Use of the Indigo CAT RX aspiration system during percutaneous coronary intervention

BACKGROUND

The use of the Indigo CAT RX Aspiration System (Penumbra Inc.) during percutaneous coronary intervention has received limited study.

METHODS

We retrospectively examined the clinical, angiographic, and procedural characteristics, outcomes, and follow-up of patients who underwent mechanical aspiration thrombectomy with the Indigo CAT RX system (Penumbra Inc.) at a large tertiary care hospital between January 2019 and April 2023.

RESULTS

During the study period, 83 patients (85 lesions) underwent thrombectomy with the Indigo CAT RX. Mean patient age was 64.9 ± 14.48 years and 31.2% were women. The most common presentations were ST-segment elevation myocardial infarction (MI) (66.2%) and non-ST-segment elevation MI (26.5%). A final thrombolysis in MI flow grade of 3 and final myocardial blush grade of 3 were achieved in 76% and 46% of the cases, respectively. Technical success was achieved in 88.9% of the cases that included Indigo CAT RX treatment only, compared with 57.1% of the cases that also included manual aspiration. There were no device-related serious adverse events. At 30-day postprocedure, the incidence of major adverse cardiac events (composite of cardiovascular death, recurrent MI, cardiogenic shock, new or worsening New York Heart Association Class IV heart failure, stroke) was 8.5%: 1.3% stroke (postprocedure, in-hospital), 1.3% MI, 6.1% cardiac death, and 7.5% developed cardiogenic shock.

CONCLUSIONS

Use of the Indigo CAT RX system is associated with high technical success and acceptable risk of complications, including stroke.

Aspiration Thrombectomy Using Inari FlowTriever System for Inferior Vena Cava Tumor Thrombus: A Case Report

Pharmacomechanical therapy and catheter-directed thrombolysis are potent treatments for venous thromboembolism. However, limited data exist regarding the management of thrombi in the inferior vena cava (IVC). IVC thrombus resulting from tumors is a particularly uncommon condition. Managing IVC tumor thrombi poses even greater challenges, as conventional therapies such as systemic anticoagulation and thrombolysis are often ineffective. In this report, we present the case of a 73-year-old male with an inferior vena cava tumor thrombus successfully managed through aspiration thrombectomy utilizing the Inari FlowTriever system.

Percutaneous aspiration of aortic valve vegetation in a patient with aortic valve endocarditis

Key Clinical Message

Percutaneous aspiration for debulking of vegetations in right-sided infective endocarditis has been well-described, however, this technique can be employed successfully for left-sided vegetations in select high-risk patients.

Abstract

We report a case of percutaneous aspiration of an aortic valve vegetation in a patient with prosthetic valve endocarditis. This novel approach was selected after patient declined surgical intervention for an enlarging vegetation despite antibiotic therapy. The procedure was successful, resulting in the complete removal of solid vegetation without complications.

Aspiration thrombectomy versus stent retriever thrombectomy as a first-line approach for cardiogenic cerebral embolism and cryptogenic stroke in large vessels of the anterior circulation

Subject

This study aims to compare the clinical efficacy of aspiration thrombectomy and stent retriever thrombectomy as first-line approaches for anterior circulation large vessel cardiogenic cerebral embolism and cryptogenic stroke.

Method

This retrospective observational study included patients with anterior circulation large vessel cardiogenic cerebral embolism and cryptogenic stroke treated with endovascular therapy. Patients were grouped according to the first-line approach they received: aspiration thrombectomy or stent retriever thrombectomy. The primary outcome measure was the change in the National Institute of Health Stroke Scale (NIHSS) score from preoperative to immediate postoperative and from preoperative to discharge. Secondary indicators included the rate of favorable prognosis at discharge [Modified Rankin Scale (mRS) score ≤ 2], successful vessel recanalization rate [modified Treatment in Cerebral Ischemia (mTICI) score ≥ 2b], time from successful femoral artery puncture to successful vessel recanalization, and perioperative complications.

Result

The study included 127 cases, with 1 case withdrawal after enrollment due to a stroke of another determined cause, with 83 in the aspiration thrombectomy group and 43 cases in the stent retriever thrombectomy group. The change in NIHSS score from preoperative to immediate postoperative was 5 (1, 8) in the aspiration thrombectomy group and 1 (0, 4.5) in the stent retriever thrombectomy group. The change from preoperative to discharge was 8 (5, 12) in the aspiration thrombectomy group and 4 (0, 9) in the stent retriever thrombectomy group. The aspiration thrombectomy group exhibited significantly better prognosis rates and shorter time from successful femoral artery puncture to successful vessel recanalization. There were no significant differences between the two groups in terms of successful vessel recanalization rates and perioperative complications.

Conclusion

As a first-line approach for anterior circulation large vessel cardiogenic cerebral embolism and cryptogenic stroke, aspiration thrombectomy leads to better improvement in neurological functional deficits and prognosis rates compared to stent retriever thrombectomy.

Aspiration thrombectomy with the Penumbra System for patients with stroke and late onset to treatment: a subset analysis of the COMPLETE registry

Background

The purpose of this study was to report the safety and performance of aspiration thrombectomy with the Penumbra System for patients with acute ischemic stroke (AIS) due to anterior circulation large vessel occlusion (LVO) and late onset to treatment.

Methods

This is a retrospective subset analysis of a global prospective multicenter registry (COMPLETE) that enrolled adults with AIS due to LVO and a pre-stroke modified Rankin Scale score (mRS) of 0 or 1 who were treated first-line with aspiration thrombectomy either alone (A Direct Aspiration First Pass Technique [ADAPT]) or in combination with the 3D Revascularization Device (ADAPT + 3D). This subset analysis included all patients in the registry who had anterior circulation LVO, an Alberta Stroke Program Early CT Score of at least 6, and late onset to treatment (>6 h from stroke onset to puncture).

Results

Of the 650 patients in the COMPLETE registry, 167 were included in this subset analysis. The rate of successful revascularization (modified thrombolysis in cerebral infarction score 2b-3 achieved) at the end of the procedure was 83.2%, the rate of good functional outcome (mRS 0-2) at 90 days was 55.4%, and the all-cause mortality rate at 90 days was 14.4%. No device-related serious adverse events (SAEs) occurred. Procedure-related SAEs occurred in 9 patients (5.4%) within 24 h and in 12 patients (7.2%) overall. The rate of successful revascularization was higher for patients treated first-line with ADAPT (88.0%) than for patients treated first-line with ADAPT + 3D (75.0%; p = 0.035); no significant difference was observed between the ADAPT and ADAPT + 3D groups for any other primary or secondary outcome.

Conclusion

For patients with AIS due to anterior circulation LVO and with late onset to treatment, aspiration thrombectomy with the Penumbra System appears to be safe and effective. The rates of good functional outcome and all-cause mortality from this study compared favorably with those rates from the medical management arms of the DAWN and DEFUSE-3 studies.

Clinical trial registration

https://www.clinicaltrials.gov, NCT03464565.

ST-Segment Elevation: An Unexpected Culprit

The clinical presentation of pulmonary embolism (PE) and acute coronary syndrome can be similar. We report a case of a patient presenting with antero-septal ST-segment elevation after cardiac arrest, found to have acute-PE-mimicking ST-segment elevation myocardial infarction (STEMI), treated with aspiration thrombectomy and catheter-directed thrombolysis (CDT). A 78-year-old man was admitted with dyspnea, chest pain and tachycardia. During evaluation, cardiac arrest in pulseless electrical activity was documented. Advanced life support was started immediately. ECG post-ROSC revealed ST-segment elevation in V1-V4 and aVR. Echocardiography showed normal left ventricular function but right ventricular (RV) dilation and severe dysfunction. The patient was in shock and was promptly referred to cardiac catheterization that excluded significant CAD. Due to the discordant ECG and echocardiogram findings, acute PE was suspected, and immediate invasive pulmonary angiography revealed bilateral massive pulmonary embolism. Successful aspiration thrombectomy was performed followed by local alteplase infusion. At the end of the procedure, mPAP was reduced and blood pressure normalized allowing withdrawal of vasopressor support. Twenty-four-hour echocardiographic reassessment showed normal-sized cardiac chambers with preserved biventricular systolic function. Bedside echocardiography in patients with ST-segment elevation post-ROSC is instrumental in raising the suspicion of acute PE. In the absence of a culprit coronary lesion, prompt pulmonary angiography should be considered if immediately feasible. In these cases, CDT and aspiration in high-risk acute PE seem safe and effective in relieving obstructive shock and restoring hemodynamics.

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.

Case Report: A balloon-based technique to remove a pearl-like embolus out of the coronary artery

Coronary embolism is considered a rare non-atherosclerotic etiology of acute myocardial infarction, whereas atrial fibrillation is the main etiology of coronary embolism. We report a rare case of a patient with coronary embolism with a specific pearl-like embolus attributed to atrial fibrillation. For this patient, we used a balloon-based technique to successfully remove the embolus from the coronary artery.

Endovascular thrombectomy for distal vessel occlusion stroke: Single-center experience

BACKGROUND

The safety and efficacy of endovascular thrombectomy (EVT) in distal vessel occlusion (DVO) are not well described. We aimed to evaluate the technical feasibility and safety of EVT in patients with DVO.

METHODS

We performed a retrospective analysis of consecutive DVOs (defined as M3/M4, A1/A2, and P1/P2 occlusion) who underwent EVT within 24 h since last known well. The primary efficacy outcome was successful reperfusion (mTICI ≥ 2B). Secondary outcomes included successful recanalization with ≤3 passes. The safety outcome measures included the rate of subarachnoid hemorrhage (SAH), all intracerebral hemorrhage (ICH), and symptomatic ICH (sICH).

RESULTS

A total of 72 patients with DVO was identified: 39 (54%) with M3/M4, 13 (18%) with A1/A2, and 20 (28%) with P1/P2 occlusions. Admission NIHSS score median (IQR) was 12 (11), and 90% of the patients had baseline mRS ≤ 2. Thirty-six percent of the patients received intravenous thrombolytic therapy. Successful recanalization was achieved in 90% of the patients. The median number of passes was 2, with successful recanalization achieved with ≤3 passes in 83% of the patients. ICH was seen in 16% of the patients, including three SAHs. However, only one patient (1.4%) had sICH. Among 48 patients in whom 90-day outcome data were available, 33 (53.2%) had favorable clinical outcome (mRS ≤ 3). In a multivariable logistic regression, only baseline NIHSS was identified as an independent predictor of poor outcome.

CONCLUSION

This single-center real-world experience demonstrates that EVT in patients with DVO stroke is safe and feasible and may lead to improved clinical outcome.

In Vitro Comparison of Several Thrombus Removal Tools

BACKGROUND

Although the routine use of thrombus aspiration is not recommended, the thrombectomy technique still might be considered for a selected population of patients. Therefore, the assessment of the effectiveness of commercially available thrombectomy devices is still clinically relevant.

AIM

Here, we present an in vitro comparison of several different types of catheters that can be used for thrombus aspiration or removal.

METHODS

Through the removal of 6 h and 24 h human blood clots in an in vitro model, four catheters were compared: the Launcher, Pronto V4, Vasco+ and the stent-retriever Catchview. The aspiration efficacy was expressed as a percentage of the initial thrombus weight. The effectiveness of the patient's aspiration was dependent on the time of thrombus formation and was significantly higher for a thrombus formed over 24 h (58.5 ± 26.5%) than for one formed over 6 h (48.0 ± 22.5%; p < 0.001). In the presented in vitro model, Pronto V4 and Launcher showed the highest efficiency.

CONCLUSIONS

Large-bore aspiration catheters were found to be more effective than narrow-bore catheters or stent-retrievers in an in vitro model of thrombus removal. The thrombus aspiration efficacy increases with longer thrombus formation times.

Continuous mechanical aspiration thrombectomy performs equally well in main versus branch pulmonary emboli: A subgroup analysis of the EXTRACT-PE trial

INTRODUCTION

The EXTRACT-PE trial evaluated the safety and performance of the Indigo Aspiration System (Penumbra Inc.) with an 8F continuous mechanical aspiration thrombectomy system for the treatment of pulmonary embolism (PE). This subgroup analysis evaluates performance outcomes of patients with main pulmonary artery (PA) emboli versus discrete unilateral or bilateral PA emboli without main PA involvement.

METHODS

The EXTRACT-PE trial was a prospective, single-arm, multicenter trial that enrolled 119 patients with acute submassive PE. Emboli location was collected at the time of enrollment, CT obstruction was measured and assessed by a Core Lab, and patients were grouped on whether emboli involved the main PA (with or without branch vessels) or not (branch vessels alone). Procedural device time, changes in the right ventricle to left ventricle (RV/LV) ratio, and systolic PA pressure from pre-and posttreatment were compared between the two groups.

RESULTS

Out of the 119 patients enrolled, 118 had core lab-assessed clot locations. Forty-five (38.1%) had emboli that involved the main PA and 73 (61.9%) had only branch emboli. No significant difference was observed between these groups for 30-day mortality, procedural device time, changes in RV/LV ratio, reduction in CT Obstruction Index, or for systolic PA pressure from pre-and posttreatment. The mean absolute reduction in clot burden was significant in both groups.

CONCLUSION

Continuous mechanical aspiration thrombectomy with the 8F Indigo Aspiration System was effective at improving clinical outcomes for submassive PE patients regardless of emboli location, and clot burden was significantly reduced in both groups.

Safety and efficacy of aspiration thrombectomy versus stent retriever thrombectomy for acute ischaemic stroke: a systematic review and meta-analysis

Introduction

Although aspiration thrombectomy has shown comparable safety and efficacy to stent retriever thrombectomy for acute ischaemic stroke (AIS), the use of aspiration thrombectomy as first-line endovascular treatment for AIS remains controversial.

Aim

To perform a systematic evaluation of the safety and efficacy of aspiration thrombectomy versus stent retriever thrombectomy in the treatment of AIS.

Material and methods

We searched the online databases PubMed, Embase, Cochrane Library, and SinoMed to collect randomized controlled trials and retrospective studies concerning the treatment of AIS with aspiration thrombectomy and stent retriever thrombectomy. Primary outcomes included 90-day all-cause mortality, a 90-day mRS scores of 0-2, intracranial haemorrhage, and successful recanalization rate. The Jadad scale and the MINORS evaluation items were used to evaluate study quality, and RevMan 5.2 was used to conduct a meta-analysis. Any differential effects in rates between the two strategies were assessed using a random effect model.

Results

A total of 15 articles were found, including 2 randomized controlled trials and 13 retrospective studies. It showed that aspiration thrombectomy and stent retriever thrombectomy had similar results in terms of 90-day all-cause mortality (p = 0.88), 90-day mRS scores 0-2 (p = 0.29), and intracranial haemorrhage (p = 0.47). And in terms of successful recanalization rates, the aspiration thrombectomy group had better outcomes than the stent retriever thrombectomy group (p = 0.0003). The heterogeneity of 90-day all-cause mortality (I² = 0%), 90-day mRS scores of 0-2 (I² = 6%), intracranial haemorrhage (I² = 21%), and successful recanalization rate (I² = 0%) were less than 30%.

Conclusions

Both aspiration thrombectomy and stent thrombectomy can be used as the first line of intravascular treatment for AIS.

Non-surgical extirpation of a non-infectious expanding tricuspid valve mass by percutaneous aspiration thrombectomy

Marantic endocarditis refers to a noninfectious lesion, usually in the aortic and mitral valves, that is most commonly seen in advanced malignancy and systemic lupus erythematosus. Inflammatory conditions, including antiphospholipid syndrome (APS), are a rare etiology making up less than 20% of reported cases. The condition is thought to be due to a hypercoagulable state and found postmortem with rates in autopsy series ranging from 0.9% to 1.6%. In comparison to infective endocarditis, marantic endocarditis has a greater tendency for valve vegetations to embolize. Common treatment modalities include anticoagulation or valve replacement. Although percutaneous aspiration thrombectomy of right-sided heart chamber thrombi exists, there are limited reports demonstrating its use with regards to treatment of right-sided endocarditis. We present the case of an older male with a history of Factor V Leiden and APS who was admitted due to a rapidly expanding mass on the tricuspid valve (TV). Despite serial blood cultures being negative, the patient received adequate antibiotic therapy for more than 4 weeks. Transthoracic echocardiogram showed an enlarged TV vegetation with an increased diameter from 10 to 30 mm over 6 weeks. Due to the patient's high operative risk and concern for embolization complications, a multidisciplinary decision was made to perform percutaneous aspiration thrombectomy of the TV vegetation. Subsequent biopsy of the lesion confirmed it was noninfectious and nonmalignant. Thus, the patient was started on systemic anticoagulation for prevention of thromboembolic events.

Initial experience with a continuous mechanical aspiration system for thrombus removal before percutaneous coronary intervention

OBJECTIVES

Here we investigate the safety and efficacy of a continuous mechanical aspiration system when used before percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS).

BACKGROUND

Historically, trials of routine manual aspiration thrombectomy in ACS patients have reported mixed results. This may be due to the technical limitations of manual aspiration, which suffers from decreasing vacuum power as aspiration is performed.

METHODS

This is a retrospective case series of all patients treated with continuous mechanical aspiration (Indigo CAT RX Aspiration System; Penumbra Inc.) before PCI between August 2017 and July 2020 at five centers in the United States. Data regarding angiographic assessments, procedure, and safety were examined.

RESULTS

Seventy-two patients (mean age 60 ± 12.5 years, 34.7% female) with ST Elevation Myocardial Infarction (STEMI) (80.6%) or Non-ST Elevation Myocardial Infarction (NSTEMI) (19.4%) were included. Target vessels were the right coronary (43.1%), left anterior descending (33.3%), and left circumflex (23.6%). Preprocedure, 94.4% had a high thrombus burden (thrombolysis in myocardial infarction [TIMI] thrombus grade ≥ 3). Median aspiration time was 35 s and median access-to-reperfusion time was 10 min. After CAT RX alone, 86.1% had complete perfusion (TIMI flow grade 3). After the procedure, 94.4% had TIMI thrombus grade <3% and 97.2% had TIMI flow grade 3. There were no cases of ischemic stroke. Cardiovascular mortality at 30 days was 1.4%.

CONCLUSIONS

In our initial experience, aspirating thrombus from ACS patients using the Indigo CAT RX Aspiration System before PCI was safe and effective for reducing thrombus burden and restoring flow.

Right Heart Clot-in-Transit: Endovascular Therapies

Right heart thrombus is a challenging high mortality disease typically seen in the setting of pulmonary embolism. Traditional treatments have included anticoagulation, thrombolysis, and surgical embolectomy. Advances in recognition and treatment of clot-in-transit have led to the development of endovascular therapies increasingly becoming the preferred method of treatment due to rapid debulking and lower morbidity. Novel endovascular devices are large bore aspiration thrombectomy systems which mitigate the use of concomitant thrombolytics. The article reviews the disease process, relevant literature, and current endovascular devices and strategies for the treatment of right heart thrombus and clot-in-transit.

Endovascular Thrombus Aspiration and Catheter-Directed Thrombolysis for Acute Thromboembolic Renal Artery Occlusion

PURPOSE

We report a case of revascularization for an occluded renal artery using endovascular renal thrombus aspiration followed by catheter-directed thrombolysis.

CASE REPORT

A 56-year-old man presented with sudden onset severe left-sided abdominal and loin pain for 6 hours. Urgent computed tomography (CT) angiogram showed occlusion of left renal artery. Emergency selective left renal angiogram and thrombus aspiration using a 5-French Cobra catheter was performed. Catheter-directed thrombolysis with urokinase was initiated after aspiration thrombectomy. Angiogram 24 hours after thrombolysis showed the left renal artery and its segmental branches were successfully revascularized. Patient was put on anticoagulation after operation and his renal function recovered well.

CONCLUSION

Percutaneous aspiration thrombectomy with conventional catheters combined with intra-arterial local fibrinolysis could be used to salvage the renal function in case of complete renal artery thromboembolic occlusion.

Technical Success and Short-Term Results From Mechanical Thrombectomy for Lower Extremity Iliofemoral Deep Vein Thrombosis Using a Computer aided Mechanical Aspiration Thrombectomy Device

BACKGROUND

Symptoms of deep vein thrombosis include severe pain and swelling, and complications can include post-thrombotic syndrome or recurrent venous thromboembolism. Aspiration thrombectomy (AT) treats arterial and venous disease by removing acute thrombus without reliance on thrombolytics, but also has the potential to remove fresh blood. Intelligent aspiration is designed to minimize blood loss during AT by aspirating continuously while in thrombus but only intermittently when in a patent vascular segment with active flow. The Indigo System with Lightning 12 intelligent aspiration (Penumbra, Inc. Alameda, California) utilizes an automatic valve controlled by a proprietary computer algorithm to optimize thrombus removal and minimize blood loss. This Computer aided Mechanical Aspiration Thrombectomy (CMAT) system was used on 16 consecutive patients and initial results are discussed here.

METHODS

This retrospective review included patients undergoing CMAT for iliofemoral acute DVT between July 2020 and June 2021. The primary outcome was greater than 70% thrombus removal as determined by multiplanar venography. Secondary outcomes included single session therapy, blood loss during aspiration, the need for post-procedure blood transfusion, thrombolytic use, symptom resolution prior to discharge, and periprocedural complications.

RESULTS

Sixteen patients (mean age 58.6 years [range 31-80], 75.0% women) underwent CMAT using Lightning 12. All patients presented with pain and swelling from 2-16 days in duration. There were no cases of phlegmasia. Access was obtained via the popliteal (11), posterior tibial (3), small saphenous (1) or soleal (1) vein. Thrombus reduction of >70% or better was achieved in 100% (16/16) of patients. Single session therapy was successful in 93.8% (15/16) of patients. Eight patients (50%) received stents. All patients achieved symptom resolution prior to discharge. Median blood loss was 155.0 ml (Interquartile range [IQR] 95.0, 187.5), and no patients received post-procedure transfusion. One patient received angioplasty post-thrombectomy, and adjunctive tissue plasminogen activator (tPA) was used in 6.2% (1/16) patients. No patients developed postoperative acute kidney failure. There were no periprocedural complications. At 1 to 8-month follow-up, 93.8% (15/16) patients had patency of the treated iliofemoral area and 87.5% (14/16) had no recurrent symptoms.

CONCLUSIONS

These results suggest that CMAT using Lightning 12 is safe for clot removal in patients with acute iliofemoral DVT with a high rate of single-session technical success and symptom resolution. In this case series, Lightning 12 was also associated with low blood loss, and no patients required blood transfusion.

Endovascular Device Choice and Tools for Recanalization of Medium Vessel Occlusions: Insights From the MeVO FRONTIERS International Survey

Background: Endovascular treatment (EVT) for stroke due to medium vessel occlusion (MeVO) can be technically challenging. Devices and tools are rapidly evolving. We aimed to gain insight into preferences and global perspectives on the usage of endovascular tools in treating MeVOs.

Methods: We conducted an international survey with seven scenarios of patients presenting A3, M2/3, M3, M3/4, or P2/3 occlusions. Respondents were asked for their preferred first-line endovascular approach, and whether they felt that the appropriate endovascular tools were available to them. Answers were analyzed by occlusion location and geographical region of practice, using multinomial/binary logistic regression.

Results: A total of 263 neurointerventionists provided 1836 responses. The first-line preferences of physicians were evenly distributed among stent-retrievers, combined approaches, and aspiration only (33.2, 29.8, and 26.8%, respectively). A3 occlusions were more often treated with stent-retrievers (RR 1.21, 95% CI: 1.07–1.36), while intra-arterial thrombolysis was more often preferred in M3 (RR 2.47, 95% CI: 1.53–3.98) and M3/4 occlusions (RR 7.71, 95% CI: 4.16–14.28) compared to M2/3 occlusions. Respondents who thought appropriate tools are currently not available more often chose stent retrievers alone (RR 2.07; 95% CI: 1.01–4.24) or intra-arterial thrombolysis (RR 3.35, 95% CI: 1.26–8.42). Physicians who stated that they do not have access to optimal tools opted more often not to treat at all (RR 3.41, 95% CI: 1.11–10.49). Stent-retrievers alone were chosen more often and contact aspiration alone less often as a first-line approach in Europe (RR 2.12, 95% CI: 1.38–3.24; and RR 0.49, 95% CI 0.34–0.70, respectively) compared to the United States and Canada.

Conclusions: In EVT for MeVO strokes, neurointerventionalists choose a targeted vessel specific first-line approach depending on the occlusion location, region of practice, and availability of the appropriate tools.

Comparison of Aspiration Thrombectomy to other endovascular therapies for Proximal Upper Extremity Deep Venous Thrombosis

OBJECTIVE

Catheter-directed thrombolysis (CDT) provides an effective method for clearing deep venous thrombosis (DVT). Unfortunately, CDT is associated with hemorrhagic complications. This study evaluated the technical success of the various endovascular therapies including a new mechanical aspiration thrombectomy (AT) device for the treatment of acute upper extremity deep venous thrombosis (UEDVT).

METHODS

This was a single-center retrospective review of patients with acute symptomatic proximal UEDVT secondary to venous thoracic outlet syndrome. Undergoing endovascular therapy from December 2013 to June 2019. Patients were treated with a variety of methods including CDT, ultrasound assisted thrombolysis (USAT), rheolytic thrombectomy (RT) and aspiration thrombectomy (AT). We evaluated outcomes for patients undergoing AT compared to non-aspiration thrombectomy (NAT) techniques. The primary outcome was technical success, defined as resolution of >70% of thrombus. The secondary endpoint was the ability to complete the therapy in a single session.

RESULTS

There were 22 patients who had endovascular management of their symptomatic proximal UEDVT. All 22 (100%) patients were successfully treated with greater than 70% thrombus resolution. 10 patients underwent AT, of which 50% (5/10) had single session therapies. 12 patients underwent NAT (3 had CDT or USAT alone; 3 had USAT with RT; and 6 had CDT followed by RT), with single session therapy occurring in only 8.3% (1/12) of the NAT group. The average total dose of thrombolytics was 12.6mg (SD= 9.65) in the AT group compared to 19.0mg (SD= 5.78) in the NAT group (mean difference -6.4; 95% CI -1.1, 13.9). All but one of the patients in the AT group went on to have successful first rib resections. All NAT patients had successful first rib resections. Venogram was not performed at the time of decompression. All patients except one underwent resection via the infraclavicular approach, with rib removal posterior to the brachial plexus, a median of 8.0 [IQR 6.0, 12.0] days following DVT therapy.

CONCLUSIONS

In this study, technical success of 100% was achieved for acute symptomatic proximal UEDVT therapies. AT technology allows for higher rates of treatment in a single session thereby minimizing a patient's risks of bleeding complications. Further research is needed to further define the role of this new technology in the treatment paradigm of UEDVT management.

Vacuuming in Crowded Dangerous Spaces: Aspiration of Large Ascending Aortic Thrombus

A patient had a stroke caused by a large, pedunculated aortic ascending mass and was deemed at high risk for near-term recurrent stroke. This case illustrates percutaneous aspiration thrombectomy of ascending aortic thrombus with the AngioVac system (Angiodynamics, Latham, New York), with conscious sedation for early stroke detection and with endovascular cerebral embolic protection. (Level of Difficulty: Intermediate.)

Aspiration Thrombectomy Versus Stent Retriever Thrombectomy Alone for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Introduction This meta-analysis was conducted to assess the safety and efficacy of aspiration thrombectomy versus stent retriever thrombectomy for acute ischemic stroke (AIS). Methods We queried online databases for original studies comparing aspiration thrombectomy with stent retriever thrombectomy in patients with AIS. After article selection, data were extracted on multiple baseline characteristics and prespecified endpoints. Dichotomous data were presented as risk ratios (RRs) and corresponding 95% confidence intervals (CIs); continuous data as mean differences and 95% CIs. The data were pooled using a random-effects model. Subgroup analysis was conducted based on study type, site of occlusion, and age. Results We shortlisted nine relevant studies (n=1453 patients; n=690 receiving aspiration thrombectomy and n=763 receiving stent retriever thrombectomy). Meta-analysis demonstrated no significant difference between the two groups in the rates of successful recanalization (RR: 0.96 [0.87, 1.06]; p=0.42), excellent functional outcome (RR: 0.90 [0.80, 1.01]; p=0.06), or procedure time (weighted mean difference (WMD): -5.39 minutes [-11.81, 1.04]; p=0.10). However, when removing the study by Nishi et al., sensitivity analysis resulted in a significant reduction in procedure time with aspiration (WMD: -11.01 [-15.54, -6.49]; p<0.0001). No significant difference was observed in safety outcomes, including all-cause mortality (RR: 0.82 [0.57, 1.19]; p=0.30), intracranial hemorrhage (RR: 0.93 [0.55, 1.59]; p=0.80), symptomatic intracranial hemorrhage (RR: 0.72[0.42, 1.21]; p=0.57), or embolization to new territory (RR: 0.71 [0.42, 1.19]; p=0.19). Subgroup analysis revealed that aspiration thrombectomy led to significantly better outcomes in patients with a mean age ≤65 (RR: 1.15 [1.03, 1.29]; p=0.001), and stent retriever thrombectomy led to increased recanalization success in patients with a mean age >65 (RR: 0.89 [0.80, 1.00]; p=0.05). Conclusions Our updated meta-analysis reveals that both aspiration and stent retriever thrombectomy are comparably effective in the management of AIS. Shorter procedure times may potentially be attained with aspiration thrombectomy, and outcomes with each procedure may be age-dependent.

Aspiration thrombectomy as the first-line treatment of M2 occlusions

PURPOSE

The aim of the present study was (i) to evaluate the safety and efficacy of aspiration thrombectomy in patients with M2 occlusions and (ii) to compare outcome of treatment of occlusion of different M2 segments.

MATERIALS AND METHODS

Between March 2016 and June 2019, 82 patients with acute ischemic stroke and isolated M2 occlusions were treated in cerebrovascular stroke center with aspiration thrombectomy as the first-line treatment. Functional outcomes of patients with different types of M2 occlusions were statistically compared. Multivariable logistic regression analysis was performed to determine the factors associated with good clinical outcome.

RESULTS

The mean age was 71.9 ± 13.4 years, 47.6% were men. Aspiration thrombectomy alone was utilized in 72.5% of patients, with 27.5% of patients being treated with a combination of aspiration thrombectomy and stent retriever. At the three-month follow-up, there was no statistically significant difference in functional outcome between different types of M2 occlusions (p = 0.662), however in the underpowered analysis because of the small sample size of patients, with good clinical outcome mRS 0-2 in 50% of all treated patients. Symptomatic intracranial hemorrhage was found in 6.1% of patients. Lower age (OR 0.932, 95% CI 0.878-0.988) and lower NIHSS score upon admission (OR 0.893, 95% CI 0.805-0.991) were independent predictors of good clinical outcome.

CONCLUSION

Aspiration thrombectomy appeared to be a safe and effective first-line treatment option for patients with M2 occlusion, being the first-line option for almost three-quarters of patients.

Endovascular Treatment of Acute Carotid Stent Occlusion: Aspiration Thrombectomy and Angioplasty

Introduction

Acute carotid stent occlusion (CSO) is a rare complication of endovascular carotid stent placement that requires emergent intervention. We describe angioplasty or combined angioplasty and aspiration thrombectomy as a new endovascular technique for CSO treatment. The technique is compared to others previously described in the literature.

Methods

We performed a retrospective cohort study of all patients who underwent endovascular treatment (ET) of acute symptomatic CSO from January 2008 to March 2018 at our neurovascular referral center. Patient demographics, endovascular treatment details, and outcome data were determined from the electronic medical record. Primary outcome was successful stent recanalization and cerebral reperfusion (modified thrombolysis in cerebral infarction (mTICI) score IIB-III). Secondary outcomes were National Institutes of Health Stroke Scale (NIHSS) shift from presentation to discharge, mortality, and modified Rankin Scale (mRS) score at 3 months. Additionally, a literature review (years 2008-2019) was performed to characterize other techniques for ET of CSO.

Results

Four patients who underwent ET of acute CSO were identified. ET treatment by angioplasty (n = 1) or combined aspiration thrombectomy and angioplasty (n = 3) resulted in carotid stent recanalization in all patients. Tandem intracranial occlusions were present in three patients (75%), and successful cerebral reperfusion was achieved in all patients. Patient symptoms improved (mean NIHSS shift -5.3 ± 7.2 at discharge). One patient died of a symptomatic reperfusion hemorrhage and another died of cardiac complications by 3-month follow-up. The mRS scores of the surviving patients were 1 and 3. Previously described studies (n = 14) using different and varied techniques had moderate recanalization rates and outcomes.

Conclusion

Combined aspiration thrombectomy and angioplasty for the neurointerventional treatment of acute CSO leads to high rates of stent recanalization and cerebral reperfusion. The recanalization rate here is improved compared to previously reported techniques. Further multicenter studies are required to risk-stratify patients for specific ET interventions.

Impact of reperfusion pump power on technical and clinical outcomes after direct aspiration thrombectomy (ADAPT)

INTRODUCTION

Higher aspiration forces using larger bore catheters in direct aspiration thrombectomy (ADAPT) have been associated with shorter procedure time and better outcomes in patients treated for acute ischemic stroke (AIS). However, the effect of using reperfusion pumps of higher aspiration power on outcomes of ADAPT has not been investigated. We evaluated the effect of using pumps with different aspiration powers on technical and clinical outcomes after ADAPT.

METHODS

We reviewed a retrospective database of AIS cases between January 2018 and February 2019, while comparing technical and clinical outcomes between patients undergoing ADAPT using the MAX pump (28.5 inHg power) vs the ENGINE pump(29.2 inHg power).

RESULTS

Among 194 patients (48% females, age 69±15 years) included in the study, 73 patients undergoing ADAPT using the ENGINE pump were age-, gender-, comorbidities-, and operator-matched to 118 patients treated using the MAX pump. The ENGINE group had shorter procedure time (20±17 vs 27±21 mins, p=0.017), lower number of aspiration attempts (2.2±1.6 vs 2.8±1.9, p=0.047), and similar rates of favorable 90 day modified Rankin Scale. Using multivariate linear regression, the use of the ENGINE reperfusion pump with higher vacuum power was independently and inversely correlated with procedure time (coefficient -2.23, p=0.027). While controlling for confounders, there was a trend toward an inverse correlation between use of the ENGINE pump and the number of attempts on linear regression (coefficient -1.04, p=0.09) and lower odds of PH2/intracranial (ICH) hemorrhages on logistic regression (OR 0.227, p=0.075).

CONCLUSION

Our findings suggest that the use of the ENGINE reperfusion pump of higher aspiration power during ADAPT decreases procedure time, without increasing complications and post-procedural hemorrhage rates.

Coronary aspiration thrombectomy after using intravenous recombinant tissue plasminogen activator in a patient with acute ischemic stroke: a case report

The complication of myocardial infarction after using intravenous recombinant tissue plasminogen activator (rt-PA) in patients with acute ischemic stroke is rare. Several of these cases have been reported in the first 3 hours after infusion of rt-PA. There is controversy on how to manage treatment of the coronary artery, such as intravenous anticoagulants and antiplatelets, at the same time. We introduce a new strategy for treatment of a patient who had ischemic stroke and developed myocardial infarction after intravenous rt-PA therapy. Our case had coronary and cerebral intervention in combination with low-dose intravenous rt-PA. He was successfully treated for coronary occlusion with aspiration thrombectomy.

Intracoronary or intravenous abciximab after aspiration thrombectomy in patients with STEMI undergoing primary percutaneous coronary intervention

OBJECTIVE

To test whether aspiration thrombectomy with intracoronary (IC) instead of intravenous (IV) administration of abciximab could reduce the no-reflow phenomenon in patients undergoing primary percutaneous intervention (PCI) for ST-elevation myocardial infarction (STEMI).

BACKGROUND

Despite recanalisation with PCI, failure to restore microvascular flow may affect the prognosis of patients with STEMI. A combination of aspiration thrombectomy with IC abciximab may improve distal perfusion.

METHODS

After aspiration thrombectomy during primary PCI for STEMI, 160 patients were randomly assigned to either an IV or IC abciximab bolus delivered through the aspiration catheter, both followed by a 12-hour IV abciximab infusion.

RESULTS

ST-segment resolution ≥ 70% was achieved in 36 of 78 patients with IC versus 30 of 82 patients with IV abciximab (46.1 vs 36.6%, p = 0.368), and partial resolution in 28 of 78 versus 31 of 82 patients (35.9 vs 37.8%, p = 0.368). Postprocedural myocardial blush grade (MBG) 3 was obtained in 62.8 vs 63.4% (p = 0.235) and MBG ≥ 2 in 89.7 vs 81.7% (p = 0.148) of patients given IC and IV abciximab, respectively. There were three deaths in each group (3.8%). Major adverse cardiac events occurred in six of 78 patients given the IC and seven of 82 patients given the IV abciximab bolus (7.6 vs 8.5%, p = 0.410). One stroke occurred in each group, and two patients in the IC and nine in the IV group developed renal failure (2.5 vs 10.9%, p = 0.414).

CONCLUSIONS

IC versus IV abciximab did not enhance myocardial reperfusion in non-selected patients with STEMI undergoing primary PCI after aspiration thrombectomy had successfully been performed.

The combined use of an aspiration catheter and balloon angioplasty for acute atherosclerotic occlusion of the middle cerebral artery

Stent-retriever thrombectomy for atherosclerotic acute occlusion of cerebral arteries is difficult. We experienced three patients with middle cerebral artery atherosclerotic occlusion who achieved successful recanalization with the combined use of aspiration thrombectomy devices and cerebral angioplasty balloons. The combination is feasible in terms of smooth delivery of the balloon catheter.

Unilateral Acute Renal Artery Embolism: An Index Case of Successful Mechanical Aspiration Thrombectomy With Use of Penumbra Indigo Aspiration System and a Review of the Literature

Acute renal artery embolism (RAE) is a rare condition associated with significant morbidity and mortality. The treatment strategy for RAE includes anticoagulation with or without thrombolysis or surgical or endovascular embolectomy. We describe here a case presentation of acute RAE secondary to atrial fibrillation treated successfully with Penumbra Indigo Aspiration System, a novel device in peripheral endovascular interventions. Our patient had ongoing symptoms and acute renal failure on presentation with contraindication to thrombolysis given hypertensive emergency. A 6F Penumbra Aspiration catheter was used to aspirate large amounts of thrombus from segmental renal arteries with restoration of flow. Patient's symptoms and renal function returned to baseline after intervention. Penumbra system is used routinely in cerebral endovascular intervention, yet here we describe its potential use in peripheral vascular interventions in addition to a literature review of all available evidence for the different treatment modalities of acute RAE.

Frontline ADAPT therapy to treat patients with symptomatic M2 and M3 occlusions in acute ischemic stroke: initial experience with the Penumbra ACE and 3MAX reperfusion system

Background

After a series of positive studies for mechanical thrombectomy in large vessel occlusion acute ischemic stroke, the question remains, can symptomatic patients with distal vessel occlusion benefit from mechanical thrombectomy?

Purpose

To assess the safety and efficacy of the 3MAX reperfusion system as frontline therapy for M2 and M3 occlusions.

Methods

This study retrospectively collected data on 58 patients treated for M2 and M3 occlusions between January and September 2016. Of these 58 patients, 31 had an isolated M2 or M3 occlusion. Eligible patients were treated with 3MAX by adirect first pass aspiration (ADAPT) technique within 6 hours following stroke onset. Effectiveness was defined by functional independence (90-day modified Rankin Scale core 0–2) and revascularization to modified Thrombolysis in Cerebral Infarction (mTICI) 2b–3 scores adjudicated by a core laboratory, while complication rates were used to determine safety of the device and the procedure.

Results

Patients with an isolated M2 or M3 occlusion had a mean age of 68.6±13.3 years (range 18–90 years), a median National Institutes of Health Stroke Score of 15 (IQR 9–19), and ASPECTS score of 9 (IQR 8–10). After intervention, 100% (31/31) of patients were revascularized to mTICI 2b–3; 77.4% (24/31) of patients showed revascularization to mTICI 3. Aspiration alone led to revascularization in 83.9% (26/31) of patients. At 90 days, 96.8% (30/31) of patients had achieved functional independence. The incidence of symptomatic intracranial hemorrhage was 0% (0/31).

Conclusions

Results suggest that the 3MAX reperfusion system is safe and effective in achieving successful revascularization and functional independence for patients with acute ischemic stroke secondary to M2 and M3 occlusions using ADAPT, either as frontline monotherapy, or in combination with adjunctive devices.

Long-term outcomes with aspiration thrombectomy for patients undergoing primary percutaneous coronary intervention: A meta-analysis of randomized trials

Randomized clinical trials that examined long-term clinical outcomes of routine aspiration thrombectomy prior to primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction have yielded different results. We hypothesized that the routine use of manual thrombus aspiration prior to primary PCI lacks long-term clinical benefits. Electronic databases were searched for randomized trials comparing routine aspiration thrombectomy and conventional PCI. We included only trials that reported clinical outcomes beyond 6 months. The primary outcome was all-cause mortality, and the secondary outcomes included major adverse cardiovascular events, re-infarction, cardiovascular mortality, and stent thrombosis (ST). A DerSimonian-Laird model was used to construct the summary estimates risk ratio (RR). We retrieved 18 trials with 20 641 ST-segment elevation myocardial infarction patients, of whom 10 331 patients underwent routine aspiration thrombectomy prior to primary PCI. At a mean follow-up of 12 months, there was no significant decrease in the risk of all-cause mortality (RR: 0.93, 95% confidence interval [CI]: 0.82-1.05, P = 0.22), major adverse cardiac events (RR: 0.95, 95% CI: 0.87-1.03, P = 0.18), re-infarction (RR: 0.95, 95% CI: 0.80-1.13, P = 0.59), cardiovascular mortality (RR: 0.80, 95% CI: 0.47-1.36, P = 0.40), or ST (RR: 0.80, 95% CI: 0.63-1.01, P = 0.06) with routine aspiration thrombectomy. Routine aspiration thrombectomy prior to primary PCI was not associated with a reduction in long-term mortality or clinical outcomes. Future randomized trials are warranted to further evaluate the role of aspiration thrombectomy in select patients and coronary lesions.

High-Resolution Magnetic Resonance Imaging Evidence for Intracranial Vessel Wall Inflammation Following Endovascular Thrombectomy

Intracranial high-resolution vessel wall magnetic resonance imaging evidence of vessel wall inflammation is present following stent retriever manipulation but absent following aspiration thrombectomy. This is presented in a case of rotatory vertebral artery compression causing multiple posterior circulation infarctions requiring multiple separate aspiration and stent retriever thrombectomies.

Catheter directed interventions for acute deep vein thrombosis

Venous thromboembolism (VTE) is an extremely common form of vascular disease and impacts a great number of patients worldwide. Acute deep vein thrombosis (DVT) is a subset of VTE and is traditionally been treated with anticoagulation. There is good quality data which suggests the use of catheter directed interventions for the treatment of acute DVT with the aim of reducing post-thrombotic syndrome (PTS). The present review will discuss the various therapies available for acute DVT, focusing on catheter directed interventions, ranging from traditional anticoagulation to the most novel forms of aspiration thrombectomy.

Application of Intravascular Ultrasound in the Emergency Diagnosis and Treatment of Patients with ST-Segment Elevation Myocardial Infarction

PURPOSE

This study aimed to examine the application of intravascular ultrasound (IVUS) in ST-segment elevation myocardial infarction (STEMI) patients with high thrombus burden (thrombus grade ≥3) undergoing emergency diagnosis and primary percutaneous coronary intervention.

METHODS

Eighty STEMI patients were enrolled and randomly assigned to the IVUS-guided group (38 patients) or non-IVUS group (42 patients). Stent implantation was performed in non-IVUS group patients. IVUS group patients were further divided into low-risk and high-risk patients on the basis of IVUS evaluation for determining whether stenting should be performed. Major adverse cardiac event (MACE) rates, changes in the left ventricular end-diastolic diameter (LVEDD) and ejection fraction (EF) values, and stent numbers were examined during hospitalization, and follow-up was performed at 1, 3, 6, and 12 months postoperatively.

RESULTS

During hospitalization, there were no significant differences in the MACE rates, LVEDD, and EF values and in the follow-up outcomes at 1, 3, 6, and 12 months postoperatively among the patients in the 2 groups (P > 0.05). A significantly lower number of stents were implanted in the IVUS group than in the non-IVUS group patients (P < 0.05).

CONCLUSION

During the IVUS-guided emergency intervention, enhanced antithrombotic therapy and best medical care for low-risk STEMI patients may be feasible.

Septic coronary artery embolism treated with aspiration thrombectomy: case report and review of literature

Coronary embolization is a potentially fatal sequela of endocarditis. We report a case of Candida endocarditis with septic embolism to the left anterior descending coronary artery. This embolism was successfully treated with aspiration thrombectomy followed by balloon angioplasty. The treatment of acute coronary syndrome in the presence of septic embolism is controversial. Aspiration thrombectomy has been performed in this situation before, and it appears to be safer and more feasible than is thrombolysis or percutaneous transluminal angioplasty.

Recurrent Thrombosis in a Case of Coronary Ectasia with Large Thrombus Burden Successfully Treated by Adjunctive Warfarin Therapy

Coronary ectasia (CE) is an uncommon disease. Most patients with CE have coexisting coronary artery stenosis, which can easily lead to acute myocardial infarction (AMI). The current standard treatment for AMI is well-established. However, for CE patients, the standard treatment might fail because of the large thrombus burden. We report a case of CE suffering from AMI twice during a two week period. Percutaneous coronary intervention with aspiration thrombectomy was performed but failed to restore adequate blood flow. Heparin and antiplatelet treatment including glycoprotein IIb/IIIa inhibitor was given for pharmacological management, but follow-up angiography still revealed a poor result. This patient was finally treated with dual antiplatelet therapy in combination with warfarin treatment. Follow-up coronary angiography a few months later showed restored TIMI 3 flow. This patient reminds us that in CE patients with large thrombus burden, if standard treatment fails, long-term warfarin in combination with antiplatelet might be a good alternative choice to decrease thrombus burden and enhance blood flow.

KEY WORDS

Acute myocardial infarction; Anticoagulation; Aspiration thrombectomy; Coronary ectasia; Warfarin.