Percutaneous Isolated Limb Perfusion (PILP) For Severe Ischemia In Non-Revascularization Candidates: Is This Real Or Just Fantasy?

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Ahsan T. Ali, M.D., John F. Eidt, M.D., Shelly Bledsoe, M.D., Venkat Kalapatapu, M.D., Mohammed Moursi, M.D..
University of Arkansas for Medical Sciences, Little Rock, AR, USA.

Background: Vascular patients with severe tibio-peroneal disease are not very good candidates for revascularization. Also, lack of distal target, no autogenous conduit or multiple medical problems make them a prohibitive risk for a bypass. Majority of these patients usually end up with an amputation. Thrombolytic therapy is time consuming and does carry risk of bleeding if carried beyond 24 hours. However, if the limbs can be isolated from the systemic circulation, higher dose of lytic agent can be given with low risk. These are the initial results of a series of 10 patients from a single institute who underwent PILP for severe ischemia.
Methods: All 10 patients (Lower ext: 9 and Upper ext 1) presented with acute ischemia with a mean ankle brachial index (ABI) of 0.15 with no recordable toe pressures. After initial heparin, they were taken to the OR and under general anesthesia, catheters (5 Fr.) were placed percutaneously in an antegrade fashion in the popliteal artery and vein. A proximal tourniquet was applied. Heparinized saline was infused via a multi side-hole arterial catheter while the vein catheter was left open. Outflow was confirmed when clear effluent came out of the venous port. Under a tourniquet, high dose lytic therapy was instilled in the arterial line and drained out of the venous catheter. After 45 minutes, arterial flow was allowed back. In 6 patients, IIb-IIIa inhibitor was used in addition to the thrombolytic agent.
Results: Pre and post arteriograms were not significantly different but the ABI improved from 0.15 to 0.36. None of the patients became eligible for a bypass. In the mean follow up of 6 months, the limb salvage rate was 100% and symptomatic relief in 9/10 patients. All patients were kept on anticoagulation postoperative period and discharged on warfarin. No bleeding complications were observed. Conclusions: PILP seem to bring symptomatic relief in short term follow up. It can be done safely, within a short time period and does not carry the morbidity of a surgical incision. It can be a last resort measure for limb preservation and pain relief for patients with ischemia/rest pain with no revascularization options. Long term follow up is needed to determine its durability.