A Hybrid Protocol of Emergent Endovascular Intervention With Adjunctive Systemic Thrombolysis for Acute Limb Ischemia: A Single-Center Pilot Study

PURPOSE: To evaluate the feasibility and early outcomes of a hybrid pharmacomechanical strategy combining emergent endovascular revascularization with adjunctive systemic thrombolysis for the treatment of acute limb ischemia (ALI). MATERIALS AND METHODS: This retrospective single-center pilot study included 20 consecutive patients presenting with ALI within 96 hours of symptom onset who underwent primary endovascular revascularization between 2016 and 2018. Mechanical thrombectomy and angioplasty were performed as first-line interventions. In cases of incomplete reperfusion, adjunctive intravenous systemic urokinase infusion was administered followed by repeat angiographic assessment within 48 to 72 hours. Technical success, limb salvage, complications, and in-hospital mortality were evaluated. RESULTS: Initial mechanical endovascular intervention achieved successful reperfusion in 13 patients (65%). Seven patients with persistent low-flow states received adjunctive systemic thrombolysis, resulting in additional successful reperfusion in 5 cases. The overall technical success rate was therefore 90%. Two patients required fasciotomy for compartment syndrome. One patient developed severe ischemia-reperfusion injury resulting in multiorgan failure and death. Limb salvage was achieved in 18 of 20 patients during the index hospitalization. Mean clinical follow-up was (145.1 ± 182.3) days (median: 65 days). CONCLUSION: A staged hybrid pharmacomechanical strategy incorporating adjunctive systemic thrombolysis following mechanical endovascular revascularization was associated with a feasible treatment option for selected patients with ALI when initial mechanical intervention results in incomplete reperfusion. Larger studies are required to determine the comparative effectiveness of this approach in contemporary endovascular practice.Clinical ImpactFor patients with acute limb ischemia and suboptimal flow (TIMI 0-1) after initial endovascular mechanical thrombectomy-defined angiographically as TIMI 0 (no antegrade flow beyond the occlusion) or TIMI 1 (minimal penetration of contrast without distal bed filling), analogous to coronary grading-adjunctive systemic thrombolysis was associated with successful salvage in 83% of otherwise refractory cases in this pilot study, raising overall technical success from 65% to 90%. This staged hybrid strategy offers a practical "bail-out" option before resorting to repeat intervention or open surgery. Urokinase was delivered as a peripheral intravenous infusion; although not available in all regions (it has not been Food and Drug Administration-approved in the United States since 2010), the principle may be applied with alternative agents such as tissue plasminogen activator. The innovation lies in its simplicity: a predefined protocol using systemic urokinase without specialized catheter-directed systems. Clinicians should consider this approach in hemodynamically stable patients with persistent low-flow states, potentially reducing the need for immediate reintervention while achieving acceptable limb salvage and mid-term amputation-free survival.