Contemporary Results of Intra-Arterial Thrombolysis for Acute and Acute-On-Chronic Lower Limb Ischemia.

BACKGROUND

To evaluate the immediate and long-term outcomes of catheter-directed thrombolysis (CDT) in infrainguinal arterial occlusions presenting with acute limb ischemia (ALI) or acute-on-chronic limb ischemia (ACLI), and to assess its safety and durability across different clinical and anatomical settings.

METHODS

We retrospectively analyzed 128 consecutive patients who underwent initial CDT for infrainguinal occlusions between January 2014 and December 2024. Patients were divided into ALI (n = 85) and ACLI (n = 43). CDT was performed with urokinase infusion via multihole catheters. Technical success, complications, and adjunctive procedures were recorded. Long-term outcomes were assessed using Kaplan-Meier analysis, with primary end points including patency, limb salvage, amputation-free survival (AFS), and freedom from reintervention.

RESULTS

CDT was effective or partially effective in 109 patients (85.1%), with similar success rates in ALI and ACLI. At 30 days, major amputation and mortality rates were 4.6% and 3.1%, respectively. Three major bleeding events required thrombolysis discontinuation. The median follow-up was 36 months (range 1-120), with a follow-up index of 0.72. At 5 years, estimated survival was 74.2%. Limb salvage was 79% in ALI and 86% in ACLI (P = 0.5), and AFS was 58.5% versus 74% (P = 0.1). Primary and secondary patency at 5 years were 22% and 26% for ALI, and 32.5% and 48% for ACLI (P = 0.7 and P = 0.2). Freedom from reintervention was 36% for ALI and 43% for ACLI (P = 0.4). Chronic kidney disease was the only independent predictor of death or amputation (hazard ratio: 2.9; 95% confidence interval: 1.2-6.8).

CONCLUSION

CDT is a safe and effective revascularization strategy for infrainguinal occlusions in both ALI and ACLI. Outcomes were not significantly influenced by clinical presentation or lesion anatomy, while comorbidities-particularly chronic kidney disease-were strongly associated with poor prognosis. Despite limited long-term patency, CDT remains a valuable option in selected patients, especially when combined with adjunctive endovascular or surgical approaches.