Intra-arterial thrombolysis is an alternative treatment to surgery for the acutely ischaemic limb. Intra-arterial streptokinase or tissue plasminogen activator (tPA) converts plasminogen into plasmin, which lyses thrombin. Following thrombolysis, an angiogram should be performed to identify any underlying stenosis.
There have been five randomised controlled trials comparing surgery with thrombolysis in the acutely ischaemic limb (including 1283 patients) that have been analysed in a systematic review [9].

Major complications were more common after thrombolysis with a 1.3% risk of stroke (compared with 0% after surgery) and an 8.8% risk of major haemorrhage (versus 3.3% after surgery).
Although there was clinical heterogeneity between the studies, the authors concluded that:

“Universal initial treatment with either surgery or thrombolysis cannot be advocated on the available evidence”[9]
There have been no further randomised controlled trials since.

In the UK, thrombolysis use peaked in the late 1990s. Most centres now use surgery as first-line management in most patients, mainly because of concerns regarding efficacy, and complication rates for thrombolysis [14].

Contraindications to thrombolysis

Table 1: Contraindications to thrombolysis
Bleeding or severe bleeding tendency
CVA/TIA <2 months ago
Intracerebral tumour/AVM/aneurysm
Surgery <2 weeks ago
Previous GI bleed
Trauma <10 days ago

Learning bite

There is no evidence to favour thrombolysis over surgery in the acutely ischaemic limb.

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