Correspondence
361
Correspondence
Thrombolysis in Critical Ischaemia Sir, The review of Non-surgical Treatment of Critical Limb Ischaemia by Lars Norgren devotes considerable space to drugs that are of very limited benefit and yet dismisses thrombolytic therapy, which is of enormous benefit to selected patients, in a few lines. In our view, it may be incorrect to suggest that chronic occlusions are more easily lysed than acute ones. Thrombolysis of acute arterial occlusions is associated with a recanalisation rate of at least 70% .1, 2 Although some authors recommend lysis for chronic occlusions the recanalisation rate is lower and successful recanalisation seems to be confined to those patients with a recent exacerbation of symptoms. 3"4 Secondly, may we draw to the attention of readers our controlled trial of tissue plasminogen activator, which was presented at the annual meeting of the Vascular Surgical Society of Great Britain & Ireland, in 1989 and subsequently published in abstract form. 5 It is our belief that patients with critical limb ischaemia would gain considerably if all Vascular Surgeons appreciated the potential benefits of thrombolysis. R. J. Lonsdale G. S. Makin P. W. Wenham B. R. Hopkinson Nottingham, U.K.
References 1 Risius B, GROAR RA, GEISINGER MA, ZELCH MG, LUCAS FV, YOUNG JR. Thrombolytic therapy with Recombinant h u m a n tissue-type Plasminogen activator: A comparison of two doses. Radiology 1987; 164: 465-468.
2 WALKERWJ, GIDDINGS AEB. A protocol for the safe treatment of acute lower limb ischaemia with intra-arterial streptokinase and surgery. Brit J Surg 1988; 75: 1189-1192. 3 POLIWODAH, ALEXANDERK, BUHL, V, HOLSTEN D, WAGNERHH. Treatment of chronic arterial occlusions with streptokinase. New Eng J Med 1969; 280: 689-692. 4 VAN BREDA A, KATZEN BT. Radiological aspects of intra-arterial thrombolytic therapy. In Comerota, AJ ed. Thrombolytic Therapy. Orlando: Grune and Stratton, 1988. 5 BERRIDGE DC, GREGSON RHS, HOPKINSON BR, MAKINGS. Systemic versus local peripheral arterial thrombolysis--a randomised trial. Brit J Surg 1990; 77: A347.
The Limited Applicability of Thrombolysis Sir, I thank Mr Hopkinson and co-workers for their interesting comments. My review was intended to discuss chronic critical limb ischaemia. My comment about the results of non-acute thrombolytic therapy should be seen in that context. Looking into the very extensive work now performed for the European Consensus Document on critical limb ischaemia, there is not convincing evidence of widespread benefit. I entirely agree there are patients who are greatly improved, but they are highly selected and it is almost impossible to predict who will be helped! The abstract of the controlled study Mr Hopkinson refers to was not available at the time I wrote this review. We are ourselves performing a randomised controlled study of acute ischaemia using recombinant tissue plasminogen activator (rtPA) vs. surgery. I look forward to more controlled studies on thrombolytic therapy to see if it is a solution to the great problem of critical i(schaemia. Lars Norgren Lund, Sweden Eur J VascSurgVol5, June 1991
361
Correspondence
Thrombolysis in Critical Ischaemia Sir, The review of Non-surgical Treatment of Critical Limb Ischaemia by Lars Norgren devotes considerable space to drugs that are of very limited benefit and yet dismisses thrombolytic therapy, which is of enormous benefit to selected patients, in a few lines. In our view, it may be incorrect to suggest that chronic occlusions are more easily lysed than acute ones. Thrombolysis of acute arterial occlusions is associated with a recanalisation rate of at least 70% .1, 2 Although some authors recommend lysis for chronic occlusions the recanalisation rate is lower and successful recanalisation seems to be confined to those patients with a recent exacerbation of symptoms. 3"4 Secondly, may we draw to the attention of readers our controlled trial of tissue plasminogen activator, which was presented at the annual meeting of the Vascular Surgical Society of Great Britain & Ireland, in 1989 and subsequently published in abstract form. 5 It is our belief that patients with critical limb ischaemia would gain considerably if all Vascular Surgeons appreciated the potential benefits of thrombolysis. R. J. Lonsdale G. S. Makin P. W. Wenham B. R. Hopkinson Nottingham, U.K.
References 1 Risius B, GROAR RA, GEISINGER MA, ZELCH MG, LUCAS FV, YOUNG JR. Thrombolytic therapy with Recombinant h u m a n tissue-type Plasminogen activator: A comparison of two doses. Radiology 1987; 164: 465-468.
2 WALKERWJ, GIDDINGS AEB. A protocol for the safe treatment of acute lower limb ischaemia with intra-arterial streptokinase and surgery. Brit J Surg 1988; 75: 1189-1192. 3 POLIWODAH, ALEXANDERK, BUHL, V, HOLSTEN D, WAGNERHH. Treatment of chronic arterial occlusions with streptokinase. New Eng J Med 1969; 280: 689-692. 4 VAN BREDA A, KATZEN BT. Radiological aspects of intra-arterial thrombolytic therapy. In Comerota, AJ ed. Thrombolytic Therapy. Orlando: Grune and Stratton, 1988. 5 BERRIDGE DC, GREGSON RHS, HOPKINSON BR, MAKINGS. Systemic versus local peripheral arterial thrombolysis--a randomised trial. Brit J Surg 1990; 77: A347.
The Limited Applicability of Thrombolysis Sir, I thank Mr Hopkinson and co-workers for their interesting comments. My review was intended to discuss chronic critical limb ischaemia. My comment about the results of non-acute thrombolytic therapy should be seen in that context. Looking into the very extensive work now performed for the European Consensus Document on critical limb ischaemia, there is not convincing evidence of widespread benefit. I entirely agree there are patients who are greatly improved, but they are highly selected and it is almost impossible to predict who will be helped! The abstract of the controlled study Mr Hopkinson refers to was not available at the time I wrote this review. We are ourselves performing a randomised controlled study of acute ischaemia using recombinant tissue plasminogen activator (rtPA) vs. surgery. I look forward to more controlled studies on thrombolytic therapy to see if it is a solution to the great problem of critical i(schaemia. Lars Norgren Lund, Sweden Eur J VascSurgVol5, June 1991
