mortality was 46%. Mortality was 11% in those patients developing ischemia without an IABP. Acute leg ischemia after cardiac surgery is predictive of high morbidity and mortality. This reflects the compromised cardiac status and multi-system disease. Treatment alternatives are based on the overall clinical status, degree of arterial insufficiency, and distribution of pre-existing peripheral vascular disease. However, ultimate limb salvage had no influence on overall patient survival in our study.

Isolated limb perfusion with urokinase for acute ischemia

Purpose: Isolated limb perfusion with urokinase was used to salvage an acutely ischemic lower limb.Methods: Isolated limb perfusion with urokinase over a 90-minute period was used in the treatment of a 69-year-old female patient with acute ischemia of the left leg after thrombosis of a femoral artery bypass graft. Previous balloon embolectomy and heparin therapy had failed. The flow rate was able to be increased progressively without rise in the line pressure during the course of the perfusion, indicating an increase in capacity of the peripheral arterial bed. Fibrinogen and plasminogen levels in the isolated circulation remained low throughout the perfusion. The concentration of cross-linked fibrin degradation particles (d. dimer) rose progressively in the isolated circulation but remained at normal levels in the systemic circulation during perfusion.Results: Completion angiography demonstrated clearance of thrombus in the popliteal artery and appearance of arteries not seen on preperfusion films. Clinical improvement paralleled the angiographic appearances, with restoration of limb viability.Conclusion: We concluded that isolated limb perfusion with use of urokinase is safe and worthy of further investigation.