Current status of thrombolytic therapy John M. Porter, M.D., Lloyd M. Taylor, M.D.  Journal of Vascular Surgery  Volume 2, Issue 2, Pages 239-249 (March 1985) DOI: 10.1016/0741-5214(85)90059-X Copyright © 1985 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 1 Schematic diagram of in vivo fibrinolysis. Streptokinase and urokinase both act to convert plasminogen to plasmin. Journal of Vascular Surgery 1985 2, 239-249DOI: (10.1016/0741-5214(85)90059-X) Copyright © 1985 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 2 Phlebogram of 60-year-old man with 24-hour history of right leg swelling and tenderness. Systemic streptokinase was begun 40 hours after onset of symptoms. A, Initial phlebogram showed total occlusion of femoral and popliteal veins. Patient received loading dose of 250,000 units of streptokinase followed by 100,000 U/hr for 70 hours. B, Three days later phlebogram showed much improvement. Patient received IV heparin for 6 days followed by warfarin for 6 months. Phlebogram on day 12 was normal (C), as was follow-up phlebogram 3 months later (D). Journal of Vascular Surgery 1985 2, 239-249DOI: (10.1016/0741-5214(85)90059-X) Copyright © 1985 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 3 A 21-year-old woman had sudden tachypnea and cyanosis 3 weeks post partum. A, Pulmonary arteriogram showed massive pulmonary embolism (arrows). She was treated with IV streptokinase 250,000 units, followed by 100,000 units for 18 hours. By that time her symptoms had resolved and she was begun on IV heparin followed by warfarin. B, Follow-up pulmonary arteriogram at 2 weeks showed complete resolution of pulmonary emboli. Journal of Vascular Surgery 1985 2, 239-249DOI: (10.1016/0741-5214(85)90059-X) Copyright © 1985 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 4 Arteriograms of 75-year-old man with chronic atrial fibrillation and congestive heart failure who presented with acute left popliteal artery occlusion (A). Catheter was positioned in mid—left popliteal artery and streptokinase infused at 5000 U/hr. By 24 hours after infusion, patency was restored (B) with normal palpable pedal pulses; however, residual thrombus prompted continuing infusion for an additional 48 hours (C). D, Although pulses persisted, small residual thrombus (arrow) did not resolve and was removed at surgery. Patient has been anticoagulated with warfarin and has maintained patency at follow-up for 2 years. Journal of Vascular Surgery 1985 2, 239-249DOI: (10.1016/0741-5214(85)90059-X) Copyright © 1985 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 5 Arteriograms of 76-year-old smoker who presented with acute onset of right foot ischemic rest pain of 48 hours' duration. Popliteal and pedal pulses were absent, and an easily palpable 4 cm fusiform mass was found in popliteal fossa. A and B, Initial arteriograms demonstrated occlusion of popliteal artery and all tibial vessels with only small unnamed vessels visible in leg (B, arrow). Catheter was positioned at level of occlusion and streptokinase infusion begun at 5000 U/hr. After 48 hours, restoration of patency of large popliteal aneurysm was demonstrated by angiography (C) and by return of pedal pulses. Infusion was stopped, patient was heparinized, and saphenous vein bypass performed with exclusion of aneurysm (D). Repair has remained patent for 2½ years. Journal of Vascular Surgery 1985 2, 239-249DOI: (10.1016/0741-5214(85)90059-X) Copyright © 1985 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 6 Arteriograms of 52-year-old male renal transplant recipient on high-dose prednisone and azathioprine who had had left femoropopliteal—saphenous vein graft 2½ years previously. He presented with graft occlusion and lower extremity rest pain of 4 days' duration. A, Catheter was positioned in origin of occluded graft and streptokinase infusion begun at 5000 U/hr. B and C, As thrombolysis progressed, catheter was advanced down graft lumen under fluoroscopic guidance to keep the infusion close to remaining thrombus. D to G, After 72 hours, complete patency was restored. Infusion was stopped and patient heparinized. Several days later he underwent operative repair of high-grade stenosis of graft origin caused by fibrous intimal hyperplasia (not shown). This graft has remained patent for 1½ years. Journal of Vascular Surgery 1985 2, 239-249DOI: (10.1016/0741-5214(85)90059-X) Copyright © 1985 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 7 Arteriograms of 67-year-old man who had acutely ischemic left foot and loss of previously palpable pedal pulses while being treated for multiple arrhythmias and low cardiac output 4 days following major myocardial infarction. A, Angiography demonstrated occlusion of popliteal artery with meniscus sign and only collateral vessels patent in leg (arrows). Through catheter positioned in distal popliteal artery, streptokinase infusion was begun at 5000 U/hr. Pedal pulses returned 24 hours later and repeat angiography (B) demonstrated restoration of patency. Infusion was stopped and patient treated with heparin followed by warfarin therapy. Arterial patency was maintained until death 8 months later of recurrent myocardial infarction. Journal of Vascular Surgery 1985 2, 239-249DOI: (10.1016/0741-5214(85)90059-X) Copyright © 1985 Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions