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Acute limb ischemia (ALI) is one sequela of peripheral arterial disease and one of the most common vascu-lar emergencies interventional radi-ologists and vascular surgeons are asked to evaluate and treat. There are diverse etiologies for ALI, with the two most common etiologies being embolus and thrombosis in situ secondary to underlying disease such as atherosclerosis. Differentiation between the two can sometimes be difficult; the latter is far more common in occluded bypass grafts. ALI is usually caused by atheroscle-rotic disease but can also arise from other etiologies (eg, dissection, inti-mal hyperplasia, in situ thrombosis secondary to a hypercoagulable state, trauma, vasculitis, aneurysm thrombosis). Outcomes and progno-sis of ALI largely depend on the rapid diagnosis and initiation of ap-propriate and effective therapy. The 30-day mortality rate is approximately 15% and there is a variable amputation rate of 10%–30% (40). For many years, primary surgical in-tervention was performed, but en-tailed significant morbidity and mor-tality (41– 43).
In 1974, Dotter et al (44) reported the feasibility of the use of transcath-eter streptokinase infusions for the treatment of arterial and graft occlu-sions. Since that time, there have been a number of advances in cath-eter-directed thrombolytic therapy. Current methods include a variety of fibrin-specific thrombolytic agents and multiple methods for local deliv-ery (eg, pulse-spray, intrathrombus bolus technique) as well as adjunc-tive use of mechanical thrombec-tomy devices (MTDs). Successful management of ALI requires optimal patient selection with astute and timely clinical assessment.
Randomized prospective trials have shown that patients with acute leg ischemia ( 14 days) have im-proved survival and long-term ben-efit compared with those who un-dergo surgery when thrombolysis is used alone or to reduce the magni-tude of surgery (8,17,45). Intraarte-rial catheter-directed administration of thrombolytic agents can achieve thrombolysis of the thrombosed segments and unmask a causative lesion in most cases. This lesion can then often be treated with endovascular techniques. In many patients, throm-bolysis with adjunctive procedures can reduce the scope of or even elim-inate the need for surgery. Surgical reperfusion therapy is a very high-risk procedure in elderly patients, with surgical mortality rates as high as 29% in high-risk populations (46).