Thrombolysis in endovascular management of chronic aortic occlusions: A narrative review

INTRODUCTION: Revascularisation of chronic juxtarenal aortic occlusions can present a complex challenge. While open repair remains the gold standard, endovascular therapy is increasingly used in high- risk patients. The role of catheter- directed thrombolysis (CDT) in chronic aortic occlusions remains unclear and might be underestimated in patients unfit for open revascularisation. METHODS: We conducted a narrative review of PubMed/MEDLINE and Embase for English- language studies from January 1, 2000, to January 31, 2025. Using MeSH and free- text terms for thrombolysis (e.g., catheter- directed thrombolysis, fibrinolysis, urokinase, tissue plasminogen activator) and chronic aortic/aroilial occlusion (including juxtarenal/infrarrenal anatomy), we included native chronic aortic or aortoiliac occlusions treated with CDT in revascularisation studies reporting technical and/or clinical outcomes. Case reports (<5 patients) were excluded. Outcomes assessed included technical success (thrombus reduction enabling definitive endovascular therapy), patency, and major complications. RESULTS: Five retrospective series were included, comprising 54 patients treated with CDT (urokinase or tPA) before endovascular aortoiliac revascularisation. All studies used CDT as an adjunct to endovascular revascularisation. Technical success rates ranged from 80 - 100%, with no 30- day mortality and low complication rates. Reported primary patency after definitive endovascular reconstruction was generally 85 - 100% at 1 year (83% at 18 months in one series), with limited longer- term follow- up. CONCLUSION: CDT may serve as a useful adjunct in the endovascular treatment of chronic juxtarenal aortic occlusions, particularly in high- risk patients. However, further prospective studies are needed to define its long- term efficacy and safety.