الفهرس 
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Abstract
Our study was a prospective study carried out in sohag in the period from July 2014 to may 2016. It included ten patients with acute thrombotic limb ischemia. Seven were males (70%) and three were females (30%) withmean age of 63.9 years. Diabetes Mellitus, hypertension, and myocardial ischemia were co morbid conditions in (60%), (60%), and (30%) of patients respectively. five patients were smokers (50%).
All patients were subjected to complete clinical evaluation. Laboratory investigations were done including HGB level, platelet count, prothrombin concentration, and serum creatinine.ECG and echocardiography were also done.Arterial Duplex was done for every case to evaluate the arterial system as regard level of occlusion, length of occlusion, and state of run off.Levels of occlusions by Duplex were CFA,proximal SFA, mid SFA, and distal SFA and popliteal artery occlusions in (10%), (20%), (30%), and (40%) of cases respectively. Occlusions were >10 cm in 7 patients (70%) and heavy calcifications detected in half of patients (5/10 patients). No distal run, single vessel, two vessel runoff were detected by Duplex in (50%), (20%), and (30%) of cases respectively. CT Angiography was done in only four cases to confirm level of occlusion and help choosing access site. Levels of occlusion were iliac, mid SFA, and distal SFA in (1/4), (2/4), and (1/4) of cases respectively. No run off, single vessel, and two vessels were detected in the CT Angiography of (2/4), (1/4), and (1/4) of cases respectively.
Preliminary diagnostic angiography shows levels of occlusions to be iliac, proximal SFA, mid SFA, anddistal SFA and popliteal arteryin (10%), (20%), (40%), and (30%) respectively. In six cases the occlusion length was more than 10 cm (60%).No run off vessel, single vessel, and two vessels run off were detected in (40%), (40%), and (20%) of cases respectively. rt-PA (Actilyse™) was the thrombolytic agent used with a mean dose of 41mg in a mean duration of 39.3 hours, also, we usedFountain Infusion Catheter™or Unifuse catheter™.
Immediate results of our patients showed technical success in seven of ten patients (70%) and clinical success in one of ten patients (10%). Successful lysis which includes both technical success and clinical success was achieved in eight of ten cases (80%) with immediate complications includingonly twominor groin hematomas (25%). One case of failure was attributed to chronic organized thrombus and the other was attributed to either hypercoagulable state or ruptured athermanous plaque.
After 30 days of follow up, no amputations or deaths occurred with patent all successfully lysed limbs,thus, both amputation and mortality rates were 0% and 30 day amputation free survival and primary patencywere 100%.
At six months of follow up one of the eight cases of successful lysis were dead with patent remaining cases of successful lysis yielding a 6-months amputation rate of 0% and 6-months mortality rate of 12.5% and therefore amputation free survival at 6-months was87.5% and primary patency rateat 6-monthswas 87.5% reflecting the survival rate as there is no major amputation occurred in our study.
Catheter directed thrombolysis should be considered the best alternative option to standard surgery in patients with acute thromboticpartial ischemia (Rutherford classI and IIa), it allows clearing of the occluding thrombus, restoration of blood flow, identifying the underlying cause and further enabling its treatment by endovascular means. Although expensive with low availability of its tools, it can offer effective treatment without the need for major invasive surgery in those criticall ill patientsand with lower incidence of complications.
Patients with acute total ischemia are not candidates for catheter directed thrombolysis as their limb cannot tolerate the period of thrombolytic therapy and tissues may proceed to infarction before restoration of arterial patency.They should be considered for urgent surgical revascularization.
To meet therapeutic expectations, catheter directed thrombolysis should be followed by definitive treatment of the underlying lesion with either percutaneous procedures or by a more limited surgical option to maintain long term patency.Catheter directed thrombolysis should not be considered as a competitor for surgery. Initial thrombolytic trial rarely demises any subsequent surgical intervention in case of lysis failure. In addition, when surgical options are still needed to treat the revealed lesion, it can be performed on an elective basis in a well prepared patient. In certain situations, clearing run-off vessels with thrombolysis allows a surgical intervention to be performed which was impossible before.
Catheter directed thrombolysis is not without risk; haemorrahgic complications are the most serious problem which may be often fatal.With proper patient selection, adherence to infusion protocols and close supervision of vital function and complications;catheter directed thrombolysis can be performed safely with maximum benefits and a more limited bleeding complications.
This study represents a brave step toward endovascular therapeutic options in our unit, which may forgive the limitation of small number of patients and our position in the start of the learning curve. Since effective with low incidence of complications, we recommend that this protocol of treatment should be adpted at our unit as an established therapeutic option for acute thrombotic ischemia. We also recommends that this study should be followed by larger studies with larger number of patients and with longer periods of follow up to obtain more reliable results for analysis, maximize benefit for patients and increase our familiarity with the procedure.