Catheter-directed Therapy Research Articles

Catheter-Directed Thrombolytic Therapy for Massive and Submassive Pulmonary Embolus: A Community Hospital Experience

Pulmonary embolism (PE) is responsible for 200,000 deaths in the United States annually. Catheter directed thrombolytic therapy (CDTT) is reserved for massive and submassive PE, and rarely practiced outside of tertiary care university settings. Here we present a series of nine consecutive patients with massive (on pressors with hemodynamic instability) or submassive PE (echocardiograms showing pulmonary artery pressure > 70 mm Hg, right heart strain, and continued need for supplemental oxygen ) treated with CDTT in a community vascular surgery practice. Four patients were treated for massive PE and five were treated for submassive PE. All patients had been treated in intensive care units with systemic anticoagulation and significant supplemental oxygen requirement for as long as 5 days prior to being referred for lytic therapy. Upon referral, patients were treated with CDTT with powerpulse infusion of 10 to 15 mg of Alteplase into the left, right, and main pulmonary arteries. The decision to use mechanical thrombectomy was made at the time of procedure based on the patient's clinical condition. All nine patients were treated in a single setting. The mean age was 54.8 ± 11.4 years, with 1 male and 8 females. The end point of treatment was weaning off pressors and/or decreased oxygen requirement. This was achieved in all nine patients (100% procedural success rate). One patient developed hemodynamically significant heart block with each attempt at powerpulse delivery, but was successfully treated with forceful injection through a running EKOS catheter. All patients were off supplemental oxygen within 24 hours of the procedure. There were no bleeding events in any patient. One patient expired 14 hours after the procedure with a suspected paradoxical embolus to the intestines (overall mortality 11%). The eight surviving patients were discharged to home within 48 hours of the intervention and had normal PA pressures without any evidence of right heart strain on echocardiogram performed one month after their CDTT procedure. Massive or submassive PE can be treated safely with CDTT in a community hospital setting. This can reduce the need for lengthy ICU stays, shorten overall hospital length of stay, eliminate the need for home oxygen therapy, and restore right heart function with an acceptable mortality rate. Development of institutional CDTT expertise in conjunction with protocols to administer this therapy early in the course of massive and submassive PE may yield significant mortality and morbidity benefits in community hospitals.

Venous Thromboembolism (VTE) Recurrence in Patients with Recurrent/Metastatic Solid Cancer Receiving Anticoagulation Therapy After Index VTE; Findings From Korean VTE Registry,

Abstract 3355 Introduction:Cancer patients (pts) with venous thromboembolism (VTE) have an increased risk of VTE recurrence. However, few data are available regarding the incidence, impact of malignancy characteristics on VTE recurrence in pts with recurrent/metastatic solid cancer. Reliable information on the factors determining the risk of VTE recurrence may facilitate tailored anticoagulation therapy by discriminating cancer-associated VTE pts according to the risk of recurrence. Therefore, the aims of this study are to investigate the incidence of VTE recurrence, its association with malignancy characteristics, and prognostic factors for VTE recurrence in pts with recurrent/metastatic solid cancer receiving anticoagulation therapy after prior index VTE. Methods:The data source in this study is a web-based registry of Korean VTE Working Party (http://kdvt.chamc.co.kr), which is an ongoing, multicenter database system recruiting consecutive patients with VTE confirmed by objective tests. The pts were eligible to enter the study cohort if they had received a diagnosis of recurrent/metastatic solid cancer between May 2005 and Dec 2010 and initiated anticoagulation therapy after the diagnosis of index VTE. Pts were excluded from the study cohort if they had received a diagnosis of hematologic malignancies, if solid cancers were not recurrent or metastatic disease, if index VTE was intra-abdominal venous thrombosis (IVT) or vascular access-induced thrombosis, or if anticoagulation therapy was not instituted. The period of follow-up considered for the analysis was the duration of anticoagulation therapy with a maximum of 6 months and pts in whom anticoagulation therapy was stopped within 6 months were censored at the time of treatment cessation. Results:The data of 363 recurrent/metastatic solid cancer pts with anticoagulation therapy following the diagnosis of index VTE were analyzed. The median age was 65 (range, 27–91) years and 201 pts (55%) were male. Eastern Cooperative Oncology Group (ECOG) performance status (PS) was 0 or 1 in 164 pts (55%). The primary sites of cancer were breast in 17 pts, genito-urinary tract in 36, stomach-esophagus in 74, colo-rectum in 81, hepato-biliary tract in 28, pancreas in 34, and lung in 93. Two hundred sixty (72%) pts received active systemic chemotherapy. The location of index VTE was isolated pulmonary embolism (PE) in 151 (42%), isolated deep venous thrombosis (DVT) in 136 (37%), and combined PE and DVT in 76 (21%). The type of anticoagulation therapy for initial therapy was low molecular weight heparin in 282 pts (78%), and for long-term therapy was warfarin in 272 (75%). Eighteen (5%) pts received systemic or catheter-directed thrombolytic therapy for their index VTE at the time of initial diagnosis. Median duration of anticoagulation therapy was 2.4 months (range, 0.1–6.0). Fifty four (15%) pts presented with VTE recurrence within the first 6 months of index VTE. The distribution of site at VTE recurrence was 32 (57%) isolated PE, 10 (18%) isolated extremity DVT, 1 (2%) isolated IVT, 10 (18%) combined PE and DVT, 2 (4%) combined DVT and IVT, and 1 (2%) combined PE/DVT and IVT.The 6-month cumulative incidence of VTE recurrence after index VTE was 26.6% (95% CI, 19.7–33.5). In the univariate analysis for cumulative incidence of VTE recurrence, male gender (P=0.022), 2 to 4 of ECOG PS (P=0.002), lung or pancreas of primary site of cancer (P<0.001), presence of diabetes (P=0.028), and PE as an index VTE (P=0.016) were associated with higher incidence of VTE recurrence. In the multivariate analysis of risk factors for the development of VTE recurrence, lung (HR, 4.26; 95% CI, 1.48–12.34) or pancreas (HR, 10.63; 3.48–32.41) of primary site of cancer, 2 to 4 of ECOG PS (HR, 2.17; 1.23–3.84), and male gender (HR, 1.86; 1.01–3.44) were independent factors for increasing risk of VTE recurrence. Conclusion:This study demonstrated that the risk of VTE recurrence in Asian patients with recurrent/metastatic solid cancer receiving anticoagulation therapy after prior VTE was substantially high. Pancreas or lung as a cancer site, poor PS, and male gender were strong predictors of VTE recurrence. These may provide basic information to optimize treatment strategies for tailored thromboprophylaxis in recurrent or metastatic solid cancer pts. Further larger studies are needed to confirm our results and to compare with different ethnicities. Disclosures:No relevant conflicts of interest to declare.

Successful Treatment of Peripartum Massive Pulmonary Embolism with Extracorporeal Membrane Oxygenation and Catheter-Directed Pulmonary Thrombolytic Therapy

Chronic thromboembolic pulmonary hypertension during pregnancy is uncommon but is associated with maternal mortality in excess of 35%. We report a case of decompensated thromboembolic pulmonary hypertension requiring emergency caesarean section and postpartum treatment with extracorporeal membrane oxygenation and thrombolytic therapy with urokinase. The use of extracorporeal membrane oxygenation, catheter-directed pulmonary thrombolytic therapy and other pulmonary vasodilators for management of this life-threatening disease is discussed.

Abstract No. 377: Massive pulmonary embolism: A review of indications and techniques of mechanical catheter directed therapy (CDT)

Abstract No. 377: Massive pulmonary embolism: A review of indications and techniques of mechanical catheter directed therapy (CDT)

Abstract No. 99: Single session catheter-directed pharmacomechanical thrombolysis therapy for the treatment of massive pulmonary embolism in patients with right ventricular (RV) dysfunction

Abstract No. 99: Single session catheter-directed pharmacomechanical thrombolysis therapy for the treatment of massive pulmonary embolism in patients with right ventricular (RV) dysfunction

Research Reporting Standards for Radioembolization of Hepatic Malignancies

Primary Liver Tumors Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver; its incidence is increasing worldwide. It ranks as the sixth most common tumor and third most common cause of cancer-related mortality (1,2). Primary liver tumors include HCC and intrahepatic cholangiocarcinoma. Surgical resection is preferred over transplantation and is considered potentially curative in patients with resectable HCC and normal liver function (3). Transplantation is considered the gold standard for patients with unresectable HCC and whose disease is within the Milan criteria (4). Resection and transplantation have limited roles, given advanced disease (chronic liver disease and/or tumor extent) at presentation and limited organ availability (5–7). Chemoembolization and radiofrequency ablation represent standard therapies in treating patients and serve as a bridge to transplantation in selected patients (8,9). Radioembolization has an emerging role in “bridging” patients within criteria by delaying tumor progression. It has also been shown to downstage disease beyond the Milan, to within, transplant criteria (10–12). A recent study has demonstrated that radioembolization leads to longer time-to-progression and better toxicity profile when compared with chemoembolization (13). Patients with macrovascular tumor involvement have also exhibited evidence of clinical benefit after radioembolization (14).

Venous Interventions in Children

Advanced medical treatment options have improved pediatric survival but often require invasive vascular procedures or venous access. These procedures increase the risk for thromboembolism in children, and there has been a corresponding increase in the reported incidence of deep venous thrombosis and postthrombotic syndrome in the pediatric population. Percutaneous venous interventions using catheter-directed therapy (CDT), like mechanical thrombectomy and infusion thrombolysis, have been used much less frequently in children, even though they have shown good results in adults. A multidisciplinary team including pediatric hematology, interventional radiology, and intensive care unit is suggested for management of venous thrombosis in children. Indications and contraindications for CDT in children are similar to adults. Mechanical thrombectomy and infusion thrombolysis are some of the more commonly performed treatments. CDT in children requires adapting to patient size and locally available equipment. Ultrasound guidance for access, "cork" technique, appropriate dosing of tissue plasminogen activator for infusion/pharmacomechanical thrombolysis, and simultaneous administration of heparin, plasminogen (fresh frozen plasma), and deficient coagulation factors are some of the important variations of CDT technique in children. Postprocedure monitoring is very important for successful thrombolysis. Retrievable inferior vena cava filters are increasingly being used in children as well, for prophylaxis against pulmonary embolism (PE) if there is a significant risk of PE with/without contraindications to anticoagulation.

Catheter directed lysis and thrombectomy of submassive pulmonary embolism

Acute pulmonary embolism (PE) is a common and potentially highly morbid disease. However, there are a broad range of clinical presentations, varying from asymptomatic to life-threatening hemodynamic compromise. Accordingly, the aggressiveness of treatment for acute PE must be adjusted to the acuity of the presentation and patient-specific comorbidities. Thrombolysis is FDA approved for massive PE with hemodynamic compromise. However, this therapy has associated risk, most notably intracranial hemorrhage and other bleeding complications. This has prompted interest in catheter-directed therapies to mechanically remove thrombus and to locally deliver reduced doses of thrombolytics. Guidelines support use of this catheter-based strategy in cases of increased bleeding risk or high acuity with insufficient time for systemic pharmacologic therapy to be effective. We present the case of an 83-year-old man with acute high-risk PE and worsening hemodynamic and respiratory status who was treated with catheter-directed thrombolysis and rheolytic thrombectomy. There was significant improvement in thrombus burden, symptoms, and hemodynamic parameters including right ventricular function and pulmonary artery pressures. However, his course was complicated by intracranial hemorrhage and access site hematoma, demonstrating that even reduced doses and local delivery of thrombolytics do not ensure freedom from bleeding complications.

Endovascular Interventions for Acute Pulmonary Embolism

Massive pulmonary embolism (PE) is a highly lethal condition with clinical manifestations of hemodynamic instability, acute right ventricular (RV) failure, and cardiogenic shock. Submassive PE, as defined by RV failure or troponin elevation, can result in life-threatening sequelae if treatment is not initiated promptly. Current treatment paradigm in patients with massive PE mandates prompt risk stratification with aggressive therapeutic strategies. With the advent of endovascular technologies, various catheter-based thrombectomy and thrombolytic devices are available to treat patients with massive or submassive PE. In this article, a variety of endovascular treatment strategies for PE are analyzed. The authors' institutional experience with ultrasound-accelerated thrombolytic therapy as well as catheter-directed thrombolytic therapy in patients with acute massive PE during a recent 10-year period is discussed. Finally, clinical evidence on the utilization of catheter-based interventions in patients with massive and submassive PE is also analyzed.

Acute symptomatic mesenteric venous thrombosis: treatment by catheter-directed thrombolysis with transjugular intrahepatic route

Objective: To assess the feasibility and effectiveness of transjugular intrahepatic route aspiration thrombectomy and catheter-directed thrombolytic therapy in patients with acute superior mesenteric venous thrombosis. Materials and methods: During a period of 8 years, 12 patients with acute thrombosis of the superior mesenteric vein (SMV) were treated by transjugular intrahepatic approach. The mean age was 41.2 years. After access to the portal system via the transjugular approach, the pigtail catheter fragmentation of the thrombus, local urokinase injection, and manual aspiration thrombectomy were used for treatment of the SMV thrombosis initially, followed by continuous thrombolytic therapy via an indwelling infusion catheter in the SMV, which was performed for 2 to 6 days (4.2 ± 1.8 days). The adequacy of anticoagulation was performed during treatment, throughout hospitalization, and after discharge. Results: Technical success was achieved in all 12 patients. Substantial clinical improvement was seen in these patients after the procedure. Minor complications at the jugular puncture site were observed in 4 patients, but the thrombolytic therapy was not interrupted. Contrast-enhanced computed tomography (CT) scan before discharge demonstrated nearly complete disappearance of SMV thrombosis in all patients. The 12 patients were discharged 5–10 days (7.6 ± 2.0) after admission. Mean duration of follow-up after hospital discharge was 37.7 months, and no recurrent episodes of SMV thrombosis developed during that time period. Conclusion: Catheter-directed thrombus aspiration, mechanical fragmentation, and local thrombolytic infusion via the transjugular intrahepatic route is a safe and effective therapy for the management of patients with acute symptomatic SMV thrombosis.

Long-term Outcomes of Low-dose Catheter-directed Thrombolytic Therapy: A 5-year Single-center Experience

To determine immediate and long-term outcomes following catheter-directed intraarterial thrombolysis of occluded native arteries and infrainguinal vein grafts by using low-dose tissue-type plasminogen activator (tPA) in patients with lower limb ischemia. One hundred eleven intraarterial thrombolysis procedures were performed in 96 patients during the 2-year study period. Patient records were available for retrospective review in 85 thrombolytic procedures performed in 74 (77%) of the 96 patients. Forty-one native vessels (four iliac, 24 superficial/common femoral, and 13 popliteal/below-knee vessels), six iliac stents, and 38 infrainguinal vein grafts were treated by using a low-dose (0.5 mg/h recombinant tPA) catheter-directed thrombolytic regimen. Procedural success was based on angiographic and clinical outcomes, and the need for further reconstructive surgery or amputation was documented. Intraarterial thrombolysis was successful in 76%, was partially successful in 11%, and failed in 13%. Adjunctive angioplasty was performed in 33 of 55 patients (60%) with successful lysis, and immediate reconstructive surgery was required in five patients. There was one episode of puncture site bleeding and one gastrointestinal hemorrhage but no procedure-related deaths at 30 days. After a median follow-up of 6.5 years, 30 of the 55 patients (55%) who underwent successful thrombolysis required no further surgical intervention; however, further surgery was required in 45% of patients after a mean interval of 301 days (range, 2-1,344 days), including 10 (18%) amputations (six major and four minor). Low-dose intraarterial thrombolysis is safe and effective, delaying and dramatically reducing the need for surgical intervention in lower limb ischemia due to native vessel or infrainguinal graft occlusion.

The Association of Periprocedural Hypertension and Adverse Outcomes in Patients Undergoing Catheter-Directed Thrombolysis

Peripheral thrombolysis is an indispensible tool in the treatment of occlusive peripheral vascular disease (PVD). However, the use of intravascular thrombolytic agents carries a significant risk of morbidity and mortality. The aim of this study is to review a contemporary series of patients treated with catheter-directed thrombolytics in the treatment of occlusive PVD. A retrospective analysis was performed reviewing all patients who underwent catheter-directed thrombolytic therapy for PVD with recombinant tissue plasminogen activator (rt-PA) between 2005 and 2008. Data included clinical and demographic variables potentially associated with endpoints of technical success, hemorrhagic complications, and death. Data were analyzed with univariate and multivariate measures. Significance was assigned with p <0.05. Over the 36-month study, 125 thrombolytic procedures were performed. Indication for treatment was occlusive thrombus in native artery (49 cases, 37.6%), vein (13 cases, 10.4%), or arterial bypass graft (63 cases, 49.6%). Twenty three cases (14.3%) used ultrasound-assisted catheter technology. Mean patient age was 57.9 +/- 1.1 years. Technical success was achieved in 82% of cases. Mean rt-PA dose was 47.3 +/- 1.4 mg (13.5 +/- 4.5 mg with ultrasound assisted catheter technology). Hemorrhagic complications occurred in 22.4% of patients with a 5.6% stroke rate. Intracranial hemorrhage (ICH) correlated with poor hypertensive control (systolic blood pressure >160 mmHg; OR, 13.67; CI, 1.59-117.68; p = 0.006) and advanced age (>80 years; OR, 9.04; CI, 1.40-58.57, p = 0.049). Hemorrhagic complications (including minor access site hematomas) correlated with poor hypertensive control (systolic blood pressure >180 mmHg; OR, 3.48; CI, 1.22-9.94; p = 0.021) and in patients with congestive heart failure (OR, 3.26; CI, 1.09-9.76; p = 0.036). Overall mortality occurred in 7 patients (5.6%), 4 as a result of hemorrhagic complications. Correlates of mortality were patients with diabetes mellitus (OR, 8.85; CI, 1.62-48.26; p = 0.003), end stage renal disease (OR, 15.33; CI, 2.07-113.39; p < .001) and congestive heart failure (OR, 6.06; CI, 1.22-30.13; p = .014). Serum fibrinogen levels, pre-procedural hypertension, and rt-PA dosage did not correlate with hemorrhagic complication or death. Peripheral thrombolysis with catheter-based technologies has a high incidence of technical success. However, the procedure continues to carry a significant complication rate. This study emphasizes the importance of periprocedural hypertensive control and identifies subgroups of patients at risk of untoward complications. On the basis of these data, the authors advocate stricter blood pressure parameters in patients undergoing peripheral thrombolysis.

Catheter-directed thrombolytic therapy for thoracic deep vein thrombosis is safe and effective in selected patients with and without cancer

To assess the safety, feasibility and efficacy of catheter-directed thrombolysis for thoracic central venous thrombosis in both cancer and non-cancer patients. A retrospective case series of 68 patients, including 35 with active cancer and 33 without cancer, was analysed. They all received catheter-directed thrombolysis with alteplase or urokinase for symptomatic acute major thoracic vein thrombosis. Substantial clot lysis was obtained in 62 out of 68 patients (91%), the results being 88.6 and 93.8% for cancer and non-cancer patients respectively (P = 0.68). The mean infusion time in patients with and without cancer was 2.11 and 1.84 days respectively (P = 0.3259). Procedure-related complications occurred in two cancer patients (8.6%) and in seven non-cancer patients (21%) (P = 0.18). One cancer patient developed a fatal intracranial bleeding. Additional intervention after successful lysis was performed in cancer (n = 18; 51%) as well as in non-cancer patients (n = 29; 88%). Catheter-directed thrombolysis is a feasible and highly effective interventional procedure with an acceptable safety profile in selected patients with and without cancer for the treatment of symptomatic thoracic central venous thrombosis. In most cases, additional endovascular or surgical procedures are required to restore and maintain vessel patency after successful thrombolysis.

Management of Pulmonary Embolism: 2010 State-of-the-Art Update

The morbidity and mortality of venous thromboembolism remain underrecognized and underappreciated. Suspected pulmonary embolism should be risk stratified using a validated clinical risk prediction tool; intermediate to high clinical suspicion requires objective diagnostic testing to confirm or refute the diagnosis. Therapy with unfractionated heparin, low molecular weight heparin, or fondaparinux should be initiated while diagnostic testing is pursued. Conversion to vitamin K antagonists requires a minimum of 5days' overlap between the parenteral agent and the vitamin K antagonist. Anticoagulation should be continued for a minimum of 3 to 6months. Longer or even indefinite therapy may be required with a persistent hypercoagulable state. In patients with cancer, low molecular weight heparin monotherapy for the initial 3 to 6months is preferred. In stable patients with normal biomarkers and a normal echocardiogram, accelerated discharge and outpatient therapy may be considered. In patients with hemodynamic instability, systemic thrombolytic therapy, catheter-directed therapy, or surgical embolectomy may be considered. Cancer screening and/or thrombophilia testing should be pursued only if the findings will directly affect patient therapy or long-term care.

Abstract No. 144: Catheter-directed thrombolytic therapy for thoracic deep vein thrombosis is safe and effective in selected patients with and without cancer

Abstract No. 144: Catheter-directed thrombolytic therapy for thoracic deep vein thrombosis is safe and effective in selected patients with and without cancer

Catheter-directed Therapy for the Treatment of Massive Pulmonary Embolism: Systematic Review and Meta-analysis of Modern Techniques

Catheter-directed Therapy for the Treatment of Massive Pulmonary Embolism: Systematic Review and Meta-analysis of Modern Techniques

Catheter-directed Therapy for the Treatment of Massive Pulmonary Embolism: Systematic Review and Meta-analysis of Modern Techniques

Systemic thrombolysis for the treatment of acute pulmonary embolism (PE) carries an estimated 20% risk of major hemorrhage, including a 3%-5% risk of hemorrhagic stroke. The authors used evidence-based methods to evaluate the safety and effectiveness of modern catheter-directed therapy (CDT) as an alternative treatment for massive PE. The systematic review was initiated by electronic literature searches (MEDLINE, EMBASE) for studies published from January 1990 through September 2008. Inclusion criteria were applied to select patients with acute massive PE treated with modern CDT. Modern techniques were defined as the use of low-profile devices (< or =10 F), mechanical fragmentation and/or aspiration of emboli including rheolytic thrombectomy, and intraclot thrombolytic injection if a local drug was infused. Relevant non-English language articles were translated into English. Paired reviewers assessed study quality and abstracted data. Meta-analysis was performed by using random effects models to calculate pooled estimates for complications and clinical success rates across studies. Clinical success was defined as stabilization of hemodynamics, resolution of hypoxia, and survival to hospital discharge. Five hundred ninety-four patients from 35 studies (six prospective, 29 retrospective) met the criteria for inclusion. The pooled clinical success rate from CDT was 86.5% (95% confidence interval [CI]: 82.1%, 90.2%). Pooled risks of minor and major procedural complications were 7.9% (95% CI: 5.0%, 11.3%) and 2.4% (95% CI: 1.9%, 4.3%), respectively. Data on the use of systemic thrombolysis before CDT were available in 571 patients; 546 of those patients (95%) were treated with CDT as the first adjunct to heparin without previous intravenous thrombolysis. Modern CDT is a relatively safe and effective treatment for acute massive PE. At experienced centers, CDT should be considered as a first-line treatment for patients with massive PE.

Treatment of massive pulmonary embolism utilizing a multidisciplinary approach: a case study

Massive pulmonary embolism (PE) is associated, historically, with a high mortality rate.Treatment options include systemic anticoagulation, catheter-directed thrombolytic therapy, surgical embolectomy, fragmentation techniques, and catheter embolectomy. Extracorporeal membrane oxygenation (ECMO) repeatedly has demonstrated effectiveness in providing cardiopulmonary support for the patient with a massive PE too unstable to undergo thrombolysis or embolectomy. The present case study describes a morbidly obese patient, status post gastric bypass surgery, who presented with PE, and acute respiratory and cardiac failure. A description of the patient's management plan, which includes a simple, rapidly deployed ECMO system (Levitronix CentriMag And Jostra Quadrox D), systemic- and catheter-directed thrombolytic therapy and rheolytic thrombectomy (AngioJet Series 3000, Possis Medical, Minneapolis, MN).

Interventional Radiologist Treatment for Inferior Vena Caval Thrombosis in a Liver Transplant Recipient

Vascular complications remain an important cause of postoperative morbidity and mortality in liver transplant patients. There is no elective treatment and the need for retransplantation is common. Herein, we have reported an unusual case of nonanastomotic inferior vena cava thrombosis in a patient with a piggyback caval anastomosis. The conditions was successfully treated with catheter-directed thrombolytic therapy and endovascular stent placement.

Can Intraoperative Thrombolytic Therapy Assist with the Management of Acute Limb Ischemia?

Catheter-directed thrombolytic therapy is a well-accepted treatment modality for acute arterial and graft occlusion, but intraoperative use of plasminogen activators as an adjunct to operative thrombectomy or thromboembolectomy is frequently overlooked by vascular surgeons. Evidence exists that intraoperative intraarterial infusion of lytic agents is safe and is accompanied by breakdown of distal thrombus. This article describes the rationale for intraoperative thrombolysis, reviews the evidence supporting its use, and suggests several technical approaches to incorporating lytic therapy intraoperatively.