日本脈管学会編：下肢閉塞性動脈硬化症の診断・治療指針 TASCⅡ． 推奨事項29． 急性下肢虚血（ALI）の評価．.
KASIRAJAN,MD,FACS, OURIEL,MD.FACS,FACC Acute Limb Ischemia Rutherford Vascular Surgery 6th ed SAUNDERS 2005 Chapter66 p960.
Cambria RP, Brewster DC, Gertler J, Moncure AC, Gusberg R, Tilson MD, Darling RC, Hammond G, Mergerman J, Abbott WM.
Vascular complications associated with spontaneous aortic dissection.
J Vasc Surg. 1988 Feb;7(2):199-209.
Abstract/Text
Three hundred twenty-five cases of spontaneous aortic dissection seen at two institutions between 1965 and 1986 were reviewed to assess the incidence, morbid sequelae, and specific management of aortic branch compromise. Noncardiac vascular complications occurred in 33% of the study group, and in these patients the overall mortality rate (51%) was significantly (p less than 0.001) higher than in patients without (29%) such complications. Although aortic rupture was the strongest correlate of mortality (90%), death specifically related to vascular occlusion was common when such occlusion occurred in the carotid, mesenteric, and renal circulation. There was a strong correlation between stroke and carotid occlusion (22/26 cases), yet specific carotid revascularization was only used during the chronic phase of the disease. Similarly, peripheral operation was ineffective in reducing the mortality rate in the setting of mesenteric (87%) and renal (50%) ischemia. Fifteen patients required either fenestration or graft replacement of the abdominal aorta for acute obstruction, rupture, or chronic aneurysm development. Thirty-eight patients (12%) demonstrated some degree of lower extremity ischemia, and one third of these required a direct approach on the abdominal aorta or iliofemoral segments to restore circulation. Selected patients with acute aortic dissection may require peripheral vascular operation in accordance with a treatment strategy that directs initial attention to the immediate life-threatening complications.
日本脈管学会編：下肢閉塞性動脈硬化症の診断・治療指針 TASCⅡ．推奨事項30． 急性下肢虚血を疑う症例．.
日本脈管学会編：下肢閉塞性動脈硬化症の診断・治療指針 TASCⅡ．推奨事項31．.
Ouriel K, Veith FJ, Sasahara AA.
A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. Thrombolysis or Peripheral Arterial Surgery (TOPAS) Investigators.
N Engl J Med. 1998 Apr 16;338(16):1105-11. doi: 10.1056/NEJM199804163381603.
Abstract/Text
BACKGROUND: Recent controlled trials suggest that thrombolytic therapy may be an effective initial treatment for acute arterial occlusion of the legs. A major potential benefit of initial thrombolytic therapy is that limb ischemia can be managed with less invasive interventions.
METHODS: In this randomized, multicenter trial conducted at 113 North American and European sites, we compared vascular surgery (e.g., thrombectomy or bypass surgery) with thrombolysis by catheter-directed intraarterial recombinant urokinase; all patients (272 per group) had had acute arterial obstruction of the legs for 14 days or less. Infusions were limited to a period of 48 hours (mean [+/-SE], 24.4+/-0.86), after which lesions were corrected by surgery or angioplasty if needed. The primary end point was the amputation-free survival rate at six months.
RESULTS: Final angiograms, which were available for 246 patients treated with urokinase, revealed recanalization in 196 (79.7 percent) and complete dissolution of thrombus in 167 (67.9 percent). Both treatment groups had similar significant improvements in mean ankle-brachial blood-pressure index. Amputation-free survival rates in the urokinase group were 71.8 percent at six months and 65.0 percent at one year, as compared with respective rates of 74.8 percent and 69.9 percent in the surgery group; the 95 percent confidence intervals for the differences were -10.5 to 4.5 percentage points at six months (P=0.43) and -12.9 to 3.1 percentage points at one year (P=0.23). At six months the surgery group had undergone 551 open operative procedures (excluding amputations), as compared with 315 in the thrombolysis group. Major hemorrhage occurred in 32 patients in the urokinase group (12.5 percent) as compared with 14 patients in the surgery group (5.5 percent) (P= 0.005). There were four episodes of intracranial hemorrhage in the urokinase group (1.6 percent), one of which was fatal. By contrast, there were no episodes of intracranial hemorrhage in the surgery group.
CONCLUSIONS: Despite its association with a higher frequency of hemorrhagic complications, intraarterial infusion of urokinase reduced the need for open surgical procedures, with no significantly increased risk of amputation or death.
Berridge DC, Kessel D, Robertson I.
Surgery versus thrombolysis for acute limb ischaemia: initial management.
Cochrane Database Syst Rev. 2002;(3):CD002784. doi: 10.1002/14651858.CD002784.
Abstract/Text
BACKGROUND: Peripheral arterial thrombolysis is a useful technique for the management of peripheral arterial ischaemia. Much is known about the indications, risks and benefits of thrombolysis, although data from randomised controlled studies are not extensive. However, it is not known whether thrombolysis works better than surgery in the initial treatment of acute limb ischaemia.
OBJECTIVES: To determine the preferred initial treatment, surgery or thrombolysis, for acute limb ischaemia.
SEARCH STRATEGY: The Cochrane Controlled Trials Register (Issue 3, 2001), and the Specialised Trials Register of the Cochrane Peripheral Vascular Diseases Group (September 2001) were searched. Proceedings from all British Vascular Surgical Society, European Vascular Surgical Society and North American Society of Vascular Surgery meetings, Society of Cardiovascular and Interventional Radiology (SCVIR) and Cardiovascular and Interventional Society of Europe (CIRSE), were handsearched. Pharmaceutical firms and trialists were asked for information about unpublished trials.
SELECTION CRITERIA: All randomised studies comparing thrombolysis and surgery in the initial management of acute limb ischaemia.
DATA COLLECTION AND ANALYSIS: Assessment of trial quality and data extraction was done independently by all reviewers.
MAIN RESULTS: Five trials with a total of 1,283 patients were included. Two trials used a list of procedures of increasing severity of intervention. If lytic treatment were successful, further intervention might prove unnecessary. There was no significant difference in limb salvage or death at 30 days, six months or one year between initial surgery and initial thrombolysis. However, with initial lysis, stroke was significantly more frequent at 30 days, 8/640 patients compared to 0/540 patients receiving initial surgery [Odds ratio (95% CI) 6.41(1.57, 26.22)]; major haemorrhage was more likely at 30 days, 52/588 versus 16/482 [Odds ratio (95% CI) 2.80 (1.70, 4.60)]; and distal embolisation was more likely at 30 days, 42/340 versus 0/338 [Odds ratio (95% CI) 8.35 (4.47, 15.58)]. Patients treated by initial lysis underwent a less severe degree of intervention [Odds ratio (95% CI) 5.37 (3.99, 7.22)], and displayed equivalent overall survival compared to initial surgery [Odds ratio (95% CI) 0.87(0.61, 1.25)].
REVIEWER'S CONCLUSIONS: Universal initial treatment with either surgery or thrombolysis cannot be advocated on the available evidence. There is no overall difference in limb salvage or death at one year between initial surgery and initial thrombolysis. Thrombolysis may be associated with a higher risk of ongoing limb ischaemia, and of haemorrhagic complications, including stroke. The higher risk of complications must be balanced against risks of surgery in each patient.
Berridge DC, Kessel DO, Robertson I.
Surgery versus thrombolysis for initial management of acute limb ischaemia.
Cochrane Database Syst Rev. 2013 Jun 6;(6):CD002784. doi: 10.1002/14651858.CD002784.pub2. Epub 2013 Jun 6.
Abstract/Text
BACKGROUND: Peripheral arterial thrombolysis is technique used in the management of peripheral arterial ischaemia. Much is known about the indications, risks and benefits of thrombolysis. However, it is not known whether thrombolysis works better than surgery in the initial treatment of acute limb ischaemia.
OBJECTIVES: To determine the preferred initial treatment, surgery or thrombolysis, for acute limb ischaemia.
SEARCH METHODS: For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched March 2013) and CENTRAL (2013, Issue 2).
SELECTION CRITERIA: All randomised studies comparing thrombolysis and surgery for the initial treatment of acute limb ischaemia.
DATA COLLECTION AND ANALYSIS: Each author independently assessed trial quality and extracted data. Agreement was reached by consensus.
MAIN RESULTS: Five trials with a total of 1283 participants were included. There was no significant difference in limb salvage or death at 30 days, six months or one year between initial surgery and initial thrombolysis. However, stroke was significantly more frequent at 30 days in thrombolysis participants (1.3%) compared to surgery participants (0%) (Odds ratio (OR) 6.41; 95% confidence interval (CI) 1.57 to 26.22). Major haemorrhage was more likely at 30 days in thrombolysis participants (8.8%) compared to surgery participants (3.3%) (OR 2.80; 95% CI 1.70 to 4.60); and distal embolization was more likely at 30 days in thrombolysis participants (12.4%) compared to surgery participants (0%) (OR 8.35; 95% CI 4.47 to 15.58).Participants treated by initial thrombolysis underwent a less severe degree of intervention (OR 5.37; 95% CI 3.99 to 7.22) and displayed equivalent overall survival compared to initial surgery (OR 0.87; 95% CI 0.61 to 1.25).
AUTHORS' CONCLUSIONS: Universal initial treatment with either surgery or thrombolysis cannot be advocated on the available evidence. There is no overall difference in limb salvage or death at one year between initial surgery and initial thrombolysis. Thrombolysis may be associated with a higher risk of ongoing limb ischaemia and haemorrhagic complications including stroke. The higher risk of complications must be balanced against risks of surgery in each person.
宮田茂樹，山本晴子：ヘパリン起因性血小板減少症（HIT）の治療．血栓止血誌 2008；19(2) : 195-198．.
