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Thrombolysis / mechanical thrombectomy for acute arterial thrombosis

Thrombolysis / mechanical thrombectomy for acute arterial thrombosis

Acute peripheral and visceral arterial thrombosis are serious conditions that require prompt and effective treatment to restore blood flow and prevent tissue damage. Both thrombolysis and mechanical thrombectomy are utilized in these scenarios, with specific considerations based on the affected artery and patient condition.

Thrombolysis

Mechanism
  • Thrombolysis involves administering medications to dissolve clots. This can be done systemically or more commonly via catheter-directed thrombolysis (CDT), where thrombolytic agents are delivered directly to the site of the clot.
Indications
  • Suitable for acute peripheral arterial occlusions, especially in smaller vessels where mechanical thrombectomy may be challenging.
  • Used for visceral arterial thrombosis, such as mesenteric artery occlusion, when rapid reperfusion is needed, and surgical options are high-risk or delayed.
Procedure
  • In CDT, a catheter is navigated to the site of the clot under imaging guidance, and thrombolytic drugs (like alteplase) are infused directly.
  • Monitoring and adjustments are made based on clot dissolution progress.
Benefits
  • Minimally invasive.
  • Can treat diffuse and extensive clots that might be difficult to remove mechanically.
  • Useful when immediate access to mechanical thrombectomy is unavailable.
Risks
  • Significant bleeding risk, including gastrointestinal and intracranial hemorrhage.
  • Contraindicated in patients with recent surgery, active bleeding, or certain medical conditions (e.g., severe hypertension).

Mechanical Thrombectomy

Mechanism
  • Mechanical thrombectomy involves physically removing the clot using devices such as aspiration catheters (Penumbra® Aspiration System.) or specialized mechanical devices (Angiojet® device).

 

Indications
  • Preferred for large or critical clots in major peripheral or visceral arteries.
  • Used when thrombolysis is contraindicated or has failed.
  • Effective in cases where rapid restoration of blood flow is crucial, such as in limb-threatening ischemia or bowel infarction.

 

Procedure
  • A catheter is introduced through the vascular system to the site of the occlusion.
  • Depending on the device, the clot is either aspirated, ensnared, or mechanically disrupted and removed.

 

Benefits
  • Immediate clot removal and restoration of blood flow.
  • Lower systemic bleeding risk compared to thrombolysis.
  • Often combined with thrombolysis in a hybrid approach to enhance efficacy.

 

Risks
  • Procedure-related complications such as vessel damage, dissection, or distal embolization.
  • Requires specialized equipment and expertise, which may not be available in all centers.

Comparative Considerations

  • Time Sensitivity: Thrombolysis can often be initiated faster, especially in settings without immediate access to mechanical thrombectomy facilities.
  • Efficacy: Mechanical thrombectomy is generally more effective for large, solid clots and provides immediate results. Thrombolysis is beneficial for more diffuse thrombi.
  • Safety: Thrombectomy has a lower risk of systemic bleeding but carries procedural risks. Thrombolysis has higher systemic bleeding risks but is less invasive.
  • Availability: Thrombolysis can be administered in a wider range of settings, while thrombectomy requires specialized interventional radiology or vascular surgery capabilities.

 

Clinical Scenarios

  1. Acute Limb Ischemia (Click here to read more on Critical Limb Threatening Ischaemia):
    • Thrombolysis: Effective for smaller, distal occlusions or when mechanical thrombectomy is not an option. CDT is used to dissolve clots in situ.
    • Mechanical Thrombectomy: Preferred for large vessel occlusions or when rapid revascularization is required to prevent limb loss.
  2. Visceral Artery Occlusion (e.g., Mesenteric Ischemia) (Click here to read more on Acute/Chronic Mesenteric Ischaemia):
    • Thrombolysis: Used when immediate surgery is not possible, or in conjunction with other interventions to improve perfusion.
    • Mechanical Thrombectomy: Applied in cases of severe, life-threatening occlusion where rapid blood flow restoration is critical to prevent organ infarction.
  3. Renal Artery Thrombosis:
    • Thrombolysis: Can be used to salvage renal function in the early stages.
    • Mechanical Thrombectomy: Preferred for large or proximal clots with significant risk to kidney function.

 

Conclusion

The choice between thrombolysis and mechanical thrombectomy for acute peripheral and visceral arterial thrombosis depends on multiple factors including the size and location of the clot, patient stability, availability of resources, and time since symptom onset. Combining both techniques (thrombolysis to soften the clot and thrombectomy for removal) can sometimes provide the best outcomes. The decision should be individualized, taking into account the specific clinical scenario and available expertise.