[Q7: D] Both pulmonary failure and myocardial infarction are more common with surgical revascularization and relatively infrequent complications in patients treated with thrombolytic therapy. Bleeding complications are the most frequent complications associated with thrombolytic therapy, and these are typically related to access bleeding that requires transfusion. The access-related bleeding rates ranged from 7% to 12.5% in the Rochester, STILE, and TOPAS trials compared to intracranial hemorrhage rates ranging from 0.5% to 2.5%. STILE found low fibrinogen levels to be associated with bleeding complications, while TOPAS found therapeutic heparin to increase the risk of complications. It is important to note that these trials limited therapy to 24–48 h for fear of bleeding complications. Bleeding, unexplained drop in hemoglobin, neurological changes, or fibrinogen levels falling below 100 mg/dL usually require cessation of thrombolytic therapy. The patient in this case represents an aggressive approach to extensive clot burden throughout the aortoiliac segment. In this example, therapy was extended to 72 h, longer than our usual arterial thrombolytic case, in order to fully dissolve all of the thrombus.

References

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3.Kashyap VS, Quinones-Baldrich WJ. Principles of thrombolytic therapy. In: Rutherford RB, ed. Vascular Surgery. 5th ed. Philadelphia, PA: W.B. Saunders; 2000:457-475.

4.Ouriel K, Shortell CK, DeWeese JA, et al. A comparison of thrombolytic therapy with operative revascularization in the initial treatment of acute peripheral arterial ischemia. J Vasc Surg. 1994;19:1021-1030.

5.The STILE Investigators. Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity, The STILE Trial. Ann Surg. 1994;220: 251-268.

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7.OurielK,VeithFJ,SasaharaAA.Acomparisonofrecombinanturokinasewithvascular­surgery as initial treatment for acute arterial occlusion of the legs. N Engl J Med. 1998;338: 1105-1111.

8.Working Party on Thrombolysis in the Management of Limb Ischemia. Thrombolysis in the management of lower limb peripheral arterial occlusion – a consensus document. J Vasc Interv Radiol.  2003 (Sept);14(9 Pt 2):S337-S349.

Part II

Acute Ischemia