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Result of intrathrombus pharmacoinvasive endovascular treatment with forced infusion technique (pulse spray) and continuous infusion of streptokinase in patients with acute lower limb ischemia

David Parraga Meza, Diego Martín Barbetta, M. Belén de Beus, Joaquín Etcheverre, Pablo Nicolás Luna

Revista Argentina de Cardioangiologí­a Intervencionista 2023;(2): 0083-0086 | Doi: 10.30567/RACI/20232/0083-0086


In the year 2020, we began a study to understand the behavior of endovascular catheter-guided streptokinase as a treatment for acute lower limb ischemia. The aim was to evaluate its benefits, potential complications, and establish a protocol for its use as the initial treatment in patients arriving at our facility with this condition.
The study included 8 patients who met the inclusion criteria. Catheter-directed fibrinolysis (CDT) was performed using two techniques combined: pulse spray and continuous infusion of streptokinase (STK) over a 12-hour period. The primary objective was to restore normal perfusion to the affected limb without causing endothelial trauma.
At the conclusion of the study, based on the observed results, it was determined that this combined strategy of pulse spray and continuous infusion showed positive outcomes in the indicated patients with acute lower limb ischemia. Due to the accessibility and availability of STK compared to other scarce and more expensive fibrinolytics, this approach can be routinely adopted in our setting.
Complications were minimal, and the success of the procedure not only relied on the chosen technique but also greatly depended on the patient's collaboration in adhering to the treatment and clinical follow-up.


Palabras clave: acute lower limb ischemia, catheter-directed thrombolysis, pulse spray thrombolysis, intrathrombus thrombolysis, streptokinase.

En el año 2020 iniciamos un trabajo para conocer el comportamiento de la estreptoquinasa endovascular guiada por catéter como tratamiento frente a una isquemia aguda de miembros inferiores, evaluar sus beneficios, posibles complicaciones y protocolizar como tratamiento inicial en el paciente que llega a nuestro servicio con dicha patología.
El estudio fue realizado con 8 pacientes que cumplían los criterios de inclusión, se realizó la fibrinólisis dirigida por catéter (FDC) utilizando dos técnicas de forma conjunta que consistían en la técnica de infusión forzada (pulse spray) y la infusión continua de estreptoquinasa (STK) durante 12 horas, con la finalidad de recuperar la perfusión normal de la extremidad afectada sin generar trauma endotelial.
Al final del estudio se dio como conclusión, de acuerdo con lo observado, que esta estrategia combinada de infusión forzada y continua dio buenos resultados en los pacientes indicados que presentan isquemia aguda de miembros inferiores; que su utilización se puede adoptar de forma rutinaria en nuestro medio por la accesibilidad y disponibilidad de la STK frente a otros fibrinolíticos escasos y de mayor valor.
Las complicaciones son pocas, el beneficio del procedimiento no depende únicamente del resultado de la técnica utilizada, va de la mano y es de suma importancia la colaboración del paciente cumpliendo con el tratamiento y el seguimiento clínico..


Keywords: isquemia aguda de miembro inferior, trombólisis dirigida por catéter, pulse spray trombólisis, trombólisis intratrombo, estreptoquinasa.


Los autores declaran no poseer conflictos de intereses.

Fuente de información Colegio Argentino de Cardioangiólogos Intervencionistas. Para solicitudes de reimpresión a Revista Argentina de Cardioangiología intervencionista hacer click aquí.

Recibido 2023-03-13 | Aceptado 2023-05-10 | Publicado


Licencia Creative Commons
Esta obra está bajo una Licencia Creative Commons Atribución-NoComercial-SinDerivar 4.0 Internacional.

Figure 1.

Figure 2. A) Proximal occlusion of the superficial femoral artery. B) Intrathrombus pulse spray tec...

Figure 3. A) Ulcerated plaque in the middle third of the superficial femoral artery post-procedure. ...

Table 1. Baseline clinical and angiographic demographic characteristics of the study group.

Table 2. Post-treatment angiographic results

Table 3.

Introduction.

Acute ischemia of the lower limb is a pathology that produces a significant and dramatic reduction in blood perfusion of a lower limb as a result of the genesis of one or more thrombi lodged at any level of the limb, compromising function, viability and reaching the amputation of the affected limb if not treated on time and even cause the death of the patient, has an incidence of 1.5 cases per house 10,000 people.1

For this reason, we began work in 2020, with the aim of learning about the benefits of pharmacoinvasive endovascular therapy with streptokinase, a well-known fibrinolytic drug in our environment, with which we have a greater chance of working in our services due to its availability and accessibility. economical compared to other more current fibrinolytics, but more expensive such as rt-PA.

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Material and method

It is a prospective, descriptive study of patients undergoing intrathrombotic pharmacoinvasive endovascular treatment with the forced infusion technique (Pulse Spray) and continuous infusion of streptokinase in patients undergoing Acute Lower Limb Ischemia treated between January 2020 and December 2021 at our hospital. The initial screening was 300 patients who presented peripheral arterial disease, of which 8 patients who met the inclusion criteria were included in the study (Figure 1).

The inclusion criteria for the study were based on patients presenting acute ischemia of the lower limb with less than 72 hours of evolution from the onset of the clinical picture, audible arterial and venous Doppler signal and without total loss of sensation and motor capacity of the affected limb, those patients who had criteria for emergency surgery or contraindications for catheter-directed thrombolysis were excluded.

Absolute contraindication

Active bleeding. Intracranial hemorrhage, compartment syndrome. Severe limb ischemia, requiring immediate surgery.

Relative contraindication

Trauma or major non-vascular surgery within the last 10 days. Uncontrolled AHT (>180 and/or 110 mmHg). Non-compressible vessel puncture, intracranial tumor, recent eye surgery, neurosurgery in the last 3 months, history of severe allergy to contrast. intracranial trauma in the last 3 months, gastrointestinal bleeding in the last 10 days, liver failure, with coagulopathy, endocarditis, pregnancy/postpartum, hemorrhage in diabetic retinopathy. life expectancy < 1 year.

Once the patient has been diagnosed, angiography is performed urgently and targeted thrombolysis is started with a 5-french multi-perforated multipurpose catheter; using 250,000 IU of streptokinase with the intrathrombo2 forced infusion technique (Pulse Spray) as shown in Figure 2, to then leave a continuous infusion of 1250,000 IU of streptokinase by means of the multipurpose catheter per infusion pump at 42 ml/h for 12 hours.

After 12 hours and the medication has been infused, a control angiography is performed where the lysis of the thrombus will be visualized, and based on the angiographic result, the decision is made to end the treatment or complement it with the stent implantation (Figure 3); He undergoes 48 hours of hospitalization and if there are no complications he is discharged.

We call the reperfusion of the vessel treated by this technique a “Successful Procedure” after lysis with thrombolytics, which is reflected through the clinical improvement of the affected limb, with the return or increase of the distal pulse, recovery of sensitivity, abolition of pain. and the angiographic image shows completion of occlusion or reduction of vessel stenosis of less than 50%.

At the time of discharge, each patient was evaluated according to their cardiovascular history. Two patients with a history of AF (Atrial Fibrillation) and reperfusion without stent implantation were given anticoagulation with dose-response Acenocoumarol + 100 mg of ASA (Acetylsalicylic Acid); two patients with AF and stent implantation received dose-response acenocoumarol + 75 mg of clopidogrel, the remaining three patients with stent implantation and no history of AF were given dual antiplatelet therapy with 75 mg of clopidogrel + 100 mg of AAS, all schemes were suggested for 1 year.

Subsequently, the patient is followed up for 12 months to evaluate the result and if he presents complications in the medium or long term, typical of the therapy used.


Objective

The objective of this work is to evaluate the result of the proposed treatment and to follow the evolution of the patients during 12 months post-treatment, to identify the benefits and complications of the therapy and to demonstrate that its implementation as a protocol is beneficial in our institution and in other institutions of our environment and even put into practice in the different services in Latin America.

Statistical analysis

The results were expressed in percentages for the variables according to each category that was established for the study.

Results

All the included patients presented acute lower limb ischemia of less than 72 hours of evolution, the average age was 72 years, with a predominance of males (87%). The main clinical characteristics of the patients can be seen in Table 1. It is noteworthy that 100% of the patients presented arterial hypertension as a cardiovascular risk factor, 87% are smokers, 75% diabetics, and 62% are dyslipidemic. they suffered from peripheral vascular disease and 50% of the patients had atrial fibrillation, of which 2 did not receive treatment.

The anatomical distribution of the thrombus was 50% in the superficial femoral artery and in 6 of the 8 patients there was ischemia in the right lower extremity (Table 1).

The treatment used was successful in 87% of the patients, of which 25% of the patients had total reperfusion and did not present significant angiographic lesions, residual thrombus or plaques, for which reason a stent should not have been implanted, while 62.50 % of patients had partial reperfusion due to the presence of significant angiographic lesions and was completed with stent implantation to optimize the final result (Table 2).

The complications we had were the presence of 1 patient with a hematoma at the puncture site that was resolved without major problems and was discharged after 7 days, additionally 2 patients presented intrathrombus thrombosis before reaching 6 months post-treatment as a result of who stopped taking the prescribed medication, including antiplatelet drugs, on their own.

Discussion

Acute ischemia of the lower limb is a pathology that causes partial or total obstruction of blood flow to an extremity as a result of the formation of a thrombus in that area. If the patient does not receive immediate attention, he runs the risk of not only losing the extremity , you can also lose your life; in fact, studies that show that revascularization of the affected limb when it is Rutherford Class A must be performed within 6 to 24 hours; On the contrary, when it is Class IIa and IIb, the ideal is to do it within the first 6 hours5. Its main causes are related to acute arterial thrombosis due to atherosclerotic accident of its wall, Embolism secondary to the presence of arrhythmias and finally as a result of arterial Trauma.

Acute ischemia of the lower limb, depending on its clinical presentation and viability of the affected limb, can be treated in the first hours and up to 14 days after the onset of the condition3.

Its clinical presentation begins with pain, paleness of the extremity and as the hours of evolution pass, the limb loses sensitivity, motor capacity and the pallor turns into cyanosis as a consequence of hypoxia of the extremity.

The diagnosis must be made early and the treatment must be immediate, it can be diagnosed and confirmed through a Doppler echo of the lower limbs, which is a more accessible and non-invasive technique, another alternative is angiotomography with contrast which has a sensitivity and specificity of 90%4, however, not all services have this technology; Once the severity of the ischemia is categorized, the most appropriate treatment is decided (Table 3).

Catheter-directed fibrinolysis (CDF) is a technique that consists of applying streptokinase in two stages, the first by forced infusion into the thrombus itself and the second with the help of an infusion pump to infuse the fibrinolytic for 12 hours, the objective of this method is to dilute the thrombus in the larger and smaller diameter vessels, reducing the risk of sudden reperfusion injury and avoiding endothelial trauma, in addition to recanalizing the occlusion, it allows angioplasty of the underlying lesion if necessary.

Current AHA/ACC guidelines recommend the use of FDC as Class I, level of evidence A; At present, this type of treatment has been studied with fibrinolytics such as urokinase, rt-PA and streptokinase (STK), with STK not showing inferiority compared to other alternatives, but with the advantage that it is available and economically cheaper in our environment. accessible6,7, so this type of technique is ideal in these patients.

Conclusion

The catheter-guided pharmacoinvasive endovascular strategy using streptokinase initially with an intrathrombotic pulse spray technique and continuous infusion of streptokinase for 12 hours is a therapeutic option that gives good results for acute lower limb ischemia in patients who they meet the criteria for this and do not present contraindications for their use, reducing the endothelial trauma caused by sudden reperfusion and acting on vessels of greater and lesser diameter. It can be routinely performed in catheterization centers anywhere in the country with successful results soon, it is more accessible and its 12-month follow-up was favorable as long as the patient collaborates with the lifestyle change, does not abandon medication and medical controls.

  1. Mitchell ME, Mohler ER, Carpenter JP. (Noviembre de 2014). Overview of acute arterial occlusion of the extremities (acutelimb ischemia).

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

  3. 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.

  4. 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

  5. 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.

  6. Aboyans V, Ricco JB, Bartelink MEL, 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.

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

Autores

David Parraga Meza
Fellowship del Servicio de Hemodinamia y Cardioangiología Intervencionista. Hospital Municipal San José de Exaltación de la Cruz.
Diego Martín Barbetta
Fellowship del Servicio de Hemodinamia y Cardioangiología Intervencionista. Hospital Municipal San José de Exaltación de la Cruz.
M. Belén de Beus
Fellowship del Servicio de Hemodinamia y Cardioangiología Intervencionista. Hospital Municipal San José de Exaltación de la Cruz.
Joaquín Etcheverre
Médico Staff del Servicio de Hemodinamia y Cardioangiología Intervencionista. Hospital Municipal San José de Exaltación de la Cruz.
Pablo Nicolás Luna
Jefe del Servicio de Hemodinamia y Cardioangiología Intervencionista. Hospital Municipal San José de Exaltación de la Cruz. Buenos Aires, Argentina.

Autor correspondencia

David Parraga Meza
Fellowship del Servicio de Hemodinamia y Cardioangiología Intervencionista. Hospital Municipal San José de Exaltación de la Cruz.

Correo electrónico: davidparragameza@hotmail.com

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Result of intrathrombus pharmacoinvasive endovascular treatment with forced infusion technique (pulse spray) and continuous infusion of streptokinase in patients with acute lower limb ischemia

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Revista Argentina de Cardioangiología intervencionista
Issue # 2 | Volumen 13 | Año 2023

Etiquetas

acute lower limb ischemia, catheter-directed thrombolysis, pulse spray thrombolysis, intrathrombus thrombolysis, streptokinase

Tags

isquemia aguda de miembro inferior, trombólisis dirigida por catéter, pulse spray trombólisis, trombólisis intratrombo, estreptoquinasa

Titulo
Result of intrathrombus pharmacoinvasive endovascular treatment with forced infusion technique (pulse spray) and continuous infusion of streptokinase in patients with acute lower limb ischemia

Autores
David Parraga Meza, Diego Martín Barbetta, M. Belén de Beus, Joaquín Etcheverre, Pablo Nicolás Luna

Publicación
Revista Argentina de Cardioangiología intervencionista

Editor
Colegio Argentino de Cardioangiólogos Intervencionistas

Fecha de publicación
2023-06-30

Registro de propiedad intelectual
© Colegio Argentino de Cardioangiólogos Intervencionistas

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