Mr X Background Hx: EVAR (AUI + R-L fem-fem crossover) Intermittent claudication L>R for the last...
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Transcript of Mr X Background Hx: EVAR (AUI + R-L fem-fem crossover) Intermittent claudication L>R for the last...
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Surgical Grand Rounds03/10/2013
Thrombolysis never too late
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Mr X
Background Hx: EVAR (AUI + R-L fem-fem crossover) Intermittent claudication L>R for the last 18
months
Case presentation
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Admitted with a 10 day hx of acute deterioration of left foot pain progressing to rest pain
2013
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Hypertension Dyslipidaemia
Medications
- Pravastatin - Amlodipine- Aspirin- Bisoprolol
NKDA
Social Hx: smokerFam Hx : PVD
Past Medical History
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Left cold, pale foot Pulses not palpable
ABIS:Right : NormalLeft : 0.3
Underwent full investigation for embolus source (Holter, Echo)
Examination
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CT angio 2013
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CT angiogram 2013
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Fem – Fem Crossover
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Angiogram prior to thrombolysis
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Angiogram Post thrombolysis
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Thrombolysis Catheter-directed thrombolysis performed
by vascular surgeons/interventional radiologists
Plan◦ Mechanism◦ Indications/contraindications◦ Technique◦ Peri-procedural protocol/complications◦ Evidence
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ACTIVATION
FDPs
FDPs
Prothrombin (II)
Thrombin (IIa)
ClotFibrinogen (I) Fibrin (Ia)Platelets
PlasminPlasminogenDEGRADATION
MECHANISM OF ACTION
tPA
(Binds)
(Converts)
(Converts)
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Indications
Acute limb iscahemia
◦ Acute embolus
◦ Thrombosis of a stenosis in a native artery
◦ Thrombosed arterial bypass graft
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Relative Contra-indications Haemorrhagic diathesis
Recent GI bleed
Hx stroke, intracranial tumour/aneurysm, spinal surgery
Pancreatitis
Bacterial endocarditis
Documented GI neoplasm, varices
Recent surgery
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Thrombolysis - Technique Contralateral access via common femoral artery Guidewire traversal test / Catheter tip into thrombus. Single vs multi side holeLow-Dose Infusion: 0.5-1mg tPA per hourHeparin – pericatheter thrombosisSequential angiogramsAdvance catheter tip / co-axial system? Treatable critical stenosisAccelerated InfusionPulse Spray, Hi-dose bolus
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tPA Protocol(Acute Limb Ischaemia)
Overnight continuous infusion techniques using multislit catheter
Surgeon/Radiologist initiating tPA to inject 5mg bolus into clot through infusion catheter
Infuse via pump at 5ml/hr (1mg tPA/ hr) to cont. until rpt angiogram
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tPA Protocol(Acute Limb Ischaemia) Cont.
Sub-therapeutic heparin given through side port of the sheath in the groin (2500 IU bolus then 500 IU/hr as maintenance)
Monitor aPTT to ensure < 60secs
Monitor Fibrinogen levels 6 hourly to maintain > 100mg/dL
Repeat angiogram the next morning
Remove sheaths after waiting 1 hr post tPA termination & Activated Clotting Time < 175
Continue therapeutic heparin arm if indicated with 6 hourly monitoring of APTT between 60-90
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Baseline obs & Dopplers
Check 1/2 hourly obs:
• T°, HR, BP• Inspect access
site of thrombolysis catheter
• Dopplers
CALL SURGICAL TEAM
Causes for concern:• Bleeding from site• Persistant tachycardia post thrombolysis
initiation• Increasing groin pain• Hypotension• Headache• Altered motor function(?TIA/CVA)• Altered mental state
Check tPA and Heparin are correctly connected and running
MANAGEMENT OF PATIENTS ON TPA
Infusion running
No Change
Infusion NOT running
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Patient Guidelines on tPA
Strict bed rest
Urinary Catheter in situ
Normal diet
Bloods: FBC, U&E, Coags, Fibrinogen levels, Group & Crossmatch (2 units)
Check angiogram day post procedure
Infusion can only be stopped upon instructions by Surgeon/Radiology team and the team is to remove infusion catheter
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TPA vs. Surgery 3 randomized, clinical trials in 1990’s
◦ Rochester series – urokinase vs surgery, 114 pts- Limb salvage rate similar in both - 82% at 12 months - Survival rate thrombolysis group (84%) vs 58% (more
cardiopulmonary complications)
◦ STILE trial – rt-PA, urokinase vs surgery, 234 pts
- Patients with acute ischemia (0-14 days) who were treated with thrombolysis had improved amputation-free survival and shorter hospital stays, but those with chronic ischemia (> 14 days), surgical revascularisation was more effective and safer
◦ TOPAS trial - urokinase - Amputation free survival
Thromb: 71.8% (6/12), 65% at 1 yrSurgery: 74.8% (6/12), 69.9%
- Major Haemorrhage 12.5% Vs 5.5%- Open procedures 315 Vs 551 at 6 months
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To summarise
Rochester – Mortality Surgery > Thrombolysis, similar outcome limbSTILE – acute cases better with lysisTOPAS – Similar outcome with decreased need for open surgeryAll showed higher risk bleeding with thrombolysis
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Berridge C et al - Surgery versus thrombolysis for initial management of acute limb ischaemia – updated 2013
All RCTs comparing thrombolysis and surgery for the initial treatment of acute limb ischaemia
Five trials with a total of 1283 participants
Cochrane review
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No significant difference in limb salvage or death at 30 days, six months or one year for initial surgery vs thrombolysis.
At 30 days, thrombolysis patients had higher rate of◦ stroke (1.3%) vs (0%) ◦ major haemorrhage (8.8%) vs (3.3%)◦ distal embolisation (12.4%) vs (0%) (OR 8.35; 95% CI
4.47 to 15.58). Participants treated by initial thrombolysis
underwent a less severe degree of intervention (OR 5.37; 95% CI 3.99 to 7.22) and displayed equivalent overall survival (OR 0.87; 95% CI 0.61 to 1.25).
Results
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National Audit of Thrombolysis for Acute Leg Ischemia (NATALI)
Data collected over 10 years
11 centres in UK, 1133 thrombolysis
Major haemorrhage rate 7.85%
Stroke rate 2.3% - ½ haemorrhagic
Earnshaw et al JVS 2004
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NATALI
Adverse Predictors of Amputation free survival
Age, DM, Duration + Severity of Ischemia, Neurosensory deficit
Poor Predictors of Patient SurvivalFemale, Age, IHD, Native vessel occlusion and
embolic etiology
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