Percutaneous thrombectomy for acute limb ischemia is associated with equivalent limb and mortality outcomes compared with open thrombectomy

BACKGROUND

Acute limb ischemia (ALI) carries a 15% to 20% risk of combined death or amputation at 30 days and 50% to 60% at 1 year. Percutaneous mechanical thrombectomy (PT) is an emerging minimally invasive alternative to open thrombectomy (OT). However, ALI thrombectomy cases are omitted from most quality databases, limiting comparisons of limb and survival outcomes between PT and OT. Therefore, our aim was to compare in-hospital outcomes between PT and OT using the National Inpatient Sample.

METHODS

We analyzed survey-weighted National Inpatient Sample data (2015-2020) to include emergent admissions of aged adults (50+ years) with a primary diagnosis of lower extremity ALI undergoing index procedures within 2 days of hospitalization. We excluded hospitalizations with concurrent trauma or dissection diagnoses and index procedures using catheter-directed thrombolysis. Our primary outcome was composite in-hospital major amputation or death. Secondary outcomes included in-hospital major amputation, death, in-hospital reintervention (including angioplasty/stent, thrombolysis, PT, OT, or bypass), and extended length of stay (eLOS; defined as LOS >75th percentile). Adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) were generated by multivariable logistic regression, adjusting for demographics, frailty (Risk Analysis Index), secondary diagnoses including atrial fibrillation and peripheral artery disease, hospital characteristics, and index procedure data including the anatomic thrombectomy level and fasciotomy. A priori subgroup analyses were performed using interaction terms.

RESULTS

We included 23,795 survey-weighted ALI hospitalizations (mean age: 72.2 years, 50.4% female, 79.2% White, and 22.3% frail), with 7335 (30.8%) undergoing PT. Hospitalization characteristics for PT vs OT differed by atrial fibrillation (28.7% vs 36.5%, P < .0001), frequency of intervention at the femoropopliteal level (86.2% vs 88.8%, P = .009), and fasciotomy (4.8% vs 6.9%, P = .006). In total, 2530 (10.6%) underwent major amputation or died. Unadjusted (10.1% vs 10.9%, P = .43) and adjusted (aOR = 0.96 [95% CI, 0.77-1.20], P = .74) risk did not differ between the groups. PT was associated with increased odds of reintervention (aOR = 2.10 [95% CI, 1.72-2.56], P < .0001) when compared with OT, but this was not seen in the tibial subgroup (aOR = 1.31 [95% CI, 0.86-2.01], P = .21, Pinteraction < .0001). Further, 79.1% of PT hospitalizations undergoing reintervention were salvaged with endovascular therapy. Lastly, PT was associated with significantly decreased odds of eLOS (aOR = 0.80 [95% CI, 0.69-0.94], P = .005).

CONCLUSIONS

PT was associated with comparable in-hospital limb salvage and mortality rates compared with OT. Despite an increased risk of reintervention, most PT reinterventions avoided open surgery, and PT was associated with a decreased risk of eLOS. Thus, PT may be an appropriate alternative to OT in appropriately selected patients.

Endovascular rehabilitation of acutely thrombosed fontan conduit in a patient with multiorgan failure

A 32-year-old man with history of hypoplastic left heart syndrome status post-Fontan palliation (20-mm aortic homograft conduit) had previously undergone Fontan conduit (FC) and left pulmonary artery (LPA) stenting to relieve conduit obstruction.

Percutaneous rheolytic thrombectomy and cerebral embolic protection in a massive thrombosis of a fenestrated Fontan conduit: a case report

Background

Clinical thromboembolism in Fontan patients is often a catastrophic event resulting in death and adverse long-term outcomes. The treatment of acute thromboembolic complications in these patients is very controversial.

Case summary

We describe the use of rheolytic thrombectomy in a Fontan patient with life-threatening pulmonary embolism, employing a cerebral protection system to reduce the risk of stroke through the fenestration.

Discussion

Rheolytic thrombectomy may be a successful alternative to systemic thrombolytic therapy and open surgical resection for the treatment of acute high-risk pulmonary embolism in the Fontan population. Embolic protection device to capture and remove thrombus/debris may be an innovative tool to reduce the risk of stroke through the fenestration while performing a percutaneous procedure in fenestrated Fontan patient.

Percutaneous thrombectomy in patients with intermediate- and high-risk pulmonary embolism and contraindications to thrombolytics: a systematic review and meta-analysis

Catheter-directed interventions have slowly been gaining ground in the treatment of pulmonary embolism (PE), especially in patients with increased risk of bleeding. The goal of this study is to summarize the evidence for the efficacy and safety of percutaneous thrombectomy (PT) in patients with contraindications to systemic and local thrombolysis. We performed a systematic review and meta-analysis using MEDLINE, Cochrane, Scopus and the Web of Science databases for studies from inception to March 2022. We included patients with intermediate- and high-risk PE with contraindications to thrombolysis; patients who received systematic or local thrombolysis were excluded. Primary endpoint was in-hospital and 30-day mortality, with secondary outcomes based on hemodynamic and radiographic changes. Major bleeding events were assessed as a safety endpoint. Seventeen studies enrolled 455 patients, with a mean age of 58.6 years and encompassing 50.4% females. In-hospital and 30-day mortality rates were 4% (95% CI 3-6%) and 5% (95% CI 3-9%) for all-comers, respectively. We found a post-procedural reduction in systolic and mean pulmonary arterial pressures by 15.4 mmHg (95% CI 7-23.7) and 10.3 mmHg (95% CI 3.1-17.5) respectively. The RV/LV ratio and Miller Index were reduced by 0.42 (95% CI 0.38-46) and 7.8 (95% CI 5.2-10.5). Major bleeding events occurred in 4% (95% CI 3-6%). This is the first meta-analysis to report pooled outcomes on PT in intermediate- and high-risk PE patients without the use of systemic or local thrombolytics. The overall mortality rate is comparable to other contemporary treatments, and is an important modality particularly in those with contraindications for adjunctive thrombolytic therapy. Further studies are needed to understand the interplay of anticoagulation with PT and catheter-directed thrombolysis.

Percutaneous Thrombectomy in Patients with Occlusions of the Aortoiliac Segment: A Case Series

OBJECTIVE

Thrombectomy of the aortoiliac segment remains a challenge for surgical and endovascular revision. This study aimed to evaluate the concept of percutaneous thrombectomy in patients with aortoiliac segment occlusions.

MATERIALS & METHODS

Eighteen patients with aortoiliac occlusion who underwent percutaneous thrombectomy were retrospectively identified using the local picture archive and divided into the stent-graft (N = 10) and native vessels (N  =  8) groups. The procedure was performed by placing a 12-24 French sheath adjacent to the distal end of the occluded vessel segment. The occlusion was passed with a balloon catheter which was retracted after inflation, to deliver the thrombus into the sheath. Technical success (reperfusion of the vessel and no residual thrombus/stenosis < 30%), complications and primary arterial patency were assessed. Follow-up included computed tomography angiography and evaluation of the clinical situation via telephone.

RESULTS

Technical success was achieved in 38% (7/18) of patients after percutaneous thrombectomy alone and in 100% after additional procedures. The most common complication was peripheral embolism (44%, 8/18), which was treated successfully in all cases and was linked to a mismatch between the sheath and target vessel of ≥ 1 mm (P < .01). There were no significant differences in the incidence of complications between the two groups. Primary patency was 72% (13/18) with no significant difference between groups (P  =  .94). Follow-up CT scans were available for 13/18 patients (72%), with a mean follow-up time of 270  ±  146 days. All patients were contacted via phone (follow-up time, 653  ±  264 days).

CONCLUSION

Percutaneous thrombectomy appears to be effective for revascularization of the aortoiliac segment, both in stent-grafts and in native vessels. The most common complication is peripheral embolism; however, the risk may be reduced by choosing an adequate sheath size.

Learning curve for percutaneous thrombectomy in treatment of acute lower extremity deep vein thrombosis

OBJECTIVE

We evaluated the effect of the learning curve on percutaneous thrombectomy (PT) outcomes for the treatment of lower extremity deep vein thrombosis (DVT).

METHODS

The present study was conducted between October 2019 and September 2020 and included 80 patients who had undergone PT to treat lower extremity DVT of the common iliac, external iliac, common femoral, femoral, and popliteal veins. For thrombectomy, aspiration and mechanical thrombectomy procedures were performed until the thrombus had completely dissolved using the Dovi aspiration system and Mantis mechanical thrombectomy system (Invamed, Ankara, Turkey). A total of 80 patients were divided equally into four groups, with the first 20 cases in group 1, the second 20 cases in group 2, the third 20 cases in group 3, and the final 20 cases in group 4. The groups were compared for the demographic characteristics, intraoperative outcomes, complication rates, and procedure success.

RESULTS

All demographic parameters were similar between the four groups. The mean operative time was 139.3 minutes for group 1, 134.8 minutes for group 2, 111.3 minutes for group 3, and 106.7 minutes for group 4. Statistical analysis revealed that the operative time was significantly shorter for groups 3 and 4 compared with that for groups 1 and 2. In addition, the fluoroscopy time was significantly decreased in groups 3 and 4 (P = .001). The complication rate was similar between the four groups (P = .899). However, success was significantly increased after the first 20 cases, and the remaining three groups had a significantly higher success rate compared with group 1 (70% for group 1, 90% for group 2, 95% for group 3, and 100% for group 4; P = .024).

CONCLUSIONS

Success in the performance of PT for the treatment of acute lower extremity DVT reaches satisfactory levels after 20 cases. Additionally, operation time and fluoroscopy time are significantly decreased after 40 cases and then start plateau.

Percutaneous Vacuum-Assisted Thrombectomy Using AngioVac Aspiration System

BACKGROUND

Surgical embolectomy and thrombolytic therapy are two common approaches for the treatment of large intra-cardiac or intravascular thrombi to prevent new or worsening pulmonary embolism (PE). Considering high operative mortality with surgical embolectomy and high bleeding risk with thrombolytic therapy, patients who are poor candidates for these treatments may benefit from percutaneous aspiration thrombectomy/Vacuum-assisted thrombectomy (VAT). AngioVac aspiration system was granted 510(k) clearance by the United States Food and Drug Administration (FDA) in April 2009. We present a case series to describe its use and outcomes in evacuating large caval thrombi or intracardiac masses.

METHODS

We did a retrospective analysis of AngioVac catheter based thrombectomy in 16 consecutive patients treated between January 2016 and January 2019 to report case characteristics and in-hospital clinical outcomes.

RESULTS

Sixteen patients (mean age 48) underwent 16 AngioVac procedures over 48 months. Indications included intracardiac mass (68.8%), caval thrombus (56.3%), and catheter associated thrombus (43.8%). 7 (43.8%) patients had concurrent PE. Peri-procedure mortality was 0% and in-hospital mortality was 12.5% at a mean follow-up of 14 days. There were no pulmonary hemorrhages, strokes or myocardial infarctions. 62.5% had a significant drop in hemoglobin, which required a blood transfusion but there was no episode of overt bleeding.

CONCLUSION

The AngioVac aspiration system has been shown to be effective at aspirating large volumes of intravascular and intracardiac thrombus. It is a reasonable alternative to surgical thrombectomy in patients with large central thrombi or masses in-transit who are at risk of complicated PE.