Rheolytic thrombectomy in the treatment of acute limb-threatening ischemia: immediate results and six-month follow-up of the multicenter AngioJet registry. Possis Peripheral AngioJet Study AngioJet Investigators

Contraindications to tissue plasminogen activator thrombolysis for acute lower extremity ischemia

OBJECTIVE

Previous randomized prospective trials have demonstrated the effectiveness of transcatheter tissue plasminogen activator (tPA) thrombolysis in treating acute limb ischemia (ALI) compared to conventional surgery. These pivotal trials have also highlighted contraindications for these procedures. Given recent advancements in techniques and technology, our aim is to reassess the relevance of these contraindications in contemporary practice.

METHODS

A retrospective chart analysis was performed utilizing the inpatient medical records of consecutive individuals who underwent tPA treatment for acute limb ischemia (ALI) from September 2016 to April 2022. Inclusion criteria encompassed patients aged 18 and above displaying clinical symptoms and imaging evidence of ALI within 14 days. All patients received tPA with suction thrombectomy following the fast-track thrombolysis protocol. In cases where a persistent thrombus or stenosis was detected, catheter-directed thrombolysis was considered overnight, and patients underwent angiography and reassessment in the operating room subsequently.

RESULTS

Patients were classified into two groups based on the STILE trial's established contraindications for endovascular treatment in acute limb ischemia (ALI). If a patient had any of these contraindications, they were placed in the contraindicated group. This resulted in 24 patients (32%) in the contraindicated group and 52 patients (68%) in the non-contraindicated group. No statistically significant demographic variations were observed between these groups. Contraindications in our study included uncontrolled hypertension (12/24, 50%), recent invasive procedures (7/27, 29%), history of cerebrovascular accident (CVA) within 6 months (3/24, 12%), and intracranial malformation/neoplasms (2/24, 8%). Three patients within the non-contraindicated group experienced bleeding complications: two with puncture site bleeds and one with nasal bleeding. In contrast, one patient in the contraindicated group had transient postoperative hematuria. There were no significant differences in bleeding complications observed between the two groups (p = .771). Additionally, no amputations were observed within our population.

CONCLUSIONS

In light of our study results and advancements in endovascular therapies, we can now safely and efficiently treat patients who were previously considered contraindicated for such treatments. It is essential to individualize treatments and carefully balance the risks and benefits of endovascular versus open surgical revascularization for these patients. Additionally, we believe that the nearly 30-year-old guidelines for endovascular therapies need to be revisited and updated to align with modern technology.

High risk and low prevalence diseases: Acute limb ischemia

INTRODUCTION

Acute limb ischemia is a rare but serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of acute limb ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Acute limb ischemia is defined as a sudden decrease in limb perfusion resulting in cessation of blood flow and nutrient and oxygen delivery to the tissues. This leads to cellular injury and necrosis, ultimately resulting in limb loss and potentially systemic symptoms with significant morbidity and mortality. There are several etiologies including native arterial thrombosis, arterial thrombosis after an intervention, arterial embolus, and arterial injury. Patients with acute limb ischemia most commonly present with severe pain and sensory changes in the initial stages, with prolonged ischemia resulting in weakness, sensory loss, and color changes to the affected limb. The emergency clinician should consult the vascular specialist as soon as ischemia is suspected, as the diagnosis should be based on the history and examination. Computed tomography angiography is the first line imaging modality, as it provides valuable information concerning the vasculature and surrounding tissues. Doppler ultrasound of the distal pulses may also be obtained to evaluate for arterial and venous flow. Once identified, management includes intravenous unfractionated heparin and vascular specialist consultation for revascularization.

CONCLUSIONS

An understanding of acute limb ischemia can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

The Prevalence of Cardiovascular Complications and Causes of AngioJet Failure: A Post-Marketing Surveillance Study Based on the MAUDE (Manufacturer and User Facility Device Experience) Database

Background and objective Aspiration thrombectomy devices, such as the AngioJet Solent Omni (Boston Scientific Corporation, Marlborough, MA) have been approved by the US FDA for the treatment of thrombi in peripheral arterial disease, venous disease, and AV fistulas. However, there is a dearth of real-world data on the most common modes of failure and complications associated with the AngioJet Solent Omni. In this study, we aimed to address this scarcity of data. Methods The MAUDE (Manufacturer and User Facility Device Experience) database was queried for reports of device failure and adverse events spanning the period from October 2012 to December 2021. Results A total of 499 events were reported during the study period. After the exclusion of duplicate reports, the final analysis included 450 reports. The most common mode of failure was catheter breakage/kinking during suction thrombectomy with 137 reports (30%). The most common vessel associated with events was the superficial femoral artery or vein, which was documented in 82 reports (18.2%). The most common adverse clinical outcome was the embedding of a piece of the device in the patient, which occurred in seven reports (1.6%). There were seven (1.6%) events of death reported during the period studied. Conclusions Based on our findings, theAngioJet Solent Omni device provides promising results; however, it is important to evaluate device safety. It is associated with complications including device embedment, catheter breakage/kinking, and death, and these adverse events are linked to patient characteristics and risk factors.

Acute ischemia of the upper and lower limbs: Tailoring the treatment to the underlying etiology

Acute limb ischemia (ALI) can be a devastating clinical emergency with potentially limb- or life-threatening consequences. It is defined as a quickly developing or sudden decrease in limb perfusion producing new or worsening symptoms and signs, often threatening limb viability. ALI is commonly related to an acute arterial occlusion. Rarely, extensive venous occlusion can lead to upper and lower extremities ischemia (ie, phlegmasia). The incidence of acute peripheral arterial occlusion causing ALI is approximately 1.5 cases per 10,000 people per year. The clinical presentation depends on the etiology and whether the patient has underlying peripheral artery disease. Except for traumas, the most common etiologies are embolic or thrombotic events. Peripheral embolism, likely related to embolic heart disease, is the most common cause of acute upper extremity ischemia. However, an acute thrombotic event may occur in native arteries, at the site of a pre-existing atherosclerotic plaque, or as a failure of previous vascular interventions. The presence of an aneurysm may predispose to ALI for both embolic and thrombotic mechanisms. Immediate diagnosis, accurate assessment of limb viability, and prompt intervention, when needed, play important roles in salvaging the affected limb and preventing major amputation. Severity of symptoms is usually dependent on the amount of surrounding arterial collateralization, which may often reflect a pre-existing chronic vascular disease. For this reason, early recognition of the underlying etiology is crucial for choice of best management and definitely for treatment success. Any error in the initial evaluation may negatively affect the functional prognosis of the limb and endanger the patient's life. The aim of this article was to discuss diagnosis, etiology, pathophysiology, and treatment of patients with acute ischemia of the upper and lower limbs.

Revascularization Strategies for Acute and Chronic Limb Ischemia

Chronic limb-threatening ischemia requires aggressive risk factor management and a thoughtful approach to the complex decision of best strategy for revascularization. Patients often have multilevel disease amenable to endovascular, open surgical, or hybrid approaches. Limited high-quality evidence is available to support a specific strategy; randomized trials are ongoing. Acute limb ischemia is associated with a high risk of limb loss and mortality. Catheter-directed thrombolysis is mainstay of therapy in patients with marginally threatened limbs, whereas those immediately threatened with motor deficits require more rapid restoration of flow with open or endovascular techniques that can establish flow in single setting.

Concomitant Acute Ischemic Stroke and Upper Extremity Arterial Occlusion: Feasibility of Mechanical Thrombectomy of the Upper Limb Using Neurointerventional Devices and Techniques

Background: Concomitant acute ischemic stroke (AIS) caused by large vessel occlusion (LVO), and acute upper extremity arterial occlusion causing upper limb ischemia (ULI) is a rarely observed coincidence. The first-line treatment for AIS is mechanical thrombectomy (MT), with or without additional intravenous thrombolysis, while there are different pharmacological, surgical and endovascular treatment options for an acute occlusion of the UL arteries. Here, we describe the practicability, efficacy and safety of neurointerventional devices and techniques for MT of upper extremity arterial occlusions. Materials and Methods: A retrospective analysis of prospectively collected patient databases from four neurovascular centers was performed. Clinical and imaging data, as well as procedural parameters, were assessed. Results: Seven out of 6138 patients (incidence: 0.11%) presenting with an AIS due to the occlusion of craniocervical arteries requiring MT and a concomitant occlusion of the brachial (4/7), axillary (2/7), or ulnar (1/7) artery causing acute ULI were identified. Craniocervical MT was technically successful in all cases. Subsequent MT of the upper limb was performed using neurointerventional thrombectomy techniques, most frequently stent retriever thrombectomy (in 4/7 cases) and direct aspiration (in 7/7 cases). MT achieved successful recanalization in 6/7 cases, and the UL completely recovered in all six cases. In one case, recanalization was not successful, and the patient still had a marginally threatened extremity after the procedure, which improved after pharmacological therapy. Conclusion: In the rare case of AIS requiring MT and concomitant acute upper extremity arterial occlusion, MT of the UL arteries using neurointerventional devices and techniques is practical, effective, and safe.

Navigating between the science and art of acute limb ischemia treatment

The diagnosis and treatment of acute limb ischemia (ALI) has long been a fierce adversary that has evolved over the last several decades with scientific advancements in endovascular therapy. History and physical examination remain the mainstay of diagnosis enhanced by detailed imaging to guide therapy. Many endovascular tools are available for prompt restoration of flow that compliment traditional surgical options. These devices incorporate the mechanical removal of thrombus and the chemical dissolution of thrombus . Medical decision-making for ALI patients must take into account the patient characteristics, anatomic variables, mechanism of ischemia, degree of ischemia, and operator skill to employ the right strategy for the right patient. This moving target challenges scientific study, making the therapeutic bedside decision making an artform. We present an overview of the field, supportive data, and a treatment algorithm that hopefully captures this delicate balance.

Acute Limb Ischemia: An Update on Diagnosis and Management

This review presents an update on the diagnosis and management of acute limb ischemia (ALI), a severe condition associated with high mortality and amputation rates. A comprehensive spectrum of ALI etiology is presented, with highlights on embolism and in situ thrombosis. The steps for emergency diagnosis are described, emphasizing the role of clinical data and imaging, mainly duplex ultrasound, CT angiography and digital substraction angiography. The different therapeutic techniques are presented, ranging from pharmacological (thrombolysis) to interventional (thromboaspiration, mechanical thrombectomy, and stent implantation) techniques to established surgical revascularization (Fogarty thrombembolectomy, by-pass, endarterectomy, patch angioplasty or combinations) and minor or major amputation of necessity. Postprocedural management, reperfusion injury, compartment syndrome and long-term treatment are also updated.

A systematic review and meta-analysis of endovascular and surgical revascularization techniques in acute limb ischemia

BACKGROUND

The initial treatment of patients with acute limb ischemia (ALI) remains undefined. The aim of this article was to compare the safety and effectiveness of catheter-driven thrombolysis (CDT) with surgical revascularization and evaluate the various fibrinolytic agents, endovascular, and pharmacochemical approaches that aim for thrombectomy.

METHODS

PubMed, Embase, and the Cochrane Library were searched for studies on the management of ALI by means of surgical or endovascular recanalization, returning 520 studies. All randomized, controlled trials, nonrandomized prospective, and retrospective studies were included comparing treatment of ALI.

RESULTS

Twenty-five studies, investigating a total of 4689 patients, were included for meta-analysis spread across nine different comparisons. No differences were found in limb salvage between thrombectomy and thrombolysis. More major vascular events were seen in the thrombolysis group (6.5% compared with 4.4% in the surgically treated group; odds ratio [OR], 0.33; 95% confidence interval [CI], 0.13-0.87; P = .02; I² = 20%). Comparable limb salvage was found for high- and low-dose recombinant tissue plasminogen activator (r-tPA). No significant differences were found in major vascular event between low r-tPA (14%) and high r-tPA (10.5%; P = .13). The 30-day limb salvage rate was 79.7% for r-tPA treatment and 60.4% for streptokinase (OR, 3.14; 95% CI, 1.26-7.85; P = .01; I² = 0%). AngioJet showed more limb salvage at 6 months compared with r-tPa (OR, 2.21; 95% CI, 1.17-4.18; P = .01; I² = 0%).

CONCLUSIONS

Both CDT and surgery have comparable limb salvage rates in patients with ALI; however, CDT is associated with a higher risk of hemorrhagic complications. No conclusions can be drawn regarding the risk of hemorrhagic complications regarding thrombolytic therapy by means of r-tPA, streptokinase, or urokinase. Insufficient data are available to conclude the preference of using a hybrid approach, ultrasound-accelerated CDT, heated r-tPA. or novel endovascular (rheolytical) thrombectomy systems. Future trials regarding ALI need to be constructed carefully, ensuring comparable study groups, and should follow standardized practices of outcome reporting.

Clinical Assessment of Peripheral Arterial Disease in the Office: What Do the Guidelines Say?

Lower extremity peripheral arterial disease (PAD) is the manifestation of atherosclerotic disease within the lower extremities. The presentation of PAD is diverse ranging from asymptomatic disease to claudication or to debilitating rest pain, nonhealing ulcers, and gangrene. PAD is associated with significant morbidity, mortality, and healthcare costs. Proper diagnosis and management of PAD is important so as to maintain quality of life and reduce the risk of cardiovascular disease and adverse limb events such as amputation. This document provides a comprehensive outpatient approach to the clinical assessment of PAD that includes risk factors, diagnosis, treatment, and follow-up options.

Percutaneous Mechanical Thrombectomy Using Rotarex® S Device in Acute Limb Ischemia in Infrainguinal Occlusions

PURPOSE

To evaluate the effectiveness of percutaneous mechanical thrombectomy using Rotarex S in the treatment of acute limb ischemia (ALI) in infrainguinal occlusions in a retrospective study of patients treated in our institution.

METHODS

In this study, we identified a total of 147 ALI patients that underwent mechanical thrombectomy using Rotarex S at our institution. In 82% of the cases, percutaneous thrombectomy was used as first-line treatment, and for the remainder of the cases, it was used as bailout after ineffective aspiration or thrombolysis. Additional fibrinolysis and adjunctive aspirational thrombectomy were utilized for outflow occlusion when required. Procedural outcomes, amputation rate, and mortality at 30 days were evaluated.

RESULTS

Of the 147 patients treated with mechanical thrombectomy, Rotarex S was used as first-line treatment in 120 cases and as second-line treatment in 27 cases. Overall, we achieved 90.5% procedural revascularization success rate when combining mechanical thrombectomy with limited thrombolysis for severe outflow obstruction, and 1 death and 3 amputations were observed. We achieved primary success in 68.7% of the patients with the mechanical thrombectomy only, and in 21.8% of the patients, we successfully used additional limited thrombolysis in the outflow. The overall mortality was 0.7% and amputation rate was 2% at 30 days.

CONCLUSION

Percutaneous mechanical thrombectomy as first-line mini-invasive treatment in infrainguinal ALI is safe, quick, and effective, and the performance outcomes can be superior to that of traditional surgical embolectomy.

Early Thrombosuction and Tirofiban Use in Knee and Below-Knee Arterial Thrombosis

BACKGROUND Acute limb ischemia (ALI) is a clinical entity with a high rate of morbidity and mortality. Despite advances and variety of its management, there is still no criterion standard treatment. The goal of this study was to evaluate the effect of tirofiban use on the early and 6-month prognosis of patients with knee and below-knee arterial thrombosis who were treated with percutaneous thrombosuction (PT) within 24 h. MATERIAL AND METHODS Data of consecutive ALI patients who were diagnosed with popliteal and infra-popliteal arterial thrombosis and underwent PT procedure within 24 h between January 2010 and September 2015 were evaluated retrospectively. Patients were separated into 2 groups according to tirofiban usage. RESULTS A total of 105 patients (mean age 67±16; 53% men) were included in the study. Atrial fibrillation (n 64, 61%) and hypertension (n 60, 57%) were the most frequent comorbidities in patients with thromboembolic events. A significantly higher rate of distal embolization (6% vs. 16%; p=0.01) and slow-flow (17% vs. 30%; p<0.01) developed in patients who were not treated with tirofiban after the PT procedure. Although major and minor bleeding were more frequent in the tirofiban group, only the rate minor bleeding was statistically significant (29% vs. 9%, p=0.001). Reverse embolic event ratio was similar in both groups. Although there was a higher rate of amputation in patients not treated with tirofiban, the difference was not significant. CONCLUSIONS Adding tirofiban to PT reduces angiographic thromboembolic complications. Usage of tirofiban in patients prone to thromboembolic events may be useful for improving success of the PT procedure, with a reasonable bleeding ratio.

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.

In response to reports from the Institute of Medicine1 ,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.3 –5 The relationships among guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.5

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.

In response to reports from the Institute of Medicine1 ,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.3 –5 The relationships among guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.5

Acute Iliac and Femoral Arterial Thrombosis Secondary to Total Hip Arthroplasty

In the presented case report, we evaluated the mechanism of the external iliac, the common femoral and the superficial femoral arterial thrombosis secondary to total hip arthroplasty. A 75-year-old female sufferd from 5.5 cm shorter left lower limb and same sade coxarthritis. Next day after arthroplasty and eqalisation of the lower limbs, an acute ishemia of the treated leg was presented. Multyscan CT angiography revealed the presence of the external iliac, the common femoral and the superficial femoral arterial thrombosis. From the best of our knowledge, it seems to be the only case of this arterial segment thrombosis after total hip arthroplasty and equalistaion of the lower limbs reported.

Axillary Arterial Thrombosis Secondary to Re-Fracture of the Humerus

In the presented case report, we evaluated mechanism of axillary artery thrombosis in cases of repeated fracture of the shoulder. A 73-year-old female fell down on an outstretched hand. Radiographs demonstrated a Neer’s 2-part displaced fracture of the proximal humerus and open fracture of the acromion. Forty years ago, in a car accident, fractures of the same proximal humerus and clavicle occurred and were surgically treated. Two hours after fixation with Kirschner wires, thrombosis of the axillary artery was quickly diagnosed and rapid treatment allowed revascularisation of the arm without any consequences.

One of the most urgent vascular circumstances: Acute limb ischemia

Acute limb ischemia is a sudden decrease in limb perfusion that threatens limb viability and requires urgent evaluation and management. Most of the causes of acute limb ischemia are thrombosis of a limb artery or bypass graft, embolism from the heart or a disease artery, dissection, and trauma. Assessment determines whether the limb is viable or irreversibly damaged. Prompt diagnosis and revascularization by means of catheter-based thrombolysis or thrombectomy and by surgery reduce the risk of limb loss and mortality. Amputation is performed in patients with irreversible damage. Despite urgent revascularization, amputation rate is 10%–15% in patients during hospitalization, mostly above the knee, and mortality within 1 year is 10%–15% due to the coexisting conditions.

Endovascular management of acute limb ischemia

Acute limb ischemia (ALI) is defined as a sudden decrease (<14 days) in limb perfusion causing a potential threat to limb viability. Endovascular treatment of ALI is an effective and appropriate primary treatment strategy in patients with a viable acutely ischemic limb due to a recent arterial occlusion. We present a case of acute limb ischemia and discuss percutaneous interventional treatment strategies including catheter-directed thrombolysis, rheolytic thrombectomy, and utilization of distal protection devices.

Isolated pharmaco-mechanical thrombectomy (IPMT) for the endovascular treatment of acute axillofemoral graft occlusion

Since the long-term patency of axillofemoral (AXF) grafts is inferior to aorto-bifemoral (ABF) grafts, limb salvage procedures are crucial in this group of patients. Emerging endovascular devices have helped in the successful restoration of flow for acute limb ischemia in both native arteries as well as bypass grafts. One such device, the Trellis thrombectomy system is being used more frequently in this setting. The device has previously been used in veins, native arteries, and rarely in aortofemoral grafts. We present its first successful use for the treatment of occluded AXF bypass graft. The use of this device helped to isolate the treatment zone in the occluded graft, which allowed the use of a lower dose of thrombolytics, less systemic release of thrombolytics, and less distal embolization. Resolution of extensive clot burden was achieved and, with subsequent stenting of the graft at the distal anastomotic site, arterial flow to the leg through the AXF graft was restored and a revision surgery was avoided.

The use of the Trellis-6 thrombectomy device in the management of acute limb ischemia due to native vessel occlusion: challenges, tips, and limitations

The role of endovascular therapy is expanding in the treatment of acute limb ischemia (ALI). In addition to catheter-based thrombolysis, there are multiple devices which allow for clot disruption and aspiration. The Trellis catheter system provides mechanical agitation of thrombus coupled with chemical thrombolysis. We present two cases of native arterial occlusions in which the Trellis catheter was used for thrombolysis. Procedural tips and challenges associated with the use of this device in native vessels are discussed.

Treatment of infrainguinal thromboembolic complications during peripheral endovascular procedures with AngioJet rheolytic thrombectomy, intraoperative thrombolysis, and selective stenting

OBJECTIVE

This study investigated the safety and effectiveness of the infrainguinal use of the AngioJet rheolytic mechanical thrombectomy system (Possis Medical, Minneapolis, Minn) for the treatment of acute infrainguinal thromboembolism occurring during lower limb revascularization procedures.

METHODS

For the interval between January 2000 and January 2011, our hospital's database was meticulously searched for all patients with acute thromboembolism that occurred during lower limb angioplasty, with or without stenting procedures, who were treated with infrainguinal AngioJet thrombectomy. Baseline patient demographics and procedural details were analyzed. Primary end points included technical success, defined as the complete revascularization of the acutely occluded vessel; clinical success, defined as the absence of death or amputation ≤ 60 days; and procedure-related complication. Secondary end points included embolized vessel primary patency and overall patient survival.

RESULTS

During this 12-year period, 3147 peripheral percutaneous procedures of angioplasty, with or without stenting, were performed in our department. Intraoperative, clinically, and angiographically evident thromboembolism occurred in 18 of 3147 procedures (0.57%), and 14 (77.7%) were managed using the AngioJet thrombectomy system. In total, 22 arteries were treated (13 infrapopliteal, 3 femoropopliteal, and 6 popliteal arteries). All patients had a completion angiogram for the assessment of the runoff vessels' status. Technical and clinical success occurred in 13 of 14 (92.8%). Adjunctive local thrombolysis or clot trapping, or both, with stenting was used in 64.3% and 42.8% of the procedures, respectively. Mean time follow-up was 38.1 ± 49.0 months. The 1-year embolized vessel primary patency rate was 50.9%, and the survival rate was 53.5% up to 11.5 years of follow-up, as estimated by Kaplan-Meier analysis. The 1-year limb salvage rate was 92.3%. There were no procedure-related minor amputations and one (7.1%) procedure-related major above-knee amputation.

CONCLUSIONS

The use of AngioJet rheolytic thrombectomy and adjunctive local thrombolysis or stenting, or both, under filter protection, is safe and effective for the management of severe thromboembolic complications occurring in the femoropopliteal and infrapopliteal arteries during peripheral endovascular procedures.

Flow control technique to prevent distal embolization during mechanical thrombectomy

In an era of increasing emphasis on minimally invasive surgery, distal embolization remains a concern in the absence of distal flow control. We present a case using an endovascular flow control technique that can be used for reducing distal embolic events during endovascular recanalization of aortoiliac occlusive disease. This technique has been used in four patients so far (two with native anatomy and two with aorto-bi-iliac grafts) with no evidence of angiographic or clinical embolic complications.

Quality improvement guidelines for percutaneous catheter-directed intra-arterial thrombolysis and mechanical thrombectomy for acute lower-limb ischemia

Percutaneous catheter-directed intra-arterial thrombolysis is a safe and effective method of treating acute and subacute lower limb ischemia, as long as accurate patient selection and procedural monitoring are ensured. Although larger, controlled trials are needed to establish the role of PTDs in ALI, mechanical thrombectomy could currently be applied combined with lytic infusion in selected cases where rapid recanalization is required or as a stand-alone therapy when the administration of thrombolytic agents is contraindicated.

Acute limb ischemia

Acute limb ischemia is a medical emergency with management options ranging from urgent revascularization to limb amputation. The best patient outcome requires tailoring the treatment to the individual patient. This article describes a step-by-step approach for diagnosis and management of patients presenting with acute limb ischemia.

Acute limb ischemia

Acute limb ischemia occurs when there is an abrupt interruption of blood flow to an extremity usually because of either embolic or thrombotic vascular occlusion. When profound ischemia ensues, this represents an emergency in which restoration of perfusion through early intervention can lead to limb salvage, whereas delay may result in significant morbidity, including limb loss and, potentially, death. Patients in whom urgent or semi-urgent surgical or endovascular revascularization is indicated may undergo catheter angiography unless there is a contraindication, such as profound critical limb ischemia, renal dysfunction, or contrast allergy. Alternative imaging modalities include ultrasound, contrast-enhanced computed tomographic angiography, and magnetic resonance angiography. The clinical degree of the ischemic insult will determine the most appropriate course of management, as severely ischemic limbs may require immediate surgical revascularization, while endovascular interventions, such as catheter-directed thrombolysis, may be appropriate in patients with moderate ischemia. Additionally, many percutaneous mechanical thrombectomy devices are being used or undergoing clinical evaluation, either alone or in combination with pharmacologic thrombolysis, for the treatment of acute limb-threatening ischemia. In this article, we present our approach to an acutely ischemic limb, with a focus on the pertinent aspects of endovascular intervention.

Endovascular treatment of peripheral vascular disease

Peripheral arterial disease (PAD) affects about 27 million people in North America and Europe, accounting for up to 413,000 hospitalizations per year with 88,000 hospitalizations involving the lower extremities and 28,000 involving embolectomy or thrombectomy of lower limb arteries. Many patients are asymptomatic and, among symptomatic patients, atypical symptoms are more common than classic claudication. Peripheral arterial disease also correlates strongly with risk of major cardiovascular events, and patients with PAD have a high prevalence of coexistent coronary and cerebrovascular disease. Because the prevalence of PAD increases progressively with age, PAD is a growing clinical problem due to the increasingly aged population in the United States and other developed countries. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, endovascular practice, percutaneous transluminal angioplasty with or without stenting, is used far more frequently for all types of lower extremity occlusive lesions, reflecting the continuing advances in imaging techniques, angioplasty equipment, and endovascular expertise. The role of endovascular intervention in the treatment of limb-threatening ischemia is also expanding, and its promise of limb salvage and symptom relief with reduced morbidity and mortality makes percutaneous transluminal angioplasty/stenting an attractive alternative to surgery and, as most endovascular interventions are performed on an outpatient basis, hospital costs are cut considerably. In this monograph we discuss current endovascular intervention for treatment of occlusive PAD, aneurysmal arterial disease, and venous occlusive disease.

Beyond intravenous thrombolysis

The National Institute of Neurological Disorders and Stroke trial of recombinant tissue plasminogen activator has been considered a landmark study in the acute treatment of ischemic stroke. Unfortunately, only a small percentage of all ischemic stroke patients presents to the hospital in time to receive the drug. Moreover, the recannalization rate of a major artery occlusion, such as the proximal middle cerebral artery or top of the internal carotid artery occlusion, after intravenous (IV) thrombolytic therapy has been disappointingly low. Since the Food and Drug Administration's approval of IV plasminogen activator, there have been numerous randomized clinical trials investigating the safety and efficacy of different thrombolytics administered in various time frames. In addition to the IV administration, efforts have been made in order to study the radiographic as well as clinical effects of intra-arterial (IA) thrombolysis. The combination of IV and IA thrombolysis has been studied. For patients who do not qualify for receiving chemical thrombolysis, new devices have been developed for mechanical thrombectomy. Angioplasty and stenting procedures are being performed more frequently than in the past as one of the treatment modalities for acute ischemic stroke patients. Relentless research effort is being made internationally in order to fight the devastating disease which now goes beyond the conventional IV thrombolysis.

Comparison of AngioJet Rheolytic Pharmacomechanical Thrombectomy versus AngioJet Rheolytic Thrombectomy in a Porcine Peripheral Arterial Model

INTRODUCTION

Rheolytic thrombectomy using the AngioJet catheter for arterial thrombosis has been shown to be effective in restoring blood flow. Additional infusion of thrombolytic agents via the AngioJet catheter results in combined rheolytic pharmacomechanical thrombolysis (PMT), which further enhances thrombectomy efficacy. However, the histologic response to rheolytic PMT therapy remains unclear. This study compares the acute and chronic vessel wall response and hemolysis due to conventional AngioJet rheolytic thrombectomy (RT) and AngioJet PMT in the porcine peripheral arterial model.

METHODS

A total of 19 juvenile pigs were divided into acute and chronic groups. In the acute group (n = 6), bilateral common carotid, femoral, and iliac arteries ranging from 3 to 6 mm in diameter were randomized to the control RT group or to PMT therapy. Vessels were analyzed 4 days following interventions. In the chronic group (n = 5), bilateral common carotid, femoral, and iliac arteries ranging from 3 to 6 mm in diameter were randomized to the control RT group or to PMT therapy. Vessels were analyzed at 30 days following interventions. Hemolytic evaluation was performed in additional eight pigs, which were randomized to either RT or PMT intervention.

RESULTS

In the acute group, similar histologic injury grades were noted between the RT- and PMT-treated femoral and iliac vessels. Endothelial denudation in the RT and PMT vessels were 43% and 39% (NS), respectively. Vessels with intact internal elastic lamina (IEL) in the RT and PMT groups were 54% and 57% (NS), respectively. In vessels < 4 mm in diameter, fractured IEL in the AT and PMT groups occurred in 23% and 27% (NS), respectively. The degrees of smooth muscle cell (SMC) loss were similar for the RT- and PMT-treated vessels (45% and 40%, respectively; NS). In the chronic group, no differences were seen between the RT and PMT groups with respect to endothelial denudation, IEL fracture rate, or SMC loss. Similar degrees of medial thickening or intimal hyperplasia were noted in the RT and PMT groups (49% and 43%, respectively; NS). No difference in hemolytic effect was noted in the treatment groups.

CONCLUSIONS

AngioJet rheolytic pharmacomechanical thrombectomy treatment incurs an equivalent safety profile in medium-caliber peripheral arteries when compared to rheolytic thrombectomy treatment. No difference in hemolytic reaction occurred in either group. The observed clinical efficacy of rheolytic pharmacomechanical thrombectomy does not result in untoward vessel injury compared to conventional rheolytic thrombectomy therapy.

Percutaneous rheolytic thrombectomy for large pulmonary embolism: A promising treatment option

BACKGROUND

Pulmonary embolism (PE) is a common cardiovascular disease with significant mortality. Some patients with large PE are not eligible for current treatment options such as thrombolysis or surgical embolectomy. We report our experience of percutaneous rheolytic thrombectomy (PRT) using the AngioJet system combined with adjunctive local thrombolytic therapy and inferior vena cava (IVC) filter placement to treat massive or submassive PE in patients ineligible for current treatment options.

METHODS AND RESULTS

Of the 14 consecutive patients ineligible for thrombolysis or embolectomy treated with PRT, 10 patients had massive PE (6 patients were hypotensive and 4 patients had intractable hypoxemia) and 4 patients had submassive PE. Adjunctive local thrombolysis was performed in 5 patients. An IVC filter was placed in 11 patients. Angiographic success based on Miller score was achieved in 13 patients (92.9%). Procedure success was obtained in 12 patients (85.7%). Procedural mortality occurred in one patient who presented in cardiogenic shock (7.1%) and non-fatal hemoptysis occurred in 1 patient (7.1%). Total in-hospital mortality occurred in 3 patients (21.4%). On a mean follow-up of 9 months, all 11 survivors had noted significant improvement in symptoms without recurrence.

CONCLUSIONS

Percutaneous rheolytic thrombectomy using the AngioJet may be a treatment option for patients with massive or submassive PE who may not be eligible for thrombolytic therapy or surgical embolectomy.

Acute pancreatitis: A complication associated with rheolytic mechanical thrombectomy of deep venous thrombosis

Percutaneous mechanical rheolytic thrombectomy is increasingly being used for the treatment of arterial, venous, and graft thromboses. We describe three cases of pancreatitis as a complication of mechanical rheolytic thrombectomy used in the treatment of caval and ileofemoral deep venous thrombosis and discuss the possible etiologic factors involved. To our knowledge, this complication has been previously reported in only two cases.

Endovascular Treatment of Peripheral Vascular Disease

An estimated 10 million people in the U.S. have symptomatic peripheral arterial disease (PAD); 20 to 30 million have asymptomatic PAD. The prevalence of intermittent claudication increases with age, affecting >5% of patients over 70. The incidence of claudication doubles or triples in patients with diabetes. As people grow older, symptoms from peripheral vascular disease increasingly limit daily activity. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, advances in minimally invasive percutaneous interventions have made endovascular procedures the primary modality for revascularization in most patients. Compared with open surgical procedures, endovascular interventions offer comparable or superior long-term rates of success with very low rates for morbidity and mortality. Furthermore, most of these interventions are performed on an outpatient basis, reducing hospital stays considerably. In this monograph we discuss current endovascular interventions for treating occlusive PAD, aneurysmal arterial disease, and increasingly common venous occlusive diseases.

Percutaneous extraction of bilateral renal mycetomas in premature infant using mechanical thrombectomy device

Although mycotic infections of the urinary system occur not infrequently, obstruction of the upper urinary tract because of mycetomas or fungus balls is exceedingly rare. Treatment consists of antifungal treatment and appropriate urinary drainage. In cases resistant to treatment with external drainage and chemotherapy, open surgery is typically performed to remove the mycetoma. However, this can also be achieved percutaneously using mechanical thrombectomy devices, as shown in this case of a 4-month-old infant presenting with renal failure due to bilateral obstructing mycetomas.