Featured ArticleNew Technology for the Treatment of Peripheral Arterial and Venous Occlusions: Ultrasound Accelerated Thrombolysis
Introduction
Occlusions of the peripheral arteries and veins are common and serious conditions that can lead to pain, limb loss, or even death. Although treatment ranges from pharmacotherapy to open surgery, many patients are also seen in the angiography suite to be treated with interventions such as catheter-directed thrombolysis (CDT), percutaneous mechanical thrombectomy (PMT) and a novel technique, ultrasound accelerated thrombolysis (USAT). When a stenosis is revealed, it is resolved with a procedure such as angioplasty, stent implantation, or plaque excision. It is important for radiology nurses caring for patients being treated for arterial or venous occlusions to understand the risk factors, presentation, treatment options, and the new technology available to improve outcomes. Our case study illustrates the successful use of USAT in a patient with extensive and potentially chronic thrombus in the lower extremity. The patient presented with acute onset of right extremity pain and a history of vascular disease. After treatment with USAT, this patient experienced early recanalization and complete thrombus resolution of her occluded femoral-tibial peroneal bypass graft with only an overnight infusion. USAT unmasked an underlying lesion that was successfully treated with angioplasty and at 1 month, the patient continued to have pulses and had no leg pain.
Section snippets
Peripheral Arterial Disease and Occlusions
Peripheral arterial disease (PAD) is a common condition whose symptoms affect approximately 10 million people in the United States. An additional 20 to 30 million Americans have asymptomatic PAD (Allaqaband et al., 2006, Hirsch and Criqui, 2001). Patients affected with the disease have an increased risk of cardiovascular events and mortality. PAD is characterized by reduced blood flow in limb arteries, typically the legs, and is most frequently caused by atherosclerotic plaque buildup that
Deep Venous Thrombosis
Deep venous thrombosis (DVT), the most common manifestation of venous thromboembolism, occurs in as many as 250,000 Americans each year (Augustinos & Ouriel, 2004). DVT typically occurs in the deep veins of the lower extremities; however, upper extremities are involved in approximately 4% of cases (Elman and Kahn, 2006, Kommareddy et al., 2002). Patients with acute DVT typically present with symptoms that abate over time with the development of collateral pathways including limb edema, pain,
Catheter-Directed Thrombolysis
CDT involving local delivery of concentrated thrombolytic agents directly into clot is preferred over systemic infusion of thrombolytics due to higher technical success rates and decreased risk of bleeding complications (Sidebar 1). Standard CDT involves continuous, stepwise, or accelerated (e.g., pulse spray technique) infusion of lytic agent through a standard infusion catheter with a hole at the distal end, a series of lateral side holes or lateral slits that open once an intraluminal
Ultrasound Accelerated Thrombolysis
A new minimally invasive technology, USAT, has been developed to more rapidly and completely resolve arterial and venous occlusions than standard thrombolysis, thereby potentially preventing bleeding complications while avoiding the limitations of percutaneous mechanical techniques and risks of open surgery. USAT combines low-power, high-frequency ultrasound with catheter-directed thrombolytic infusion. Simultaneous delivery of directed ultrasound energy with local thrombolytic infusion
Case Study
A 66-year-old female with a history of peripheral vascular disease and smoking (stopped 20 years prior) presented with pain in her right leg. She had a right femoral-tibial peroneal bypass graft implanted 18 months prior with a right femoral-popliteal and aortobifemoral bypass grafts placed before that (Figure 1).
The patient presented with acute right leg pain and reported that she had had intermittent rest pain in her right leg since 1-month postgraft implant. Lower extremity angiography
Conclusion
Occlusions of the peripheral vasculature are serious conditions with significant rates of morbidity and mortality (Augustinos and Ouriel, 2004, Ouriel, 2002). Profound limb ischemia requires rapid recanalization through an interventional procedure or surgical treatment (Ouriel, 2002). In addition to resolving symptoms, rapid elimination of residual thrombus in DVT patients may prevent serious complications including acute PE and the development of chronic PTS.
USAT is an interventional procedure
Stephanie D. Crouch, RN, is with Interventional Radiology Department, St. Anthony's Medical Center, at St. Louis, MO
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Stephanie D. Crouch, RN, is with Interventional Radiology Department, St. Anthony's Medical Center, at St. Louis, MO
Deborah Hill, RN, is with Interventional Radiology Department, St. Anthony's Medical Center, at St. Louis, MO
Donna Bridwell RT (R) (VI), is with Interventional Radiology Department, St. Anthony's Medical Center, at St. Louis, MO
The authors hold no financial interest in any product or manufacturer mentioned in the article.