Tabla 1.

Figura 1. A. Oclusión proximal de la arteria femoral superficial (AFS). B. Defecto de relleno de a...

Figura 2. Técnica de pulse spray intratrombo con 250.000 UI de estreptoquinasa, a través de caté...

Figura 3. A. Placa ulcerada en el tercio medio de la arteria femoral superficial (AFS). B. Implante ...

CLINICAL CASE

A 75-year-old patient, hypertensive, dyslipidemic, a hierarchical smoker (15 cigarettes per day / 55 years), atrial fibrillation (AF) without treatment (Enalapril, Rosuvastatin), went to the ward for presenting intense pain in the lower right limb for 24 hours of evolution at rest.

Physical examination revealed paleness, coldness, absence of popliteal and tibial pulses of the right lower limb, echo-Doppler of the extremity was performed, confirming absence of flow from the superficial femoral artery (SFA) throughout its entire trajectory, including the popliteal artery (AP) and anterior tibial (TA) and posterior tibial (TP) artery.

It is interpreted as critical acute ischemia Rutherford grade IV. Angiography of the lower limb was performed and proximal occlusion of the AFS, filling defect in PA due to femoral artery thrombosis, absence of infrapatellar flow secondary to hypo perfusion (Figure 1) is evidenced.

The viability of the limb was evaluated and after ruling out contraindications for thrombolysis, endovascular treatment was decided with the intrathrombus “pulse spray” technique with 250,000 IU of streptokinase, through a multipurpose 5 French perforated catheter (6) (Figure 2).

Continuous intrathrombus infusion with 1,250,000 IU of streptokinase at 42 ml / h for 12 hours is left through a multipurpose catheter.

After 12 hours, the pain disappeared and the popliteal and tibial pulse returned, a control angiography was performed and the patent superficial femoral artery was visualized with a lesion in the middle third, for which it was decided to implant 70 x 120 mm self-expanding stents (Figure 3).

After successful resolution, perfusion of the femoral and infrapatellar circulation was restored (Figure 3), the patient was discharged at 48 hours with enalapril, acetylsalicylic acid, clopidogrel, atorvastatin, beta-blockers and anticoagulation for AF.

The quarterly clinical controls after discharge showed that the patient is in complete normality, performs asymptomatic daily aerobic physical activity, without limitations. The control echo-Doppler at 3 months shows triphasic flow in the femoral and infrapatellar region.

DISCUSSION

At present, acute ischemia of the lower limbs is pathology of great interest at the public health level, because its incidence is increasing and is related to the age of the patient and common comorbidities that generate thrombosis, such as diabetes mellitus, smoking, arrhythmias, among other.

It has a mortality rate of 5 to 15% and amputation from 10 to 18% if the patient is treated and treated within the first 24 hours, however, if the treatment is after 24 hours the mortality increases from 20 to 40% and the amputation rate of 18 to 50%.

Symptomatic peripheral arterial disease increases with age and varies annually, from approximately 0.3% in men aged 40 to 55 years to approximately 1% in men older than 75 years (1), with an annual incidence of ischemia acute of up to 1.5 cases per 10,000 people per year. (2). the most common cause is thrombosis of previously patent arteries or prostheses, but it can also occur due to arterial embolism from proximal sources, dissection, aneurysm, or direct arterial trauma. (3)

Acute ischemia of the lower limb must be treated urgently to save the viability of the affected limb and avoid its amputation, always evaluating which is the best treatment according to its genesis and the degree of ischemia that the patient presents, the treatment can be endovascular or surgical.

Acute ischemia of lower limbs is a pathology that depending on its clinical presentation and viability of the affected member can be treated in the early hours and up to 14 days from the beginning of the symptoms. (Table 1) (7)

Fibrinolysis directed by catheter (FDC) is a technique used in acute ischemia of lower limbs, aim is to dilute the thrombus in vessels of greater and lesser diameter, reducing the risk of sudden reperfusion lesion and endothelial trauma injury generated by the others generated Therapeutic alternatives, in addition to recanalizing occlusion, allows angioplasting the underlying injury if necessary.

For its diagnosis, the Echo-Doppler is very useful because it is accessible and non-invasive, it shows the presence or absence of the arterial and venous pulse. It allows locating the arterial occlusion as well as identifying the underlying cause, such as an aneurysm or arteriosclerotic plaque. It should be remembered that computed tomography angiography is indicated due to its easy use in emergency cases, and it also has a specificity and sensitivity of 90%. (4) It helps us to evaluate where the obstruction is located, however, the GOLD STANDARD continues to be the arteriography that, beyond being the best diagnostic mechanism, is also the initial means of treatment and in some cases, the definitive treatment with current endovascular methods. Angiography can be iodine or carbon dioxide angiography; It has no adverse effect on kidney function, although it should be used with special care in patients with severe chronic obstructive pulmonary disease.(5)

The current AHA/AC guides recommend the use of FDC as class I, level of evidence A; In the presence of the ischemia of lower limbs at viable limbs (Rutherford class), FDC revascularization must be carried out within 6 to 24 hours, on the contrary, when ischemia is class IIA and Iib (threatened limb) the ideal is ideal do it within the first 6 hours.(8)

The most studied and used fibrinolitics for the FDC is the loud, uroquinase and tissue activator of recombinant plasminogen (RT-PA). A recent review of fibrinolytics in peripheral vascular disease mentions that selective intra -arterial RTPA is more effective than the intra -arterial administration of reptptoquinase or intravenous RTPA to obtain arterial permeability in acute occlusion. When comparing the RTPA with Urookinase there is no evidence that it is more effective, but there is certainty that the initial lysis can be faster with the RTPA.( 9-10)

Its form of administration by intra -arterial infusion can be non -selective; with the catheter proximal to the thrombus without entering the injury; and selective; embodying the catheter tip in the thrombus and administer it continuously by high dose infusion pump in the first hours and then maintenance dose for a certain time and by forced infusion (pulse spray) is the vigorous infusion intractrombo To the same in order to increase the lysis surface, with this method, greater penetration of the agent within the thrombus is achieved and the infusion period is shortened. Initially the catheter is placed a few centimeters above the distal thrombus leaving a small occluded part without treated. In this way, any possible distal micro embolism would be avoided. Forced injection of lithic agent is supplied manually through a 2-5 cc syringe, every 20-30 seconds.

There are several protocols in terms of dose, however, these are the most used:

1. Uroquinase 240000 IU in bolus, followed by 12000 IU/ hour per infusion pump. (No more than 48 hours)
2. 2400000 Rueptoquinase in Bolo, followed by 100,000 IU/ hour per infusion pump.
3. RT-PA 4 mg in bolus, followed by 0.5 mg/h. By infusion pump.

   Among the complications that may occur are: Intracranial hemorrhage 1.2 %and 2.1 %, greater hemorrhage 5.1 %, minor bleeding (puncture site) 15 %, anaphylactic reaction (more frequent with the right -handed) serum disease reactions at 2 - 3 weeks of treatment with the presence of joint fraud, fever, microscopic hematuria.

   The global permeability of the FDC is 60 - 70%, secondary reinterventions 20%, amputation rate 9.6%; Stile did not show differences between complications or efficiency between UK and RT-PA.

   Unique indication:

   Only member with a audible venous Doppler signal and without total loss of sensitivity and motor capacity, on the contrary, if the patient is presented with deep muscle paralysis (muscle rigor), sensitive loss and signal of venous doppler inaudible and absence of hair filling, The indication is surgical (revascularization or amputation). Intermittent claudication is not an indication.

   Contraindications for thrombolysis directed

   by catheter:

   Absolute: Active hemorrhage. Intracranial hemorrhage, compartmental syndrome. Severe member ischemia, which requires immediate surgery.

   Relative: Trauma or non -vascular major surgery within the last 10 days. Non -controlled HTA (> 180 and/or 110 mmHg). non -compressible vessel puncture, intracranial tumor, ocular surgery

   Recent, neurosurgery in the last 3 months, a history of severe contrast allergy. Intracranial trauma in the last 3 months, digestive bleeding in the last 10 days, liver failure, with coagulopathy, endocarditis, pregnancy/postpartum, bleeding in diabetic retinopathy. life expectancy < 1 year.

   In conclusion, the FDC is a technique that has been used and studied for a long time in several projects such as Natali, Stile, among others. Its use has increasingly taken more relevance and is an option in other pathologies such as pulmonary embolism.

   In order for this method to be successful in the suggested time and the ideal clinical presentation, in this way the standard Gold method against acute ischemia of lower limbs becomes.

1. Cheng C, Cheema F, Fankhauser G, Silva M. Enfermedad arterial periférica. Editores: Towsend C, Beauchamp D, Evers M, Mattox K. Sabiston Tratado de cirugía: Fundamentos biológicos de la práctica quirúrgica moderna. 20th edición. USA: Elsevier; 2016. P. 1754-1805

2. Mitchell, M. E., Mohler, E. R., & Carpenter, J. P. (Noviembre de2014). Overview of acute arterial occlusion of the extremities (acutelimb ischemia).

3. Norgren, L., Hiatt, W., Dormandy, J., Nehler, M., Harris, K., & Fowkes, F. (2007). TASC II — Inter-Society Consensus for the Management of PAD.

4. Dehesa E, Hernández DA, Peña HG, Salas RR, Tamayo B, Rochin JL. Un caso raro de acidosis láctica persistente. Medicina Interna de México. 2017;33:03

5. Sociedad Argentina de Cardiología Área de Consensos y Normas. Consenso de enfermedad vascular periférica. Rev Argent Cardiol. 2015;83(Supl.3):101. Fecha de consulta: 21 de julio de 2019. Disponible en: https:// www.sac.org.ar/wp-content/uploads/2016/01/consenso-de-enfermedad-vascular-periferica.pdf

6. Kessel DO, Berridge DC, Robertson I (2004) Infusion techniques for peripheral arterial thrombolysis. Cochrane Database Sys tRev 1:CD000985

7. Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. 1997;26:517–38

8. Marie D. Gerhard-Herman, Heather L. Gornik, Coletta Barrett, Neal R. Barshes, Matthew A. Corriere. et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

9. Aboyans V, Ricco JB, Bartelink MEL, Björck M, Brodmann M, Cohnert T, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries Endorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018;39:763---816.

10. Giannakakis S, Galyfos G, Sachmpazidis I, Kapasas K, Kerasidis S, Stamatatos I, et al. Thrombolysis in peripheral artery disease. Ther Adv Cardiovasc Dis. 2017;11:125-

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