Intra-arterial Infusion Of Urokinase Research Articles

Safe and effective thrombolysis in free flap salvage: Intra-arterial urokinase infusion.

Despite the high success rate in reconstruction using free tissue transfer, flap failure is often caused by microvascular thrombosis. In a small percentage of cases with complete flap loss, a salvage procedure is performed. In the present study, the effectiveness of intra-arterial urokinase infusion through the free flap tissue was investigated to develop a protocol to prevent thrombotic failure. The retrospective study evaluated the medical records of patients who underwent salvage procedure with intra-arterial urokinase infusion after reconstruction with free flap transfer between January 2013 and July 2019. Thrombolysis with urokinase infusion was administered as salvage treatment for patients who experienced flap compromise more than 24 hours after free flap surgery. Because of an external venous drainage through the resected vein, 100,000 IU of urokinase was infused into the arterial pedicle only into the flap circulation. A total of 16 patients was included in the present study. The mean time to re-exploration was 45.4 hours (range: 24-88 hours), and the mean quantity of infused urokinase was 69,688 IU (range: 30,000-100,000 IU). 5 cases presented with both arterial and venous thrombosis, while 10 cases had only venous thrombosis and 1 case had only arterial thrombosis; in a study of 16 patients undergoing flap surgery, 11 flaps were found to have survived completely, while 2 flaps experienced transient partial necrosis and 3 were lost despite salvage efforts. In other word, 81.3% (13 of 16) of flaps survived. Systemic complications, including gastrointestinal bleeding, hematemesis, and hemorrhagic stroke, were not observed. The free flap can be effectively and safely salvaged without systemic hemorrhagic complications using high-dose intra-arterial urokinase infusion within a short period of time without systemic circulation, even in delayed salvage cases. Urokinase infusion results in successful salvage and low rate of fat necrosis.

Primary Catheter-Directed Thrombolysis for Porto-Mesenteric Venous Thrombosis (PMVT) in Non-Cirrhotic Patients.

Purpose: To report our thrombolytic technique, treatment strategy, and clinical outcomes for porto-mesenteric venous thrombosis (PMVT) in non-cirrhotic patients. Methods: Sixteen acute or chronic non-cirrhotic PMVT patients (mean age: 48.6 years) with imminent intestinal ischemia were enrolled from 2004 to 2020. Eight patients presented thrombus extension into the peripheral mesenteric vein, close to the venous arcade. Transhepatic catheter-directed thrombolysis (CDT) was performed by urokinase infusion (60,000–30,000 IU/h concomitant with heparin 300–400 IU/h), catheter aspiration, and/or balloon dilation/stent placement. Additional intra-arterial mesenteric infusion of urokinase (30,000 IU/h) was given in patients with the peripheral mesenteric venules involved. Transjugular intrahepatic porto-systemic shunt (TIPS) was created in patients with poor recanalization of the intrahepatic portal flow (PV). Results: The transhepatic route was adopted in all patients, with adjunct indirect mesenteric arterial thrombolytic infusion in eight patients. A total of up to 20.4 million IU urokinase was infused for 1–21 days’ treatment duration. TIPS was created in three patients with recanalization failure of the intrahepatic PV. Technical success was achieved in 100% of patients with complete recanalization of 80% and partial recanalization of 20%. No major procedure-related complications were encountered. The 30-day mortality rate was 6.7%. The overall two-year primary patency was 84.6%. Conclusions: CDT can be performed as a primary salvage treatment once the diagnosis is made. CDT via the transhepatic route with tailored thrombolytic regimen is safe and effective for both acute and chronic PMVT. TIPS creation can be preserved in non-cirrhotic PMVT patients if intrahepatic PV recanalization fails.

Pharmacomechanical Thrombectomy for Acute Limb Threatening Lower Extremity Arterial Thrombosis Secondary to COVID-19

Abstract Purpose The aim of this study was to report the clinical effectiveness and safety of pharmacomechanical thrombectomy (PMT) for acute limb threatening lower extremity arterial thrombosis secondary to coronavirus disease 2019 (COVID-19). Methods In this retrospective study, the clinical and imaging records of six patients (6 men, mean age 56 years) with COVID-19-related lower extremity arterial thrombosis and treated with PMT using the Angio-Jet device were reviewed. Patients presented with symptoms of acute pain in the affected limb, pallor, pulselessness, paresthesia, or paralysis. Thrombosis involved below knee arteries in all patients, and above knee arteries in three patients. Reteplase 18 mg was infused into the thrombus using the power pulse mode on the Angio-Jet device. This was followed by rheolytic thrombectomy and then, intra-arterial infusion of urokinase 100,000 IU/hour for 5 hours. All patients received systemic intravenous heparin. Technical success, clinical success, and complications of PMT were analyzed. Results The mean thrombectomy duration was 190.83 ± 99.18 seconds. Adjuvant balloon angioplasty was performed in two patients. The mean hospital stay was 7.67 ± 4.50 days. PMT was technically successful in all (100%) patients. Five patients had excellent clinical outcome with at least one palpable pulse and no tissue loss. One patient required minor amputation. One patient developed self-limiting retroperitoneal hematoma. Conclusion In our series, PMT with supplemental intra-arterial urokinase infusion was highly successful in treating acute peripheral arterial thrombosis secondary to COVID-19.

Endovascular and Clinical Outcomes of Vertebrobasilar Intracranial Atherosclerosis-Related Large Vessel Occlusion.

Background and Purpose: Endovascular treatment (EVT) for acute vertebrobasilar intracranial atherosclerosis-related large vessel occlusion (ICAS-LVO) and its outcomes are not well known. We aimed to evaluate endovascular and clinical outcomes of vertebrobasilar ICAS-LVO patients who underwent EVT.Methods: Consecutive acute stroke patients who underwent EVT for vertebrobasilar LVO were retrospectively reviewed. Patients were assigned to the ICAS (+) or the ICAS (–) group based on angiographical findings. Procedural details and clinical outcomes were compared between the ICAS (+) and ICAS (–) groups.Results: This study included 77 patients with acute vertebrobasilar LVO who underwent EVT. Among the study subjects, 24 (31.2%) had an ICAS-LVO. Recanalization was achieved in 19 patients in the ICAS (+) group (79.2%), which was comparable with the ICAS (–) group (84.9%; p = 0.529). However, recanalization using conventional endovascular modalities (stent retriever thrombectomy, contact aspiration thrombectomy, or intra-arterial urokinase infusion) was less successful in the ICAS (+) group (36.8%) than the ICAS (–) group (100.0%; p < 0.001). All the remaining patients in the ICAS (+) group required specific rescue treatments appropriate for ICAS, including balloon angioplasty, stenting, or intra-arterial glycoprotein IIb/IIIa inhibitor infusion to obtain a successful recanalization. Procedural time was not significantly longer in the ICAS (+) group. The rates of favorable outcomes (37.5% vs. 41.5%; p = 0.740), death, and symptomatic intracerebral hemorrhage were not significantly different between the groups.Conclusion: ICAS-LVO was common in patients who underwent EVT for acute vertebrobasilar LVO. Although conventional modalities were often ineffective for vertebrobasilar ICAS-LVO, a comparable recanalization rate could be obtained with ICAS-specific modalities. Recanalization rate and procedural time were comparable, and clinical outcomes did not differ between patients with or without ICAS-LVO.

Abstract TP19: Impact of Revascularization Therapy on Patient Outcome by the Severity of Acute Ischemic Stroke

Background and Purpose: It has not fully investigated whether the benefit from revascularization therapy for patients with mild acute ischemic stroke (AIS) can overweigh the risk. The aim of this study was to investigate the impact of revascularization therapy on patient outcome as related to the severity of the stroke. Methods: From our hospital’s stroke database from January 2006 to March 2017, we extracted data for patients with AIS. Eligible criteria for the patients were: modified Rankin Scale (mRS) of 0 or 1 before onset, admitted less than 24 hours after onset, and followed up for at least 3 months. Revascularization therapy included intravenous tissue plasminogen activator; endovascular therapy (intra-arterial urokinase infusion, percutaneous transluminal angioplasty, emergent carotid artery stenting, and thrombectomy); and carotid endarterectomy performed within 14 days from onset. Patients were divided into 4 groups based on the severity using the National Institutes of Health Stroke Scale (NIHSS) on admission : Group 1 = 0-4, Group 2 = 5-9, Group 3 = 10-19, and Group 4=20-. We defined a good outcome as mRS score of 0-1 at 3 months after onset. The odds ratio of a good outcome was computed among 4 groups, adjusting for age and sex. Results: We extracted data for 3275 patients with AIS (71.3 years, 65.1% men). Of these, 17.9% received revascularization therapy of any type. This was distributed across the 4 NIHSS groups as follows: 6.1% of Group 1 (n=2193), 27.1% of Group 2 (n=527), 56.4% of Group 3 (n=298), and 55.6% of Group 4 (n=257). The odds ratios (95% confidence interval) of treatment for good outcome in group 1 to 4 were 0.42 (0.29-0.62), 1.15 (0.78-1.72), 2.80 (1.60-4.90), and 4.40 (1.79-10.82), respectively. Group 1 was further divided into 5 subgroups by each NIHSS scores of 0-4. The odds ratios for each subgroup (NIHSS scores 0, 1, 2, 3, and 4) were 0.20 (0.07-0.61), 0.28 (0.11-0.69), 0.27 (0.11-0.69), 0.93 (0.43-2.03), and 0.88 (0.42-1.85), respectively. Conclusions: Approximately half of the patients with NIHSS score of ≥10 received revascularization therapy and had significant benefit. However, revascularization therapy for patients with mild AIS (specifically NIHSS scores of 0, 1, or 2) could be rather harmful.

Intra-arterial infusion of tirofiban and urokinase for thromboembolic complications during coil embolization of ruptured intracranial aneurysms.

To investigate the effectiveness and safety of intra-arterial tirofiban and urokinase for thromboembolic complications during detachable coil treatment of ruptured intracranial aneurysms. Fourteen patients who had a thromboembolic complication during detachable coil treatment of ruptured cerebral aneurysms from May 2011 to October 2013 were enrolled in this study. Within one hour of thrombus formation, patients underwent intra-arterial infusion of tirofiban plus urokinase with digital subtraction angiography monitoring. Blood flow was checked every 5 min with angiography until complete or partial recanalization of the occluded artery occurred. Of the 14 patients, 10 exhibited complete recanalization immediately after the thrombolytic treatment, and had no neurological dysfunction except one patient with mild hemiplegia. Two patients with partial recanalization exhibited mild neurological dysfunction and one died of cardiac infarction during the recovery period. Two patients had intracranial hemorrhage. In one of these, this was caused by rupture of the aneurysm and the patient died during the thrombolytic treatment. In the remaining patient, intracranial hemorrhage was caused by a puncture of the left posterior internal frontal artery caused by mechanical thrombolysis. Intra-arterial administration of tirofiban plus urokinase is an effective and safe treatment for thromboembolism during detachable coil treatment of ruptured intracranial aneurysms.

Recanalization of Acute Intracranial Artery Occlusion Using Temporary Endovascular Bypass Technique

PurposeThe purpose of this study is to present our preliminary experience of the temporary endovascular bypass (TEB) technique using an Enterprise stent for recanalization of acute intracranial artery (IA) occlusion.Materials and MethodsPatients treated by TEB were enrolled in this retrospective study from January 2009 to May 2010. All the procedures consist of temporary partial deployment and subsequent retrieval of Enterprise stent, supplemented by intra-arterial infusion of urokinase (UK) and/or tirofiban. According to the thrombolysis in cerebral infarction (TICI) classification, recanalization was evaluated with initial and postprocedural angiography. Safety was evaluated related to the procedure and clinical outcomes were assessed by National Institute of Health Stroke Scale (NIHSS) score at discharge and modified Rankin scale (mRS) score at 3 months.ResultsEleven patients (median NIHSS 12.8, mean age 61.6 years, male: female = 8:3) with acute IA occlusion were treated with TEB. All the patients presented with TICI 0, and the occluded vessel was the middle cerebral artery (n=7), the basilar artery (n=1), and the distal ICA occlusion (n = 3). IV infusion of tissue plasminogen activator (tPA) was done in 4 patients and mechanical thrombolysis with intra-arterial UK was performed in 9. Recanalization was achieved in 73% (8 patients; TICI ≥ 2). There were no procedure-related complications except for two asymptomatic intracranial hemorrhages. Improvement (≥ 4 points on the NIHSS) and good outcome (mRS ≤2) after 90 days was shown in six patients (55%). One patient died 6 days after procedure.ConclusionTEB may be a valuable treatment option in acute thromboembolic IA occlusion without stent implantation.

Hepatic Artery Reconstruction in Living Donor Liver Transplantation: Running Suture Under Surgical Loupes by Cardiovascular Surgeons in 180 Recipients

ObjectivesThe aim of our study was to retrospectively investigate the outcomes of hepatic artery (HA) reconstruction by cardiovascular surgeons in adult-to-adult living donor liver transplantation (A-A LDLT). MethodsFrom April 2007 to April 2011, 187 recipients underwent A-A LDLT. After excluding seven ABO-incompatible transplant recipients, we reviewed the courses of 180 patients including 125 men and 55 women of mean age 52.5 ± 9.2 years (range = 23–71). One hundred seventy-seven patients received right-lobe grafts with inclusion of middle hepatic vein (MHV); two, right-lobe grafts without MHV; and one, left-lobe graft. A continuous, single-stitch, running suture with the parachute technique was used for HA reconstruction. The anastomosis was performed by cardiovascular surgeons employing surgical loupes with 4.5× magnification. ResultsThe mean time for an arterial reconstruction was 10.7 ± 4.0 minutes (median = 10, range = 4–30). Hepatic arterial thrombosis (HAT) was encountered in 3 (1.66%) patients. One HAT that developed on postoperative day 1 was successfully rescued by the intra-arterial infusion of urokinase. Another patient required reoperation due to a redundant kinked HA. A third HAT patient underwent successful retransplantation with a cadaveric graft on postoperative day 6. In our series, no delayed HAT was detected and no recipient deaths were related to HAT. ConclusionHA reconstruction with a running suture under surgical loupes is a feasible technique in A-A LDLT. A speedy reconstruction can be performed by an experienced cardiovascular surgeon with a low incidence of HAT.

頚動脈ステント留置術後，急性期ステント内血栓を繰り返した１例：症例報告

【目的】頚動脈ステント留置術（carotid artery stenting；CAS）において，治療後のステント内血栓症は非常に重篤で，時に致命的となりうる合併症である．今回我々は治療後短期間にステント内血栓症を繰り返し，その治療に難渋した症例を経験したので報告する．【症例】68歳の男性，両側頚動脈狭窄症に対して両側ともCASによる治療を行うこととした．右側病変に対するCASは問題なく終了したため，2ヵ月間の間隔をおいて左内頚動脈病変に対するCASを施行したが，術後第5，第10，第14病日にステント内血栓症によるステント内閉塞を合併した．ステント内血栓症は可能な限りの薬物治療や新たなステントの追加留置にも関わらず繰り返され，第17病日に脳内出血を来し重篤な状態に陥った．【結論】CAS後に繰り返すステント内血栓症に対して長期間の強力な抗血栓療法を行うことは頭蓋内出血の危険を増加させることも念頭に置き，頚動脈血栓内膜剥離術による外科的摘出を含めた治療方針の検討が必要である．

The Susceptibility Vessel Sign of the Middle Cerebral Artery on the T2*-Weighted Gradient Echo Imaging: Semi-quantification to Predict the Response to Multimodal Intra-Arterial Thrombolysis

Purpose: We wanted to determine whether or not the “susceptibility asymmetry index” (SAI) of acute stroke on the T2*-weighted image is related with successful recanalization using multimodal intra-arterial thrombolysis (IAT). Materials and Methods: The 81 patients who underwent multimodal IAT for middle cerebral artery (MCA) territory acute stroke were included in this retrospective study. The multimodal IAT included intra-arterial urokinase infusion, clot disruption by a microwire, microcatheter and balloon manipulation, and balloon angioplasty and/or stenting for the flow-limiting stenosis. The diameter of the susceptibility vessel sign was measured on the T2*-weighted gradient echo imaging (GRE), and the diameter of the contralateral normal MCA at the corresponding level was measured on magnetic resonance angiography (MRA); the ratio between these two diameters was defined as the susceptibility asymmetry index. The relation between the TICI (Thrombolysis In Cerebral Infarction) score of 2-3 after multimodal IAT and the SAI was assessed. The receiver operating characteristic (ROC) curve analysis was performed on the SAI to predict a TICI score of 2-3 after multimodal IAT. Results: The mean SAI of 81 patients was 1.66 ± 0.66. Seventy nine percent of the patients had a TICI of 2-3 after multimodal IAT. According to the ROC curve analysis, an SAI less than 1.3 was optimal for predicting the presence of stenotic lesion after recanalization (area under the curve: 0.821, sensitivity: 88.2%, specificity: 69.8%, p=0.0001), and the SAI ≤1.61 (area under the curve: 0.652, sensitivity: 60.9%, specificity: 70.6%, p=0.0226) could predict a TICI score of 2-3. The TICI score of 2-3 after multimodal IAT was achieved in 88.6% of the cases with a SAI ≤ 1.61 and in 67.6% of the cases with a SAI >1.61 (p=0.028). Conclusion: The lower SAI on T2*-GRE could predict stenotic lesion and successful recanalization after performing IAT.

Outcome in Acute Stroke with Different Intra-Arterial Infusion Rate of Urokinase on Thrombolysis

Intra-arterial infusion of urokinase (UK) has been widely used. However, the optimal infusion rate of the reagent has never been determined. This was investigated in the acute stage of middle cerebral artery (MCA) embolism in the present study. Sprague Dawley male rats (n=43) were randomly divided into sham-operation and five ischemic groups with urokinase administration at different infusion rates or without urokinase administration. Ischemia was induced with MCA embolism. Two hours after embolism, total urokinase (urokinase, 170,000U/kg) was given in groups A,B,C and D (n=8 each) at different rates: 1,000 U (0.03 ml/min) per minute, 4,000U (0.12 ml/min), 10,000U (0.30 ml/min), and 16,000U (0.48 ml/min), respectively. Group E received normal saline at a rate of 0.48 ml/min. The sham-operation group (no embolism) received urokinase at (170,000U/kg, 1.5 ml, 16,000 U/min). During ischemia and thrombolysis, regional cerebral blood flow (CBF) was monitored by laser Doppler flowmetry. The neurological deficits, infarct volumes and mortalities in each group were determined. The CBF in ischemic hemisphere were significantly (p<0.05) decreased after embolism in groups A∼E at similar levels (27.32±8.20% to 34.71±6.84%). After different treatments, in group B 4,000U/min infusion of UK induced the best reperfusion, the least neurological deficits and infarct volume, as well as the least mortality and lowest incidence of hemorrhage. The effect of intra-artery thrombolysis of urokinase was related to the infusion rate. Our study demonstrated an optimal infusion rate at 4,000U/min, suggesting relatively low levels of infusion are better able to improve brain reperfusion and reduce brain injury after stroke.

Recurrent ischemic stroke in a patient with idiopathic thrombocytopenic purpura

Recurrent cerebral infarctions developed in a patient with idiopathic thrombocytopenic purpura (ITP). At the time of the first stroke, there were large thrombi in the right proximal internal carotid artery (ICA) and an occlusion of the right terminal ICA. The occlusion was recanalized by intra-arterial infusion of urokinase. After 20 months, he suffered another ischemic attack. The autoantibodies in ITP directed against antigens presented on both platelets and endothelial cells might induce the endothelial damage, thrombus formation, and embolic occlusion of the artery.

Empty Microcatheter Technique for the Deployment of a Self‐Expanding Stent to Treat Refractory Middle Cerebral Artery Occlusion in the Setting of Severe Proximal Tortuosity

We report a case of an acute middle cerebral artery (M2 segment) occlusion that was refractory to intravenous tissue plasminogen activator (IV t-PA), thrombectomy with the Merci device, intra-arterial infusion of urokinase and eptifibatide, and balloon angioplasty. The artery was so tortuous that over-the-wire stent placement failed and a salvage technique was required to place the self-expanding stent.

Randomized Trial of Intraarterial Infusion of Urokinase Within 6 Hours of Middle Cerebral Artery Stroke

The Middle Cerebral Artery Embolism Local Fibrinolytic Intervention Trial (MELT) Japan was organized to determine the safety and clinical efficacy of intraarterial infusion of urokinase (UK) in patients with stroke within 6 hours of onset. Patients with ischemic stroke presenting within 6 hours of onset and displaying occlusions of the M1 or M2 portion of the middle cerebral artery on carotid angiography were randomized to the UK or control groups. Clinical outcome was assessed by the modified Rankin Scale, National Institutes of Health Stroke Scale, and Barthel Index. The Independent Monitoring Committee recommended stopping the trial after approval of intravenous infusion of recombinant tissue plasminogen activator in Japan. A total of 114 patients underwent randomization, 57 patients in each group. Background characteristics were comparable between the 2 groups. The primary end point of favorable outcome (modified Rankin Scale 0 to 2) at 90 days was somewhat more frequent in the UK group than in the control group (49.1% and 38.6%, OR: 1.54, 95% CI: 0.73 to 3.23) but did not reach a significant level (P=0.345). However, excellent functional outcome (modified Rankin Scale 0 to 1) at 90 days, a preplanned secondary end point, was more frequent in the UK group than in the control group (42.1% and 22.8%, P=0.045, OR: 2.46, 95% CI: 1.09 to 5.54). There were significantly more patients with National Institutes of Health Stroke Scale 0 or 1 at 90 days in the UK group than the control group (P=0.017). The 90-day cumulative mortality was 5.3% in the UK group and 3.5% in the control group (P=1.000), and intracerebral hemorrhage within 24 hours of treatment occurred in 9% and 2%, respectively (P=0.206). The trial was aborted prematurely and the primary end point did not reach statistical significance. Nevertheless, the secondary analyses suggested that intraarterial fibrinolysis has the potential to increase the likelihood of excellent functional outcome.

Intra-Arterial Thrombolysis for Left Middle Cerebral Artery Embolic Stroke During Coronary Angiography

Cerebral thromboembolism is an uncommon but serious complication of cardiac catheterization. Early diagnosis and rapid treatment by reperfusion techniques have been shown to prevent long-term neurological morbidity. We report 2 consecutive cases of successful local intra-arterial thrombolysis (LIT) for embolic stroke of the middle cerebral artery (MCA) during diagnostic coronary angiography that resulted in complete neurological recovery. A 77-year-old woman with severe valvular aortic stenosis was admitted to our catheterization laboratory for a preoperative coronary angiography. Performed from the femoral approach, it showed a normal angiographic pattern. Immediately after the procedure, the patient became stuporous with right hemiplegia and global aphasia. She was hemodynamically stable. The left carotid digital subtraction angiography that was performed immediately revealed total occlusion of the M2 part of the left MCA. There was no extravasation of contrast (Figure 1). We decided to administer selective intra-arterial urokinase infusion. After systemic heparinization (bolus of 5000 UI), a 6F Amplatz Right Guide catheter was placed in the left internal …

血栓溶解療法1カ月後に消化管穿孔にて再発した上腸間膜動脈血栓症の1例

血栓溶解療法1カ月後に消化管穿孔にて再発した上腸間膜動脈血栓症の1例

A Case of Acute Thrombotic Renal Artery Occlusion Treated with Local Urokinase Infusion

Acute thrombotic renal artery occlusion is rarely identified at premortem. Early diagnosis and treatment are crucial for salvage of renal function. We reported a case of successfully dissolved acute thrombotic occlusion of renal artery of 9 hour duration with intra-arterial infusion of urokinase in a 83-year-old man. (Korean Circulation J 2003;33 (3):246-249)

Outcome Evaluation of Intra-arterial Infusion of Urokinase for Acute Ischemic Stroke

Pupose: To evaluate the results of intra-arterial urokinase thrombolysis in cases of acute ischemic stroke and to define the factors affecting prognosis. Materials and Methods: Forty-eight patients with angiographically proven occlusion of the intracranial arteries were treated with local intra-arterial infusion of urokinase within six hours of the onset of symptoms. Neurologic status was evaluated on admission and on discharge using the NIH(National Institute of Health) stroke scale score (SSS). When the SSS decreased by at least four points, this was considered indicative of an improved clinical outcome. Results: Complete recanalization was achieved in 17/48 patients (35%), including 8 of 13 (62%) with occlusion of the vertebrobasilar artery (VBA), 9 of 20 (45%) with occlusion of the middle cerebral artery (MCA), and none of 15 with occlusion of the internal carotid artery (ICA). Neurologic status improved in 12 (60%) of patients with MCA occlusion, in five (38%) of those with VBA occlusion and in three (20%) of those with ICA occlusion (P

Treatment of Upper-Extremity Phlegmasia Cerulea Dolens with Intra-arterial Thrombolysis

Upper-extremity deep vein thrombosis is a common iatrogenic complication in patients who have had central venous catheters, and is usually associated with mild symptoms. This report is of a 57-year-old craftsman who developed phlegmasia cerulea dolens of his left upper extremity 16 hours after removal of an ipsilateral subclavian vein catheter. The extremity was tensely edematous, hand was mottled, and tips of the digits were cyanotic. Arterial Doppler signals were normal. Fourteen hours of extremity elevation and heparin anticoagulation resulted in no clinical improvement. Duplex ultrasonography and venography showed diffuse thrombosis of the veins of the arm and forearm, but patent axillary and subclavian veins. Due to the severity of the edema and evidence of vascular compromise, an infusion catheter, introduced through the right common femoral artery, was positioned in the left brachial artery and an intra-arterial urokinase infusion of the left upper extremity initiated. Within 12 hours, the patient's left upper extremity improved notably. Ninety-three hours later, the urokinase infusion was stopped and the left upper extremity appeared normal. Follow-up duplex ultrasonography documented no residual thrombus in the deep veins of the left arm and forearm. Six months later, the patient has no residual disability, extremity edema, or limitations in function. An extensive review of the English literature identified no previous reports of intraarterial thrombolysis for upper-extremity phlegmasia cerulea dolens. This case is discussed and pertinent literature reviewed.

Morphological abnormalities revealed after successful intra-arterial thrombolysis of infra-inguinal native arteries and bypasses.

To characterise morphological abnormalities depicted after successful intra-arterial thrombolysis; to determine whether these differed in infra-inguinal native arteries and bypasses; and to evaluate whether balloon angioplasty was an appropriate treatment of stenoses in the acute phase after thrombolysis. Patient records, radiology records, and angiograms from 47 patients with acute or subacute occlusions of infra-inguinal arteries (n = 21) or bypasses (n = 26) successfully treated with continuous intra-arterial infusion of streptokinase, urokinase or tissue plasminogen activator were retrospectively reviewed. Angiographic morphological abnormalities were depicted in 18 of 21 arteries (86%) and in 23 of 26 bypasses (88%), the most common abnormality being stenoses. Haemodynamically significant stenoses were found in 15 arteries (71%) and 18 bypasses (69%). The majority of the stenoses were successfully treated with balloon angioplasty, both in native arteries (12/15; 80%) and in bypasses (14/18; 78%). Morphological abnormalities are most often shown after successful intra-arterial thrombolysis in arteries, autogenous and non-autogenous bypasses. In all types of conduits, stenoses are the most commonly revealed lesion, which in the majority of cases can be treated with balloon angioplasty. Short-term outcome after catheter-directed thrombolysis and angioplasty seems fair.