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Surgery versus thrombolysis for initial management of acute limb ischaemiaBerridge DC, Kessel DO, Robertson I
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SummarySurgery versus thrombolysis for initial management of acute limb ischaemiaThrombolysis involves dissolving a blood clot by injecting an enzyme into the blood clot. It is used as an alternative to surgery for managing severely reduced blood flow (acute ischaemia) in the leg. A blood clot (thrombosis) forms in a leg blood vessel where there is severe narrowing (stenosis) in a natural artery or a bypass graft. The review authors identified five controlled trials with a total of 1283 participants who were randomly allocated to receive initial peripheral arterial thrombolysis or surgery for the immediate management of acute limb ischaemia. There was no evidence in favour of either initial thrombolysis or initial surgery as the preferred option in terms of preventing the need for major amputation (limb salvage) or death within one year. More major complications occurred within 30 days of the procedure with thrombolysis, including stroke and major bleeding (haemorrhage). A total of 1.3% of patients receiving thrombolysis had a stroke compared to none in surgery patients; 8.8% had a major haemorrhage after thrombolysis compared to 3.3% in surgery patients. People receiving initial thrombolysis underwent a less severe degree of intervention but may have a higher risk of ongoing limb ischaemia. These
This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2010 Issue 1, Copyright © 2010 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
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January 22. 2001 AbstractBackgroundPeripheral arterial thrombolysis is technique used in the management of peripheral arterial ischaemia. Much is known about the indications, risks and benefits of thrombolysis. However, it is not known whether thrombolysis works better than surgery in the initial treatment of acute limb ischaemia. ObjectivesTo determine the preferred initial treatment, surgery or thrombolysis, for acute limb ischaemia. Search strategyThe Cochrane Peripheral Vascular Diseases Group searched their Specialized Register (last searched January 2009) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (last searched Issue 1, 2009). Proceedings from all British Vascular Surgical Society, European Vascular Surgical Society and North American Society of Vascular Surgery meetings, Society of Cardiovascular and Interventional Radiology (SCVIR) and Cardiovascular and Interventional Society of Europe (CIRSE) were handsearched. Pharmaceutical firms and trialists were asked for information about unpublished trials. Selection criteriaAll randomised studies comparing thrombolysis and surgery for the initial treatment of acute limb ischaemia. Data collection and analysisEach author independently assessed trial quality and extracted data. Agreement was reached by consensus. Main resultsFive trials with a total of 1283 participants were included. There was no significant difference in limb salvage or death at 30 days, six months or one year between initial surgery and initial thrombolysis. However, stroke was significantly more frequent at 30 days in thrombolysis participants (1.3%) compared to surgery participants (0%) (Odds ratio 6.41; 95% confidence interval (CI) 1.57 to 26.22). Major haemorrhage was more likely at 30 days in thrombolysis participants (8.8%) compared to surgery participants (3.3%) (Odds ratio 2.80; 95% CI 1.70 to 4.60); and distal embolization was more likely at 30 days in thrombolysis participants (12.4%) compared to surgery participants (0%) (Odds ratio 8.35; 95% CI 4.47 to 15.58). Participants treated by initial thrombolysis underwent a less severe degree of intervention (Odds ratio 5.37; 95% CI 3.99 to 7.22) and displayed equivalent overall survival compared to initial surgery (Odds ratio 0.87; 95% CI 0.61 to 1.25). Authors' conclusionsUniversal initial treatment with either surgery or thrombolysis cannot be advocated on the available evidence. There is no overall difference in limb salvage or death at one year between initial surgery and initial thrombolysis. Thrombolysis may be associated with a higher risk of ongoing limb ischaemia and haemorrhagic complications including stroke. The higher risk of complications must be balanced against risks of surgery in each person. |