Fibrinolytic agents for peripheral arterial occlusion.

Abstract

BACKGROUND:

Peripheral arterial thrombolysis is used in the management of peripheral arterial ischaemia. Streptokinase was originally used but safety concerns led to a search for other agents. Urokinase and recombinant tissue plasminogen activator (rt-PA) have increasingly become established as first line agents for peripheral arterial thrombolysis. Potential advantages of these agents include improved safety, greater efficacy and a more rapid response. Recently drugs such as pro-urokinase, recombinant staphylokinase and alfimperase have been introduced. This is an update of a review first published in 2010.

OBJECTIVES:

To determine which fibrinolytic agents are most effective in peripheral arterial ischaemia.

SEARCH METHODS:

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched March 2013) and CENTRAL (2013, Issue 3) for randomised controlled trials (RCTs) comparing fibrinolytic agents to treat peripheral arterial ischaemia.

SELECTION CRITERIA:

RCTs comparing fibrinolytic agents to treat peripheral arterial occlusion.

DATA COLLECTION AND ANALYSIS:

Data were analysed for the outcomes vessel patency, time to lysis, limb salvage, amputation, death, complications including major haemorrhage, stroke, and distal embolization.

MAIN RESULTS:

Five RCTs involving a total of 687 participants with a range of clinical indications were included. No new studies were included in this update. In one three-pronged study, vessel patency was greater with intra-arterial recombinant tissue plasminogen activator (rt-PA) than with intra-arterial streptokinase (P < 0.04) or intravenous rt-PA (P < 0.01). In participants with peripheral arterial occlusion there was no statistically significant difference in limb salvage at 30 days with either urokinase or rt-PA, though this may reflect the small numbers in the studies. Incidences of haemorrhagic complications varied with fibrinolytic regime but there was no statistically significant difference between intra-arterial urokinase and intra-arterial rt-PA. In the three-pronged study intravenous rt-PA and intra-arterial streptokinase were associated with a significantly higher risk of haemorrhagic complications than with intra-arterial rt-PA (P < 0.05).

AUTHORS' CONCLUSIONS:

There is some evidence to suggest that intra-arterial rt-PA is more effective than intra-arterial streptokinase or intravenous rt-PA in improving vessel patency in people with peripheral arterial occlusion. There was no evidence that rt-PA was more effective than urokinase for patients with peripheral arterial occlusion and some evidence that initial lysis may be more rapid with rt-PA, depending on the regime. Incidences of haemorrhagic complications were not statistically significantly greater with rt-PA than with other regimes. However, all of the findings come from small studies and a general paucity of results means that it is not possible to draw clear conclusions.

• Authors: Iain Robertson, David O Kessel, David C Berridge
• Journal: The Cochrane database of systematic reviews (Cochrane Database Syst Rev) Issue 12 Pg. CD001099 (Dec 19 2013) ISSN: 1469-493X [Electronic] England
• PMID: 24357258 (Publication Type: Journal Article, Meta-Analysis, Research Support, Non-U.S. Gov't, Review, Systematic Review)

Chemical References

• Fibrinolytic Agents
• Recombinant Proteins
• Streptokinase
• Tissue Plasminogen Activator
• Urokinase-Type Plasminogen Activator

Topics

• Arterial Occlusive Diseases (drug therapy)
• Fibrinolytic Agents (adverse effects, therapeutic use)
• Humans
• Peripheral Vascular Diseases (drug therapy)
• Randomized Controlled Trials as Topic
• Recombinant Proteins (adverse effects, therapeutic use)
• Streptokinase (adverse effects, therapeutic use)
• Thrombolytic Therapy (adverse effects, methods)
• Thrombosis (drug therapy)
• Tissue Plasminogen Activator (adverse effects, therapeutic use)
• Urokinase-Type Plasminogen Activator (adverse effects, therapeutic use)