Intraoperative intra-arterial urokinase therapy after failed embolectomy in acute lower limb ischemia

Background Aim of this study is to evaluate the use of intraoperative intra-arterial urokinase infusion (IIUI) in overcoming residual thrombi after thromboembolectomy in acute lower limb ischemia. Methods. Design: retrospective study over a 3-year period. Setting: University affiliated hospital. Patients: 21 patients with acute lower limb ischemia who underwent IIUI after embolectomy (18 transfemoral, 3 trans-popliteal) had failed to achieve adequate distal perfusion. Postoperatively, all patients were maintained on full dose heparinization. Main outcome measurements: complete or partial clot lysis. on post-IIUI angiography; restoration of pedal pulses and a viable leg at discharge. Results. Angiographically, complete and partial lysis was demonstrated in 14 and 3 patients, respectively. Two patients with prolonged ischemia required fasciotomy. one of these eventually had an amputation. Altogether, limb amputations (1 above knee, 2 below knee) were necessary in 3 patients. The angiographic appearance of lysis correlated well with the restoration of pedal pulses and/or limb viability. One patient died of myocardial infarction 3 days after the procedure. Postoperatively, there were 5 (24%) wound hematomas of which I required surgical exploration. Over a mean follow-up period of 8 months (range 1-16), limb salvage was sustained in the 17 patients with successful angiographic lysis. Conclusions. IIUI is an effective therapeutic adjunct to failed embolectomy in acute lower limb ischemia. Use of this procedure is recommended as part of the routine management in such cases.