Factors Affecting the Thrombolytic-Treatment-Related Outcomes in Patients with Acute Lower Limb Ischaemia

Tutkimustuotos: VäitöskirjaCollection of Articles

Abstrakti

Acute lower limb ischaemia (ALLI) is a condition that often requires urgent or emergent surgical or endovascular treatment. This disorder is associated with major amputations and mortality. The aetiopathogenesis of ALLI has changed within the last decades. Currently, it mainly presents with atherosclerosis-associated thrombotic occlusions. An increasing volume of data has been published in favour of a possible bacterial inflammation that can contribute to the pathogenesis of thrombotic events, particularly in patients with atherosclerotic changes. The patients who present with ALLI are often elderly individuals with multiple comorbidities. Therefore, mini-invasive treatment modalities are preferred. Nonetheless, catheter-directed thrombolysis occasionally fails and leads to amputations. Even after successful fibrinolysis, some patients develop recurrent ischaemia and require new interventions.

The aim of this work was to study the possible aetiological issues related to ALLI from the viewpoint of bacterial deoxyribonucleic acid (DNA) presence in the thrombi. Further aims were to evaluate possible reasons behind thrombolytic treatment failure and recurrent ALLI, and to assess the long-term outcome of thrombolytic treatment.

The thrombus aspirates were obtained aseptically and examined for the presence of bacterial DNA with a quantitative polymerase chain reaction from September 2014 to October 2016. A retrospective analysis of the ALLI patients treated at Tampere and Turku University Hospitals from January 2002 to December 2015 was performed to address the other aforementioned questions.

A total of 303 cases of ALLI (159 men [52.5%]) were registered in the studies. The mean age of the patients was 71 years. A total of 58% of the native arterial and 75% of the bypass graft thrombi were identified as positive for bacterial DNA. Synthetic graft thrombi demonstrated positivity for bacterial DNA in 77.8% of the cases. Of the positive samples, 90% contained the Streptococcus mitis group DNA.

In patients managed with thrombolysis, an early treatment failure occurred in 23%. A delay in treatment initiation increased the risk of failure by 5% per day. Hyperlipidaemia and previous bypass grafting were also independently associated with failure. This resulted in an almost 40% risk of major amputations within the first month. Nearly 43% of the patients developed recurrent ischaemia within a median of 40 months. Bypass graft reocclusions were predominant (65%). The absence of appropriate antiplatelet or anticoagulant treatment in native arteries and worsened tibial runoff in bypass grafts were independently associated with the risk of recurrent ALLI.

At one year, almost 80% of the patients were alive. The primary patency rate at this point for native arteries was 87%. The primary patency rates for bypass grafts ranged from 31% to 62%, with the lowest rates found in autologous vein grafts. The amputation-free survival rate was 66%.
The long-term outcomes were unfavourable. At five and ten years, 56% and approximately 30% of the patients, respectively, were alive. The survival was independently associated with the presence of atrial fibrillation and an age of over 83 years. The 10-year primary patency rates for native arteries and conduits were 18.7% and 15.2%, respectively. The amputation- free survival was independently affected by an age of over 75 years and represented a rate of 24% at 10 years.

The information on the presence of bacterial DNA in the thrombi must be interpreted with caution. Additional studies are needed to establish whether these findings are involved in the actual thrombotic process. The short-term post-thrombolytic outcomes are superior to the long-term outcomes, which are poor. Recurrent ischaemia is frequent and affects the results. Both modifiable and non-modifiable factors have an impact on the treatment outcome. They should be taken into consideration in the clinical work and further investigations.
AlkuperäiskieliEnglanti
JulkaisupaikkaTampere
ISBN (elektroninen)978-952-03-1447-7
TilaJulkaistu - 2020
OKM-julkaisutyyppiG5 Artikkeliväitöskirja

Julkaisusarja

NimiTampere University Dissertations - Tampereen yliopiston väitöskirjat
Vuosikerta214
ISSN (painettu)2489-9860
ISSN (elektroninen)2490-0028

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