II-128

J ENDOVASC THER
2004;11(Suppl II):II-128II-133

l REVIEW

A History of Thrombolytic Therapy

Kenneth Ouriel, MD
Department of Vascular Surgery, The Cleveland Clinic Foundation,
Cleveland, Ohio, USA.
l

Thrombolytic therapy has been available for the last 5 decades, but the modern era of
thrombolysis began in the early 1990s, with the execution of 3 multicenter trials designed
to compare this potentially less invasive therapy to the then standard of care for acute
limb ischemia, open surgical revascularization. Even with the development of several bioengineered lytic agents, the major risk of thrombolytic therapy continues to be bleeding
complications. Nevertheless, data exist to suggest that thrombolysis should be considered
as an adjunct to open surgery, percutaneous interventions, or, occasionally, as sole therapy
for acute vascular occlusion. This review summarizes the developmental milestones in the
history of thrombolysis and reviews data supporting its use in acute arterial occlusions.
J Endovasc Ther 2004;11(Suppl II):II-128II-133

Key words: thrombosis, thrombolytic therapy, peripheral arteries, occlusion, streptokinase,

urokinase, reteplase, tenecteplase
l

Thrombolytic therapy, which offers a potentially less invasive option for the treatment of
patients with peripheral arterial and venous
occlusions, has gained prominence as an initial intervention, infusing thrombolytic agents
directly into the occluding thrombus via a
catheter-directed approach. Agents such as
urokinase, alteplase, and reteplase can recanalize occluded vessels, in many cases allowing the clinician to identify and address the
culprit lesions responsible for the occlusion.
Oftentimes, an endovascular procedure, e.g.,
balloon dilation of a vein graft stenosis or
stenting of a common iliac venous web, can
be performed to minimize the risk of reocclusion. In other cases where open surgical intervention is still necessary, the procedure
can be performed on an elective basis in a
well-prepared patient.
While intellectually attractive, thrombolytic
therapy has been criticized on the basis of a
high reocclusion rate, prohibitive cost, and inferior long-term patency.1,2 Some of the criti-

cisms were based on a misunderstanding of

therapeutic expectations. The need for subsequent intervention to address unmasked lesions was often neglected. Experience has
demonstrated that thrombolysis must be followed by definitive therapy to address the
culprit lesion that caused the occlusion. In
fact, when no such lesion can be found, the
risk of early rethrombosis is unacceptably
high. As testimony to this caveat, Sullivan et
al.3 observed post-thrombolytic 2-year patency rates of 79% in bypass grafts with flowlimiting lesions corrected by angioplasty or
surgery versus only 9.8% in grafts without
such lesions.

EARLY DEVELOPMENT OF
THROMBOLYTIC THERAPY
The history of thrombolytic therapy begins in
1933, when Tillett and Garner4 at the Johns
Hopkins Medical School discovered that filtrates of broth cultures of certain strains of

Address for correspondence and reprints: Kenneth Ouriel, MD, Chairman, Division of Surgery, Desk
E32, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195 USA. Fax: 1-216445-6302; E-mail: ourielk@ccf.org
Q 2004 by the INTERNATIONAL SOCIETY

OF

ENDOVASCULAR SPECIALISTS

Available at www.jevt.org

J ENDOVASC THER
2004;11(Suppl II):II-128II-133

hemolytic Streptococcus bacteria could dissolve fibrin clot. This byproduct, originally
termed streptococcal fibrinolysin, was crude
and impure, so clinical use awaited adequate
purification. Tillett and Sherry5 administered
streptokinase (SK) intrapleurally to dissolve
loculated hemothoraces in the late 1940s, but
intravascular administration was not attempted until the following decade, when Tilletts
group injected a concentrated and partially
purified SK (Varidase; Lederle Laboratories,
Wayne, NJ, USA) into 11 volunteers. The
study was intended to gain data on the safety
of the agent; in no case was the SK administered to dissolve pathological thrombi. Fever
and hypotension developed as the amount of
SK approached therapeutic levels. Whereas
fever was generally mild and controllable
with antipyretics, hypotension was sometimes prominent. The mean fall in systolic
pressure was 31 mmHg, and 3 of the patients
manifested systolic pressures ,80 mmHg.
These untoward reactions were more likely a
result of contaminants in the preparation rather than the SK itself. Despite these reactions,
systemic proteolysis was observed, with a decrease in fibrinogen and plasminogen and an
increase in the prothrombin time.
These early studies were followed by reports on the use of SK in patients with occluding vascular thrombi. In 1956, E. E. Cliffton at the Cornell University Medical College
in New York was responsible for the first brief
description of the clinical effectiveness of intravascular thrombolytic administration.7 The
following year, Cliffton8 published his results
in 40 patients with occlusive thrombi treated
with an SK-plasminogen in combination. The
location of the occlusions was diverse: peripheral arterial thrombi, venous thrombi, pulmonary emboli, retinal occlusions, and occlusive carotid thrombi in 2 patients. Clifftons
clinical results were far from exemplary; recanalization was not uniform, and bleeding
complications were frequent. Nevertheless,
he must be credited with the first use of
thrombolytic agents for the treatment of pathological thrombi, as well as with the first catheter-directed administration of a thrombolytic
agent.
These early studies were followed by the
larger retrospective series of the 1970s and

10 YEARS OF THROMBOLYTIC THERAPY

Ouriel

II-129

1980s. Dotter and colleagues9 followed the

lead of Cliffton, employing a regional approach to thrombolytic administration. Streptokinase was the agent administered according to a low-dose protocol. In theory, such an
approach should have been associated with a
lower rate of complications, but this was not
the case.10 Bleeding was all too frequent, possibly occurring as a result of the intense systemic proteolytic state that was common despite local administration.11
The fibrinolytic potential of human urine
was first described by Macfarlane and Pilling
in 1947.12 The active molecule was extracted,
isolated, and named urokinase (UK) in
1952.13 The high-molecular-weight form predominates in UK isolated from urine, while
the low-molecular-weight form is found in UK
obtained from tissue culture of kidney cells.
Unlike SK, UK directly activates plasminogen
to form plasmin; prior binding to plasminogen or plasmin is not necessary for activity.
Also in contrast to SK, preformed antibodies
to UK are not observed. The agent is nonantigenic, and untoward reactions of fever or
hypotension are rare.
The most commonly employed UK in the
US has been of tissue-culture origin, manufactured from human neonatal kidney cells
(Abbokinase; Abbott Laboratories, Abbott
Park, IL, USA). UK has been fully sequenced,
and a recombinant form of UK (rUK) was tested in a single trial of patients with acute myocardial infarction (MI) and in two multicenter
trials of patients with peripheral arterial occlusion.14 rUK is fully glycosylated, since it is derived from a murine hybridoma cell line. rUK
differs from Abbokinase in several respects:
rUK has a higher molecular weight than Abbokinase and a shorter half-life than its lowmolecular-weight counterpart. Despite these
differences, however, the clinical effects of the
two agents have been quite similar.
A precursor of UK was discovered in urine
in 1979.15 Prourokinase was characterized and
subsequently manufactured by recombinant
technology using Escherichia coli (nonglycosylated) or mammalian cells (fully glycosylated). This single-chain form is an inactive zymogen, inert in plasma but activated by
kallikrein or plasmin to form active 2-chain
UK, which accounts for amplification of the

II-130

10 YEARS OF THROMBOLYTIC THERAPY

Ouriel

fibrinolytic process. As plasmin is generated,

more prourokinase is converted to active urokinase, and the process is repeated. Prourokinase is relatively fibrin-specific, that is, its
fibrin degrading (fibrinolytic) activity greatly
outweighs its fibrinogen degrading (fibrinogenolytic) activity. This feature is explained
by the preferential activation of fibrin-bound
plasminogen found in a thrombus over the
free plasminogen in flowing blood. Nonselective activators such as SK and UK activate
free and bound plasminogen equally and induce systemic plasminemia, with resultant fibrinogenolysis and degradation of factors V
and VII.
Given the potential advantages of prourokinase over urokinase, Abbott Laboratories
produced a recombinant form of prourokinase (r-proUK) from a murine hybridoma cell
line. Named Prolyse, this recombinant agent
is converted to active 2-chain UK by plasmin
and kallikrein. Prolyse has been studied in the
settings of MI, stroke, and peripheral arterial
occlusion. To date, it appears that r-proUK offers the advantages associated with an agent
that does not originate from a human cell
source.
McNamara and Fischer16 were the first to
describe the use of urokinase for local thrombolytic treatment, using a high-dose protocol
featuring graded, stepwise reductions in dose
as the infusion progressed. For the first time,
clinicians felt comfortable with the risk-benefit equation when treating patients with
thrombolytic agents. McNamaras work set
the scene for the large randomized trials of
the 1990s, many of which employed doses
similar to those initially investigated by Dr.
McNamara.
Tissue plasminogen activator (tPA), originally developed in the mid 1980s for acute
coronary artery occlusion, is a naturally occurring fibrinolytic agent produced by endothelial cells and is intimately involved in the
balance between intravascular thrombogenesis and thrombolysis. Natural tPA is a singlechain (527 amino acid) serine protease, and
in contrast to most serine proteases (e.g., urokinase), the single-chain form has significant
activity. tPA has potential benefits over other
thrombolytic agents. For one, the agent exhibits significant fibrin specificity; in plasma,

J ENDOVASC THER
2004;11(Suppl II):II-128II-133

the agent is associated with little plasminogen activation. At the site of the thrombus,
however, the binding of tPA and plasminogen
to the fibrin surface induces a conformational
change in both molecules, greatly facilitating
the conversion of plasminogen to plasmin
and dissolution of the clot. tPA also manifests
the property of fibrin affinity, that is, it binds
strongly to fibrin. Other fibrinolytic agents,
such as prourokinase, do not demonstrate fibrin affinity.
Recombinant tPA (rtPA) was produced in
the 1980s after molecular cloning techniques
were used to express human tPA DNA.17 Activase (Genentech, Inc., South San Francisco,
CA, USA), a predominantly single-chain form
of rtPA, was eventually approved in the US for
the indications of acute MI and massive pulmonary embolism. rtPA has been studied extensively in the setting of coronary occlusion.
In the GUSTO-I study of ;41,000 patients with
acute MI, rtPA was more effective than SK in
achieving vascular patency.18 Despite a slightly greater risk of intracranial hemorrhage with
rtPA, overall mortality was significantly reduced.
In an effort to lengthen the duration of bioavailability of tPA, the molecule was systematically bioengineered.19 Initial investigations
identified regions in kringle-1 and the protease portion of tPA, which mediated hepatic
clearance, fibrin specificity, and resistance to
plasminogen activator inhibitor. Three sites
were modified to create TNK-tPA, a novel
molecule with a greater half-life and fibrin
specificity. The longer half-life of TNK-tPA allowed successful administration as a single
bolus, in contrast to the infusion required for
rtPA. In addition, TNK-tPA manifests greater
fibrin specificity than rtPA, resulting in less fibrinogen depletion. In studies of acute coronary occlusion, TNK-tPA performed at least as
well as rtPA, concurrent with greater ease of
administration.20
Similar to TNK-tPA, the novel recombinant
plasminogen activator reteplase comprises
the kringle-2 and protease domains of tPA.21
Reteplase was developed with the goal of
avoiding the necessity of a continuous intravenous infusion, thereby simplifying ease of
administration. Reteplase (Retavase; Centocor, Malvern, PA, USA), produced in Esche-

J ENDOVASC THER
2004;11(Suppl II):II-128II-133

richia coli cells, is nonglycosylated, demonstrating a lower fibrin-binding activity and a

diminished affinity to hepatocytes. This latter
property accounts for a longer half-life than
rtPA, potentially enabling bolus injection versus prolonged infusion. Similar to UK, the fibrin affinity of reteplase was only 30% of that
exhibited with tPA. The decrease in fibrin affinity was hypothesized to reduce the incidence of distant bleeding complications in a
manner similar to that of SK over rtPA in the
GUSTO trial.18 In fact, several properties of reteplase may account for a decreased risk of
hemorrhage, including poor lysis of older,
platelet-rich clots.22 Reteplase has been studied in several small trials, and its safety and
efficacy appear to be similar to alteplase.2325

THROMBOLYSIS FOR PERIPHERAL

ARTERIAL OCCLUSION
The modern era of thrombolytic therapy began with the organization and execution of 3
multicenter trials designed to compare this
potentially less invasive therapy to the then
standard of care for acute limb ischemia,
open surgical revascularization. The first
study, the Rochester series, compared urokinase to primary operation in a single-center
experience of 114 patients presenting with
what has subsequently been called hyperacute ischemia.26 Enrolled patients in this trial all had severely threatened limbs (Rutherford category IIb) with mean symptom
duration of ;2 days. After 12 months, 84% of
patients randomized to UK were alive compared to only 58% of patients allocated to primary operation. By contrast, the rate of limb
salvage was identical at 80%. A closer inspection of the raw data revealed that the defining
variable for mortality differences was the development of cardiopulmonary complications
during the periprocedural period. The rate of
long-term mortality was high when cardiopulmonary sequelae occurred but was relatively low when they did not. It was only the
fact that these complications occurred more
commonly in patients taken directly to the operating theater that explained the greater
long-term mortality in the operative group.
The second prospective, randomized analysis of thrombolysis versus surgery was the

10 YEARS OF THROMBOLYTIC THERAPY

Ouriel

II-131

Figure l Thirty-day outcome measures from the

STILE data.

Surgery or Thrombolysis for the Ischemic

Lower Extremity (STILE) trial.27 Genentech,
the manufacturer of the Activase brand of
rtPA, funded the study. At its termination, 393
patients had been randomized to rtPA, urokinase, or primary operation. Subsequently, the
2 thrombolytic groups were combined for
purposes of data analysis when the outcome
was found to be similar. While composite untoward events were more frequent in thrombolytic patients, the more relevant and objective endpoints of amputation and death were
equivalent (Figure). In separate subgroup
analyses of the STILE data, one relating to native artery occlusions28 and another to bypass
graft occlusions, 29 thrombolysis appeared
more effective in patients with graft occlusions. The rate of major amputation was higher in native arterial occlusions treated with
thrombolysis (10% versus 0% surgery at 1
year; p50.0024). By contrast, amputation was
lower in patients with acute graft occlusions
treated with thrombolysis (p50.026). These
data suggest that thrombolysis may be of
greatest benefit in patients with acute bypass
graft occlusions ,14 days old.
The third and final randomized comparison
of thrombolysis and surgery was the Thrombolysis Or Peripheral Arterial Surgery (TOPAS) trial, funded by Abbott Laboratories. Following completion of a preliminary
dose-ranging trial in 213 patients,30 544 patients were randomized to a recombinant
form of UK or primary operative intervention.31 After a mean 1-year follow-up, the rate
of amputation-free survival was identical in
the 2 treatments: 68.2% in the urokinase
group and 68.8% in the surgical patients.

II-132

10 YEARS OF THROMBOLYTIC THERAPY

Ouriel

While this trial failed to document improvement in survival or limb salvage with thrombolysis, fully 31.5% of the thrombolytic patients were alive without amputation at 6
months after nothing more than a percutaneous procedure. After 1 year, this number
had decreased only slightly, with 25.7% alive
without amputation and with only percutaneous interventions. Thus, the original goal of
the TOPAS trial, to generate data on which
regulatory approval of recombinant UK would
be based, was not achieved. Nevertheless,
the findings confirmed that acute limb ischemia could be managed with catheter-directed
thrombolysis, achieving amputation and mortality rates similar to surgery but avoiding the
need for open procedures in a significant percentage of patients.

REFERENCES
1. Faggioli GL, Peer RM, Pedrini L, et al. Failure
of thrombolytic therapy to improve long-term
vascular patency. J Vasc Surg. 1994;19:289
296.
2. Korn P, Khilnani NM, Fellers JC, et al. Thrombolysis for native arterial occlusions of the lower extremities: clinical outcome and cost. J
Vasc Surg. 2001;33:11481157.
3. Sullivan KL, Gardiner GA, Kandarpa K, et al.
Efficacy of thrombolysis in infrainguinal bypass grafts. Circulation. 1991;83(2 Suppl):I99
105.
4. Tillett WS, Garner RL. The fibrinolytic activity
of hemolytic streptococci. J Exp Med. 1933;58:
485.
5. Tillett WS, Sherry S. The effect in patients of
streptococcal fibrinolysin (streptokinase) and
streptococcal desoxyribonuclease on fibrinous,
purulent, and sanguinous pleural exudations. J
Clin Invest. 1949;28:173.
6. Tillett WS, Johnson AJ, McCarty WR. The intravenous infusion of the streptococcal fibrinolytic principle (streptokinase) into patients. J
Clin Invest. 1955;34:169185.
7. Cliffton EE, Grunnet M. Investigations of intravenous plasmin (fibrinolysin) in humans. Circulation. 1956;14:919.
8. Cliffton EE. The use of plasmin in humans. Ann
N Y Acad Sci. 1957;68:209229.
9. Dotter CT, Rosch J, Seaman AJ. Selective clot
lysis with low-dose streptokinase. Radiology.
1974;111:3137.
10. van Breda A, Robison JC, Feldman L, et al. Lo-

J ENDOVASC THER
2004;11(Suppl II):II-128II-133

11.

12.
13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

cal thrombolysis in the treatment of arterial

graft occlusions. J Vasc Surg. 1984;1:103112.
Graor RA, Risius B, Denny KM, et al. Local
thrombolysis in the treatment of thrombosed
arteries, bypass grafts, and arteriovenous fistulas. J Vasc Surg. 1985;2:406414.
Macfarlane RG, Pilling JJ. Fibrinolytic activity
of normal urine. Nature. 1947;159:779.
Sobel GW, Mohler SR, Jones NW, et al. Urokinase: an activator of plasma fibrinolysin extracted from urine. Am J Physiol. 1952;171:
768769.
Credo RB, Burke SE, Barker WM, et al. Recombinant urokinase (r-UK): biochemistry, pharmacology, and clinical experience. In: Sasahara AA, Loscalzo J, eds. New Therapeutic
Agents in Thrombosis and Thrombolysis. New
York: Marcel Dekker, Inc.; 1997:513537.
Husain SS, Lipinski B, Gurewich V. Isolation of
plasminogen activators useful as therapeutic
and diagnostic agents (single-chair, high-fibrin
affinity urokinase). US patent 4,381,346. 1979.
McNamara TO, Fischer JR. Thrombolysis of
peripheral arterial and graft occlusions: improved results using high-dose urokinase. AJR
Am J Roentgenol. 1985;144:769775.
Hoylaerts M, Rijken DC, Lijnen HR, et al. Kinetics of the activation of plasminogen by human
tissue plasminogen activator. Role of fibrin. J
Biol Chem. 1982;257:29122919.
The GUSTO Investigators. An international
randomized trial comparing four thrombolytic
therapies for acute myocardial infarction. N
Engl J Med. 1993;329:673682.
Keyt BA, Paoni NF, Refino CJ, et al. A fasteracting and more potent form of tissue plasminogen activator. Proc Natl Acad Sci USA. 1994;
91:36703674.
Cannon CP, McCabe CH, Gibson CM, et al.
TNK-tissue plasminogen activator in acute
myocardial infarction. Results of the Thrombolysis in Myocardial Infarction (TIMI) 10A
dose-ranging trial. Circulation. 1997;95:351
356.
Martin U. Clinical and preclinical profile of the
novel recombinant plasminogen activator reteplase. In: Sasahara AA, Loscalzo J, eds. New
Therapeutic Agents in Thrombosis and Thrombolysis. New York: Marcel Dekker, Inc.; 1997:
495511.
Meierhenrich R, Carlsson J, Seifried E, et al.
Effect of reteplase on hemostasis variables:
analysis of fibrin specificity, relation to bleeding complications and coronary patency. Int J
Cardiol. 1998;65:5763.
Ouriel K, Katzen B, Mewissen M, et al. Retepla-

J ENDOVASC THER
2004;11(Suppl II):II-128II-133

24.

25.

26.

27.

se in the treatment of peripheral arterial and

venous occlusions: a pilot study. J Vasc Interv
Radiol. 2000;11:849854.
McNamara TO, Dong P, Chen J, et al. Bleeding
complications associated with the use of rt-PA
versus r-PA for peripheral arterial and venous
thromboembolic occlusions. Tech Vasc Interv
Radiol. 2001;4:9298.
Mewissen MW. Catheter-directed thrombolysis
for lower extremity deep vein thrombosis. Tech
Vasc Interv Radiol. 2001;4:111114.
Ouriel K, Shortell CK, DeWeese JA, et al. A
comparison of thrombolytic therapy with operative revascularization in the initial treatment
of acute peripheral ischemia. J Vasc Surg.
1994;19:10211030.
Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity: the STILE trial. Ann
Surg. 1994;220:251268.

10 YEARS OF THROMBOLYTIC THERAPY

Ouriel

II-133

28. Weaver FA, Comerota AJ, Youngblood M, et al.

Surgical revascularization versus thrombolysis
for nonembolic lower extremity native artery
occlusions: results of a prospective randomized trial. The STILE Investigators. J Vasc Surg.
1996;24:513523.
29. Comerota AJ, Weaver FA, Hosking JD, et al.
Results of a prospective, randomized trial of
surgery versus thrombolysis for occluded lower extremity bypass grafts. Am J Surg. 1996;
172:105112.
30. Ouriel K, Veith FJ, Sasahara AA. Thrombolysis
or peripheral arterial surgery: phase I results.
TOPAS Investigators. J Vasc Surg. 1996;23:64
75.
31. Ouriel K, Veith FJ, Sasahara AA. A comparison
of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. Thrombolysis or Peripheral
Arterial Surgery (TOPAS) Investigators. N Engl
J Med. 1998;338:11051111.