Peripheral Intra Arterial Thrombolysis

Peripheral Intra Arterial Thrombolysis

Cannulate the vessel and pass a guidewire across the thrombus before thrombolysis. Heparin is given intravenously as soon as the guide wire passes the thrombus. Heparin bolus followed by infusion is used to maintain therapeutic level. Catheter with multiple side holes is used for thrombolysis. Streptokinase is not generally used in view of bleeding complications. Either Urokinase or tPA is used. Immediate success is achieved in 60-90% and 2 year patency up to 80%.

Complications expected with PIAT

Most common complication is 3 -20% site bleed.
Intracranial bleeds can occur in 0.5 – 2%.

A Cochrane review concluded that there is some evidence indicating that intra-arterial tissue plasminogen activator is more effective than intra-arterial streptokinase or intravenous tissue plasminogen activator in improving vessel patency in peripheral arterial occlusion [1]. The conclusion was reached after evaluating five randomized controlled trials involving a total of 687 participants.

One retrospective study reported on 71 patients with acute popliteal artery occlusion, with a mean 6 day old ischemic time before thrombolysis [2]. Technical success was achieved in 90% and clinical success in 87% of cases. Of the 71 patients, 33 had embolic occlusion while 38 had thrombotic occlusions. There were no major bleeding complications.

Balloon catheter guided PIAT

Another method for PIAT is using a porous balloon with low pressure [3]. Recanalization could be obtained in 13 of the 14 cases in that study and the usage of fibrinolytic agent was low. The limb salvage rate at 6 months after recanalization was 92% and the mean stay in the monitored area was around one day. This method could reduce hemorrhagic risk in the elderly because of localized delivery of lower quantity of fibrinolytic agent.

Ultrasound accelerated PIAT

• Another study compared ultrasound accelerated vs multi-hole infusion catheter for thrombolysis in acute limb ischemia [4]. There was no significant difference in mean infusion duration, volume of tissue plasminogen activator or technical success rate between the two cohorts. No difference was noted in major limb loss, compartment syndrome, overall complication rate and 30 day mortality between the two catheter systems in that study.

References

1. Robertson I, Kessel DO, Berridge DC. Fibrinolytic agents for peripheral arterial occlusion. Cochrane Database Syst Rev. 2013 Dec 19;(12):CD001099. 
2. Della Schiava N, Naudin I, Bordet M, Boudjelit T, Moia A, Arsicot M, Tresson P, Lermusiaux P, Millon A. Intra-arterial thrombolysis in acute popliteal artery occlusion is a safe and effective technique reducing the rate of open surgery. J Cardiovasc Surg (Torino). 2020 Dec;61(6):745-751. 
3. Dakhil B, Lacal P, Abdesselam AB, Couffinhal JC, Gordienco A, Bagan P. Evaluation of balloon catheter-guided intra-arterial thrombolysis for acute peripheral arterial occlusion. Ann Vasc Surg. 2013 Aug;27(6):781-4.
4. Chait J, Aurshina A, Marks N, Hingorani A, Ascher E. Comparison of Ultrasound-Accelerated Versus Multi-Hole Infusion Catheter-Directed Thrombolysis for the Treatment of Acute Limb Ischemia. Vasc Endovascular Surg. 2019 Oct;53(7):558-562.