Injection intra-arterial thrombolysis using only ultrasound navigation for thrombosis and embolism of lower extremity arteries (initial experience of use)

• Dmitriy Yu. Kornilov
• Alexey V. Satinov
• Samandarbek Kazakov
• Aleksandr V. Maksimov

Abstract

Background. Catheter-directed thrombolysis today is, along with open revascularization, the method of choice in the treatment of patients with acute limb ischemia (not more than Rutherford class IIa–b), with a positive result achieved in at least 80% of cases. However, the main factor limiting its use is the need for technical, economic and staff resources, an X-ray endovascular operating room with appropriate consumables and trained personnel.

Objective. To develop a technique for injection intra-arterial thrombolysis using only ultrasound navigation and evaluate its immediate results.

Patients and methods. We retrospectively analyzed a group of 23 patients (13 men and 10 women aged from 47 to 47 years, mean 64.6±1.7 years) admitted to the Nizhnevartovsk District Clinical Hospital from October 2023 to January 2024 with thrombosis and embolism of the arteries of the extremities and operated on using injection thrombolysis.

Tissue plasminogen activator (t-PA – Actilyse) was used as a thrombolytic drug administered under ultrasound guidance by puncturing the thrombosed segment with an 18–25 G needle from 2–4 points, achieving impregnation of the thrombus with the drug along the entire length. The initial dose of the drug was 10–20 mg t-PA. If necessary, repeated injections were performed, usually after 2–4 hours depending on the clinical effect. The average frequency of injections was 1.8±0.19 (1–4).

Results. Technical success (restoration of antegrade blood flow and reduction in thrombus volume by more than 95%) of injection thrombolysis was achieved in 87% of the cases, with the overall clinical effect (relief of acute ischemia or its decrease to grade I) amounting to 100%. The duration of thrombolysis ranged from 20 minutes to 48 hours (average – 8.7±1.6 hours, median – 6 hours). The amount of the drug used was 29.5±3.0 mg (15–65 mg), 7.8±2.2 mg/hour (1.7–40.0 mg/hour).

3 (13%) subjects developed local hematomas at the puncture sites, requiring no revision. One patient died from polysegmental viral pneumonia.

In 15 patients, after relief of acute ischemia, an angiographic examination was carried out to verify the primary cause of thrombosis. Once pathology revealed, endovascular correction was additionally performed. In two patients with an extended thrombus, the procedure was supplemented with catheter-directed thrombolysis.

Conclusion. The method of injection intra-arterial thrombolysis using ultrasound navigation alone allows achieving the results comparable to those yielded by the conventional procedure of catheter-directed thrombolysis. The described technique can urgently be performed in any surgical hospital.

Keywords: catheter-directed thrombolysis; arterial thrombosis; embolism; injection thrombolysis; ultrasound navigation