Accelerated thrombolysis with high dose bolus t-PA extends the role of peripheral thrombolysis but may increase the risks.

Low dose intra-arterial thrombolysis is too slow for many patients with severe acute limb ischaemia. Accelerated thrombolysis with high dose bolus t-PA was used in a consecutive series of 43 patients. Complete or clinically useful lysis was achieved in 39 patients, with a median duration of 7 h. Lysis occurred in 46% in under 4 h. Fifty-six per cent of patients required further procedures after lysis. Eleven per cent suffered a major bleed. The limb salvage rate at 30 days was 56%. Amputation was required in 22% and 22% died. Most deaths were due to associated thrombotic conditions: myocardial infarction (5), pulmonary embolism (1) and malignant thrombosis (1). One patient died from pneumonia two weeks after lysis and two died from renal failure within a week of thrombolysis. The high mortality rate was not associated with bleeding but may reflect the high risks involved in treating this group of patients. High dose bolus t-PA infusion appears to predict immediate outcome of thrombolysis as well as reducing infusion times. It may expand the indications for the non-surgical treatment of acute limb ischaemia to include most patients with the condition. Careful case selection is still necessary for optimal results.