Catheter-Directed Intraarterial Thrombolysis as Part of a Multidisciplinary Management Protocol of Frostbite Injury

Purpose To evaluate intraarterial catheter-directed thrombolysis for prediction and prevention of delayed surgical amputation as part of multidisciplinary management of frostbite injury. Materials and Methods A retrospective review was performed of 13 patients (11 men, 2 women; median age, 33.4 y; range, 8–62 y) at risk of tissue loss secondary to frostbite injury and treated with catheter-directed tissue plasminogen activator (t-PA) thrombolysis. Amputation data were assessed on follow-up (mean, 23 mo; range, 9–83 mo). Angiographic findings were classified into complete, partial, and no angiographic response and assessed for association with follow-up amputation rates. Correlation between amputation outcome and duration of cold exposure (mean, 23 h; range, 5–96 h), time between exposure and rewarming therapy (mean, 25.5 h; range, 7–95 h), and time between exposure and t-PA thrombolysis (mean, 32 h; range, 12–96 h) was assessed. Complications were recorded. Results Of 127 digits at risk on baseline angiography that were treated with catheter-directed thrombolysis, complete recovery was seen in 106 (83.4%). Total mean t-PA dose per extremity was 27.5 mg (range, 12–48 mg) over a mean period of 34 hours (range, 12–72 h). Patients with complete angiographic response (8 patients; 79.5% of digits) did not require amputations; 4 of 5 patients (80%) with partial angiographic response (20.5% of digits) underwent amputation (P =.007). There was no significant correlation between amputation rates and duration of cold exposure (P =.9), time to rewarming therapy (P =.88), and time to thrombolysis (P =.56). Femoral access site bleeding in 2 patients was managed conservatively. One patient underwent surgical exploration for brachial artery hematoma. Conclusions Intraarterial catheter-directed thrombolysis should be included in initial management of frostbite injury, as it may prevent delayed amputations. The degree of angiographic response to thrombolysis can potentially predict amputation outcomes.