Thrombolyse des artériopathies des membres

Thrombolytic therapy has been employed for 40 years, by systemic infusion, in the treatment of acute artery occlusions, and since 1971 by local infusion. Several randomised studies published during the 1990's have compared thrombolysis to surgery; they showed the benefits of the thrombolytic therapy, together with, however, the risks and potential complications. The use of thrombolysis combined with endovascular treatment of arterial lesions by recanalisation, thrombo-aspiration, angioplasty with or without endoprosthesis, has allowed defining new therapeutic strategies. The aim of the present chapter is to update one of our previous works by the identification of those new treatment modalities that have been used during the last decade, the presentation of the mechanism of action of standard thrombolytic drugs, streptokinase (SK) and urokinase (UK) utilised by systemic infusion, local fusion, and during per-operative procedures, and finally modern thrombolytic treatments from the plasminogen activator (tPA) to the staphylokinase. A European consensus has allowed to precise indications, contraindications and complications of such treatment (TASC). Recommendation # 59 concludes that there is no more indication for the systemic treatment of acute arterial occlusions with currently available thrombolytic drugs. The contraindications published in 1998 are actually widely known. Current indication remains local thrombolysis. The procedure duration, in addition to the associate risk of complications, is not always compatible with the emergency pattern of the revascularisation necessitated by some acute ischemias. Intra operative treatment is useful in by-pass occlusions. Despite insufficient published data, the combination of surgery and thrombolysis allows reducing both the dose and the duration of the procedure, which can be very important in severe cases of acute ischemia.