Use of Embolic Protection Devices in Peripheral Interventions

Novel artificial intelligence approach in neurointerventional practice: Preliminary findings on filter movement and ischemic lesions in carotid artery stenting

BACKGROUND AND OBJECTIVES

Embolic protection devices (EPDs) used during carotid artery stenting (CAS) are crucial in reducing ischemic complications. Although minimizing the filter-type EPD movement is considered important, limited research has demonstrated this practice. We used an artificial intelligence (AI)-based device recognition technology to investigate the correlation between filter movements and ischemic complications.

METHODS

We retrospectively studied 28 consecutive patients who underwent CAS using FilterWire EZ (Boston Scientific, Marlborough, MA, USA) from April 2022 to September 2023. Clinical data, procedural videos, and postoperative magnetic resonance imaging were collected. An AI-based device detection function in the Neuro-Vascular Assist (iMed Technologies, Tokyo, Japan) was used to quantify the filter movement. Multivariate proportional odds model analysis was performed to explore the correlations between postoperative diffusion-weighted imaging (DWI) hyperintense lesions and potential ischemic risk factors, including filter movement.

RESULTS

In total, 23 patients had sufficient information and were eligible for quantitative analysis. Fourteen patients (60.9 %) showed postoperative DWI hyperintense lesions. Multivariate analysis revealed significant associations between filter movement distance (odds ratio, 1.01; 95 % confidence interval, 1.00-1.02; p = 0.003) and high-intensity signals in time-of-flight magnetic resonance angiography with DWI hyperintense lesions. Age, symptomatic status, and operative time were not significantly correlated.

CONCLUSION

Increased filter movement during CAS was correlated with a higher incidence of postoperative DWI hyperintense lesions. AI-based quantitative evaluation of endovascular techniques may enable demonstration of previously unproven recommendations. To the best of our knowledge, this is the first study to use an AI system for quantitative evaluation to address real-world clinical issues.

Three-Year Results of Combining Debulking Devices with Drug-Coated Balloons for the Treatment of De Novo Femoropopliteal Arteriosclerosis Obliterans

BACKGROUND

To compare the safety and efficacy of debulking devices, including directional atherectomy (DA) and excimer laser atherectomy (ELA), when combined with drug-coated balloons (DCBs) for treating de novo femoropopliteal atherosclerotic obliterans (ASO). Additionally, to evaluate the long-term outcomes and application status of these different debulking devices.

METHODS

Clinical data were collected from patients with femoropopliteal ASO who underwent combined debulking and DCBs at the Vascular Surgery Department of Xuanwu Hospital, Capital Medical University, China, between January 2018 and January 2023. In accordance with the different atherectomy devices used during the surgery, patients were divided into the DA group and the excimer laser group. Patient baseline characteristics, Rutherford classification, lesion length, stenosis degree, TASC II classification, calcification degree, and surgical-related data were recorded. Follow-up data over 36 months were collected to obtain efficacy indicators such as primary patency rate and freedom from clinically driven target lesion revascularization rate (fCD-TLR), and so on.

RESULTS

A total of 167 primary femoropopliteal lesions were treated with debulking combined with DCB intervention, with a technical success rate of 100%. The DA combined with DCB group included 90 cases, while the ELA combined with DCB group included 77 cases. Both groups showed significant improvement in postoperative Rutherford classification compared to preoperative. The primary patency rates at 12, 24, and 36 months for the DA and ELA groups were 88.89% vs. 81.74% (P = 0.15), 74.66% vs. 74.01% (P = 0.99), and 63.37% vs. 67.24% (P = 0.84), respectively. The fCD-TLR rates were 94.44% vs. 92.15% (P = 0.53); 83.82% vs. 80.87% (P = 0.42); and 68.47% vs. 72.87% (P = 0.22), with no significant statistical differences. Notably, there were certain intergroup differences. Patients in the DA group had more comorbidities but lighter Rutherford classification compared to the ELA group. In the ELA group, the average lesion length was significantly longer than that in the DA group (140 mm vs. 108 mm, P = 0.007), and 75.3% of the lesions were occlusive. In contrast, only 24.4% of the lesions in the DA group were occlusive (P < 0.001). Additionally, the use of embolic protection devices was more common in the DA group (78.9% vs. 49.4%, P < 0.001), while the ELA group had a higher incidence of dissection and a higher rate of bailout stent implantation. Subgroup analysis showed that for severe stenotic lesions, the primary patency rate in the DA group was higher than that in the ELA group (P = 0.04), whereas for occlusive lesions, the ELA group had a better primary patency rate (P = 0.002). Independent risk factors for restenosis included smoking history, hypertension, coronary artery disease, and severe calcified lesions.

CONCLUSION

Both DA and ELA can treat femoropopliteal ASO effectively and improved clinical symptoms with few perioperative complications. However, the specific applications and long-term outcomes of the 2 debulking devices are influenced by the characteristics of the lesions. Additionally, there are certain differences in the use of bailout stenting and distal protection devices. Severe calcified lesions were an independent risk factor for reduced primary patency rate, warranting further in-depth research on the treatment of highly calcified lesions.

Protrieve Sheath embolic protection during venous thrombectomy: early experience in seventeen patients

PURPOSE

The Protrieve Sheath (Inari Medical; Irvine, CA) is designed for embolic protection during venous thrombectomy. This report describes experience with its use.

MATERIALS AND METHODS

Between November 2022 and December 2023 (13 months), seventeen patients, including nine (52.9%) females and eight (47.1%) males (mean age 58.8 ± 13.3 years, range 37-81 years), underwent deep venous thrombectomy following the Protrieve Sheath placement for embolic protection. Gender, age, presenting symptoms, procedural indications, obstructed venous segments, the Protrieve Sheath access and deployment sites, thrombectomy devices utilized, need for stent reconstruction, technical success, clinical success, adverse events (the Protrieve Sheath maldeployment or clinically significant embolic events), removed thrombi analyses, and mortality were recorded. Technical success was defined as successful deployment of the Protrieve Sheath funnel central to the thrombectomy site. Clinical success was defined as improvement in presenting venous occlusive symptoms without procedure-related venous thromboembolism.

RESULTS

The most common presenting symptom was extremity swelling (n = 15; 88.2%). Nine (52.9%) patients had malignant and eight (47.1%) had benign etiologies of venous obstruction. Obstructed venous segments included the inferior vena cava (IVC) and lower extremity (n = 9; 52.9%), isolated lower extremity (n = 4; 23.5%), isolated IVC (n = 2; 11.8%), thoracic central veins and superior vena cava (n = 1; 5.9%), and isolated thoracic central vein (n = 1; 5.9%). The Protrieve Sheath access sites included the right internal jugular vein (n = 15; 88.2%) for IVC and lower extremity obstructions and the right common femoral vein (n = 2; 11.8%) for thoracic central vein and superior vena cava obstructions. The Protrieve sheath funnel deployment locations included intrahepatic IVC in 13 patients (n = 13; 76.5%), suprarenal IVC in two (n = 2; 11.8%), and inferior cavoatrial junction in two (n = 2; 11.8%). Thrombectomy devices used included the ClotTriever System (Inari Medical) (n = 15; 88.2%), the InThrill Thrombectomy System (Inari Medical) (n = 4; 23.5%), the FlowTriever System (Inari Medical) (n = 2; 11.8%), the Lightning Flash 16 Aspiration System (Penumbra; Salt Lake City, UT) (n = 2; 11.8%), the Cleaner Rotational Thrombectomy System (Argon; Plano, TX) (n = 1; 5.9%), and the RevCore Thrombectomy System (Inari Medical) (n = 1; 5.9%). Ten (58.8%) patients required stent reconstruction following thrombectomy. Technical success was achieved in all patients. Clinical success was achieved in 16 (94.1%) patients. No immediate adverse events, including the Protrieve Sheath maldeployment or clinically significant embolic events, occurred.

CONCLUSION

Use of the Protrieve Sheath during large-bore venous mechanical thrombectomy resulted in favorable technical and clinical outcomes without device-related adverse events or clinically significant thromboembolic events.

Use of Wallstent device as an embolic protection device during stenting of aortic thrombus

Blue toe syndrome can occur due to distal embolization from proximal lesions such as an aortic thrombus. We describe the case of a patient who presented with chronic limb threatening ischemia due to a flow-limiting infrarenal aortic thrombus, with gangrene from distal embolization to the left fifth toe, and was successfully treated with endovascular aortic stent graft insertion. Distal embolization during instrumentation was successfully prevented by using a partially deployed Wallstent (Boston Scientific) as an embolic protection device. The reconstrainable Wallstent device can be considered for distal thromboembolic protection during aortic stenting, in particular, when distal embolization is a concern and commercial devices are not readily available.

Embolic protection devices are not associated with improved outcomes of atherectomy for lower extremity revascularization

OBJECTIVE

Atherectomy is associated with a risk of distal embolization, but the role of embolic protection devices (EPD) during atherectomy is not well-defined. This study examines the utilization and impact of EPD on the outcomes of atherectomy during peripheral vascular interventions (PVI).

METHODS

The annual trend in utilization of EPD during atherectomy in the Vascular Quality Initiative PVI files (2010-2018) was derived. Patients with concomitant open surgery, acute limb ischemia, emergent-status, concomitant thrombolysis, missing indication, missing EPD use, missing long-term follow up data were excluded. The characteristics of patients undergoing atherectomy with and without EPD were compared. Propensity matching based on age, gender, race, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), end-stage renal disease (ESRD), prior PVI, indication, urgent-status, TransAtlantic interSociety Consensus (TASC) classification and anatomical location of lesion was performed. The perioperative and 1-year outcomes of the matched groups were compared.

RESULTS

EPD was used in 23.3% of atherectomy procedures (N=5,013 / 21,500). The utilization of EPD with atherectomy increased from 8.8% to 22.7% (P=0.003) during the study period. Patients undergoing atherectomy without EPD were more likely to have ESRD (7.8% vs 5.2%; P<0.001), tissue loss (31% vs 23.1; P<0.001), tibial intervention (39.6% vs 23.3%; P<0.001), higher number of arteries treated (1.78 ±0.92 vs 1.68±0.93; P=0.001), and longer length of lesion (21.15±21.14 vs 19±20.27cm; P=0.004). Conversely, patients undergoing atherectomy with EPD were more likely to be white (81.1% vs 74%; P<0.001), have a history of smoking (80.6% vs 74.5%; P<0.001), COPD (24.8% vs 21.6%; P<0.037), CAD (38.5% vs 33.2%; P=0.002), prior PCI (24.3% vs 19.9%, P=0.005), prior CABG (32.3% vs 24.9%; P<0.001), prior PVI (49.2% vs 45.1%; P=0.023). After propensity matching, there were 1,007 patients in each group with no significant difference in baseline characteristics. There was no significant difference in short-term outcomes including rate of distal embolization, technical success, dissection, perforation, discharge to home, and 30-day mortality. The use of EPD was, however, associated with longer fluoroscopy time. At 1-year, there was also no difference in primary patency, ipsilateral minor or major amputation, ABI improvement, reintervention or mortality rate between patients who underwent atherectomy with and without EPD.

CONCLUSION

EPD has been increasingly utilized in conjunction with atherectomy especially in patients with claudication and femoropopliteal disease. However, the use of EPD during atherectomy does not seem to impact the outcomes. Further research is needed to justify the additional cost and fluoroscopy time associated with the use of EPD during atherectomy.

Extended Use of Distal Embolic Protection Devices in Treatment of Distal Embolism During Lower Extremity Arterial Endovascular Interventions

There is no consensus on the best treatment modality for acute distal embolization complications during endovascular interventions for peripheral arterial diseases. We report on 3 patients who underwent mechanical embolectomy using a distal embolic protection device (EPD). All patients showed angiographic evidence of distal embolism, which occurred during lower extremity limb salvage endovascular procedures. After embolectomy, all had complete recanalization of the involved vessel on completion angiogram, and none had any device-related complications or adverse outcomes from the embolization. This initial experience suggests that EPD can be used for both the prevention and treatment of intraoperative distal embolization during endovascular intervention of lower extremity arterial disease.

Comparison and Analysis between the NAV6 Embolic Protection Filter and SpiderFX EPD Filter in Superficial Femoral Artery Lesions

Objective

To compare the safety and efficacy between the SpiderFX EPD and Emboshield NAV6 filter in the collection of embolic debris created from lower limb atherectomy procedures in patients with PAD.

Materials and Methods

Between January 2014 and October 2015, 507 patients with symptomatic peripheral artery disease were treated with directional atherectomy (SilverHawk), rotational atherectomy (JetStream), or laser atherectomy (Turbo Elite) based on operator discretion. Emboshield NAV6 (n = 161) and SpiderFX (n = 346) embolic protection devices were used with each of the 3 atherectomy devices. The primary study endpoint was 30-day freedom from major adverse events (MAEs). An MAE was defined as death, MI, TVR, thrombosis, dissection, distal embolization, perforation at the level of the filter, and unplanned amputation. A descriptive comparison of the MAE rates between Emboshield NAV6 and SpiderFX embolic protection devices was conducted.

Results

The freedom from major adverse event (MAE) rate was 92.0% (CI: 86.7%, 95.7%) in patients who received an Emboshield NAV6 filter compared to 91.6% (CI: 88.2%, 94.3%) in patients who received the SpiderFX filter (p=0.434). The lower limit of 86.7% freedom from major adverse event rate in the Emboshield NAV6 group was above the performance goal of 83% (p < 0.0008).

Conclusions

There were no significant clinical outcome differences between Emboshield NAV6 and SpiderFX EPD filters in the treatment of lower extremities. This evaluation indicates the safety and efficacy to use either filter device to treat PAD patients with lower extremity lesions.

Coronary-subclavian steal syndrome, an easily overlooked entity in interventional cardiology

Coronary-subclavian steal syndrome (CSSS) is a severe complication of coronary artery bypass graft (CABG) surgery with internal mammary artery grafting. It is caused by functional graft failure due to a hemodynamically significant proximal subclavian artery stenosis. In this manuscript, we provide a comprehensive review of literature and we report a series of five consecutive CSSS cases. This case series illustrates the variable clinical presentation, thereby emphasizing the importance of raised awareness concerning this pathology in CABG patients.