Thrombolytic therapy in an isolated limb

Intraoperative thrombolytic therapy is a useful adjunct to balloon catheter thromboembolectomy for treatment of acute embolism or thrombosis, but the technique is frequently limited by incomplete thrombolysis and systemic hemorrhage. In an attempt to improve results and reduce complications of conventional thrombolytic therapy, urokinase was infused into a limb that was isolated with a tourniquet. This isolated limb perfusion technique was initially developed in an animal model and subsequently used for limb salvage in patients who failed thromboembolectomy. The animal model demonstrated that a fibrinolytic state could be achieved and isolated to the extremity, even when using extremely high dose (20,000 to 50,000 IU/kg) of thrombolytic agents. The fibrinogen level was unmeasurable and the prothrombin, partial thromboplastin, and thrombin times were significantly prolonged in the isolated limb (p < 0.001), whereas no changes occurred in these parameters in the systemic circulation. In seven patients, streptokinase (27,000 to 200,000 IU) and urokinase (150,000 to 300,000 IU) were infused into isolated extremities after thrombectomy alone had failed to restore blood flow. All extremities showed improved perfusion after thrombolytic therapy and five remained viable 6 months after treatment. There were no systemic bleeding complications despite two patients having undergone major operations within 6 days. Tourniquet isolation of the limb can achieve extremely high concentrations of thrombolytic drugs while reducing the potential for systemic fibrinolysis and allows lysis of previously inaccessible thrombus.