Long-term results of catheter-directed thrombolysis to treat infrainguinal bypass graft occlusion: The urokinase era

Purpose: This study was undertaken to review the long-term results of catheter-directed thrombolysis in treatment of infrainguinal bypass graft occlusion. Methods: From January 1987 to December 1998, 67 patients with 69 acutely occluded infrainguinal arterial bypass grafts (48 vein grafts, 21 prosthetic grafts) underwent treatment with catheter-directed thrombolysis with urokinase. Longterm results were assessed with Kaplan-Meier life-table analysis, and factors predictive of success were determined with multivariate analysis. Results: Thrombolysis was aborted in 7 patients (10%) because of major complications or technical failure and was unsuccessful in restoring graft patency (less than or equal to90% lysis) in 13 patients (19%). Successful lysis was achieved in 49 patients (71%). A causative lesion was identified and treated with percutaneous transluminal angioplasty (PTA) or limited operative revision in 33 patients. Diffuse vein graft intimal hyperplasia or poor runoff was identified in the remaining 9 patients, who were offered no further intervention. Cumulative patency at 60 months was 65% +/- 8% for successfully lysed vein grafts; however, only 3 of 16 successfully lysed prosthetic grafts were patent at 9 months. Although univariate analysis identified several factors associated with successful long-term vein graft function, only white race was significant at multivariate regression analysis. Conclusions: Coupled with identification and aggressive treatment of underlying causative lesions, catheter-directed thrombolysis can salvage many thrombosed vein grafts, with expectation of long-term patency similar to that with repeat bypass grafting. Poor short-term results of thrombolysis of occluded prosthetic grafts support repeat operation with a completely new bypass graft as a more appropriate option.