Recanalisation of thrombotic arterial occlusions with rotational thrombectomy

Safety and Efficacy of Rotational Thrombectomy for Treatment of Arterial Occlusions of the Lower Extremities: A Large Single-Center Retrospective Study

Purpose To evaluate the safety and efficacy of rotational thrombectomy (RT) in a large single-center real-world cohort for total vascular occlusions of the lower extremity.

Materials and Methods The clinical records and images of all patients between 2010 and 2020 treated via RT (Rotarex, BD) were assessed. Patient demographics, clinical data, procedural characteristics, and outcome parameters were documented. In total, 397 procedures in 293 patients were included (mean age 69.8 ± 12.0 years; 64.8 % male). Occlusions were acute (47.5 %), subacute and acute-on-chronic (22.2 %), and chronic (30.3 %). The target lesions were the iliac artery (7.1 %), iliac/femoropopliteal (5.0 %), femoropopliteal (59.4 %), femoropopliteal/below-the-knee (27.0 %), below-the-knee (1.5 %), and after bypass surgery (14.9 %). Lesion length was > 20 cm in 61.5 % of cases.

Results Clinically successful revascularization was achieved in 90.4 % of cases. Additional thrombolysis was necessary for 32.0 % of procedures. The arithmetic mean ankle-brachial index increased from 0.33 ± 0.29 to 0.81 ± 0.25 (p < 0.0001). Bypass grafts were less likely to be fully treatable and required additional lysis (p < 0.001). The overall primary patency (no clinically driven target lesion revascularization) was 93.2 %, 88.8 %, 79.1 %, and 72.4 % at 1, 3, 6, and 12 months, respectively. Adverse events occurred in 46.1 % of cases, of which peripheral embolization (22.4 %) was most frequent, requiring interventional treatment in 67.4 % of cases. RT was directly associated with 7.1 % (n = 28) of complications, which consisted of perforations 2.8 %, arteriovenous fistula 1.3 %, and dissections 2.0 %.

Conclusion Rotational thrombectomy is a safe and efficient method for the treatment of occlusions of the arterial circulation of the lower extremity with bypass occlusions having a higher propensity for residual thrombi requiring further lysis therapy.

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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.

Percutaneous Mechanical Thrombectomy for Acute Limb Ischemia With Aorto-iliac Occlusion

Background

To evaluate the outcomes of percutaneous mechanical thrombectomy (PMT) with Rotarex catheter in patients with acute lower limb ischemia (ALI) caused by aorto-iliac occlusion.

Materials and Methods

Data of patients with ALI caused by aorto-iliac occlusion in our institutions from January 2010 and April 2020 were reviewed. The primary end point was limb salvage rate. The secondary end points included technical success rate, survival rate, complications after the operation and during the follow-up.

Results

A total of 85 patients with ALI was diagnosed with aorto-iliac occlusion. Thirty-eight patients were treated by PMT with Rotarex catheter and enrolled in present study. Twenty-four were male (63.2%), and 14 were female (36.8%). The mean age was 66 years (range 28–83). All 38 patients were treated with PMT, with additional catheter directed thrombolysis (2/38, 5.3%), balloon angioplasty (8/38, 21.1%) and stent deployment (7/38, 18.4%). The mean procedure time was 123 ± 31 min. Seven patients (18.4%) underwent continuous renal replacement therapy. Two patients received major amputations (above the knee) and 2 patients died for renal insufficiency and heart failure during the hospital stay. Thirty-day survival rate was 94.7% and limb salvage was 94.4%. The mean follow-up time was 14.0 months (8–22 months). There was no major amputation and target artery occlusion occurred during the follow-up period.

Conclusion

PMT with Rotarex catheter could be new option for acute aorto-iliac occlusion, leading to safe and effective results.

Mechanical rotational thrombectomy in long femoropopliteal artery and bypass occlusions: risk factors for periprocedural peripheral embolization

PURPOSE

We aimed to examine lesion characteristics influencing technical outcome and periprocedural peripheral embolization (PPE) during percutaneous mechanical rotational thrombectomy (PMT) of long femoropopliteal artery and bypass occlusions.

METHODS

Retrospectively, 65 consecutive patients (43 male patients, mean age 70±12 years; Rutherford category I-III), undergoing PMT (Rotarex®, Straub Medical AG) with acutely/subacutely occluded femoropopliteal arteries/bypasses were included. Occlusions (mean length, 217±98 mm) were treated by PMT followed by percutaneous transluminal angioplasty (PTA) plus drug-coated balloon or PTA plus stenting/stentgrafting. Technical success was defined as residual stenosis <30%. Follow-up included duplex ultrasound and ankle-brachial index (ABI) after 12 months. Endpoints were technical success, complications, improvement of Rutherford category, ABI, and patency (re-stenosis <50%). The influence of lesion length, duration, and thrombus density (measured in preinterventional computed tomography angiography) on technical success and PPE was analyzed.

RESULTS

Technical success was 18% (12/65) after PMT alone, 92% (60/65) after additional means. Four patients (6%) underwent bypass surgery and one patient (2%) amputation. PPE occurred in 11% (7/65). During the 12-month follow-up, three patients (5%) were lost to follow-up. ABI increased from baseline 0.5±0.12 to 0.81±0.14 (p = 0.001) and Rutherford category increased by at least one level in 57 patients at 12-month follow-up (clinical success, 88%). At 12 months, primary patency was 57.4% (95% CI, 45.8%-68.9%) and secondary patency was 75.0% (95% CI, 59.8%-72.3%). As risk factors for PPE, we identified lesion length >200 mm (15%; 6/39; OR 4.5; 95% CI, 0.5-40; p = 0.014) and thrombus density ≤45 HU (20%; 2/10; OR 3.0; 95% CI, 0.2-38.9; p = 0.05). No significant relation between risk factors and technical success was found.

CONCLUSION

PMT followed by PTA or implantation of stent (grafts) appears to be effective and safe for revascularization of acute/subacute long occlusions. Thrombus density <45 HU and lesion length above 20 cm represent risk factors for PPE during PMT.

The effectiveness of percutaneous mechanical thrombectomy in the treatment of acute thromboembolic occlusions of lower extremity

Objectives

The objective of this study was to evaluate the effectiveness of percutaneous mechanical thrombectomy as the initial thrombus removal method in the treatment of acute lower extremity ischemia.

Methods

The patients with acute lower limb ischemia who underwent percutaneous mechanical thrombectomy between August 2016 and February 2018 were retrospectively reviewed. The patients were diagnosed by clinical examination and computed tomography angiography. The percutaneous mechanical thrombectomy was performed as the initial thrombus removal method, followed by anticoagulation therapy. The patients were followed up by clinical examination, imaging, and ankle brachial index (ABI) examination.

Results

Thirty-two patients (21 males, 11 females; average age of 68.53 ± 8.05; three cases of grade III, 29 cases of grade IIB) were reviewed. Recanalization of the thromboembolic occlusions were achieved in all patients. ABI significantly ( p < 0.01) increased postoperatively (preoperative ABI: 0.51 ± 0.13; postoperative ABI: 0.85 ± 0.65, ABI at three months postoperatively: 0.84 ± 0.66). Eleven patients underwent balloon dilation and three patients had stent placement. Complete thrombus removal was achieved in all patients. The primary patency at 3 months, 6 months, and 12 months postoperatively was 90%, 85%, and 56%, respectively. The secondary patency at 3 months, 6 months, and 12 months postoperatively was 93%, 87%, and 65%, respectively.

Conclusions

The immediate result appeared to be effective to use percutaneous mechanical thrombectomy as the first thrombus removal method in the treatment of acute thromboembolic occlusions in the lower extremity, while the midterm result needs to be further improved.

Percutaneous Rotational Mechanical Atherectomy Plus Thrombectomy Using Rotarex S Device in Patients With Acute and Subacute Lower Limb Ischemia: A Review of Safety, Efficacy, and Outcomes

Acute and subacute ischemia of lower limbs is associated with high risk of amputation and potential severe life-threatening complications. Despite a lack of clear therapeutic recommendations, surgical treatments such as thrombectomy or bypass and/or catheter-directed thrombolysis (CDT) have been first-line procedures in both acute and subacute limb ischemia, but each therapy may lead to significant morbidity and mortality. Such situations demand fast restoration of appropriate flow to preclude limb loss and other complications. Percutaneous mechanical atherectomy plus thrombectomy (MATH) represents a minimally invasive approach for quickly recanalizing thrombus-containing lesions whatever the age of thrombus. Indeed, many chronic patients can present with critical limb ischemia, with thrombus-containing occlusive lesions triggered by underlying atherosclerotic disease. MATH offers various advantages over surgery and CDT, with lower invasiveness, faster recanalization, and the possibility to immediately treat the underlying lesions, with a lower rate of bleeding complications and no need for intensive care unit stay. Currently, several mechanical thrombectomy devices are offered as an alternative therapy and can be divided into pure rotational MATH systems and rheolytic thrombectomy devices. The only pure rotational MATH device currently available on the market is the Rotarex S device. We aimed to review contemporary clinical data regarding the safety, efficacy, and outcomes of MATH therapy using Rotarex S catheter in acute and subacute thrombus-containing arterial lesions of lower limbs. Future perspectives of Rotarex S MATH treatment and cost-effectiveness of its routine use will be also discussed.

Endovascular treatment of aortic saddle embolism through percutaneous mechanical Thrombectomy via Straub Rotarex catheter

BACKGROUND

To summarize our experience of endovascular treatment for abdominal aorta saddle embolism (ASE) through percutaneous mechanical thrombectomy (PMT).

METHODS

Clinical data of three ASE patients treated with an endovascular approach using percutaneous mechanical thrombectomy (PMT) were reviewed and analyzed.

RESULTS

After PMT, blood flow of limbs was restored in all of the three patients. However, two patients died from sudden cardiac arrest caused by hyperkalemia several hours after the procedure. The other one patient survived through continuous renal replacement therapy, which was initialized shortly after the surgical procedure.

CONCLUSION

Endovascular treatment through PMT can quickly restore blood flow in the ASE patients. Blood purification through renal replacement therapy is crucial to reduce mortality after restoring blood flow of the limbs.

Combination of Percutaneous Rotational Thrombectomy and Drug-Coated Balloon for Treatment of Femoropopliteal Artery Nonembolic Occlusion: 12-Month Follow-up

PURPOSE

To evaluate safety and efficacy of percutaneous mechanical thrombectomy using the Rotarex catheter combined with drug-coated balloon (DCB) in treatment of femoropopliteal artery occlusive disease.

MATERIALS AND METHODS

Between January 2016 and February 2018, 81 patients with acute or subacute femoropopliteal artery occlusions were treated with the Rotarex catheter combined with DCB. Lesions were classified according to the onset of symptoms as acutely (< 14 d) or subacutely (14 d to 3 mo) occluded. The mean lesion length was 12.1 cm ± 6.7. The primary endpoint was target lesion patency at 1 year as evaluated by duplex ultrasound (peak systolic velocity ratio < 2.4) and freedom from clinically indicated target lesion revascularization. Amputation rate, major adverse events, and ankle-brachial index at 12 months were evaluated.

RESULTS

Technical success rate was 100% (n = 81). Bailout stents were necessary in 14 patients owing to residual stenosis or flow-limiting dissection. Additional thrombolysis was applied in 10 interventions. No major adverse events occurred during hospital stay. There were 9 restenosis cases during the 12-month follow-up period. Primary patency rate was 87.3% (62/71), and freedom from target lesion revascularization rate was 90.1% (64/71). Ankle-brachial index significantly increased from 0.46 ± 0.15 to 0.77 ± 0.14 during follow-up. The amputation rate was 1.4% at 12 months.

CONCLUSIONS

These initial data from 2 centers suggest that the combination of the Rotarex catheter and DCB may be safe and effective for treatment of acute or subacute thrombotic femoropopliteal occlusion with superior immediate and midterm results achieved.

Mechanical rotational thrombectomy with Rotarex system augmented with drug-eluting balloon angioplasty versus stenting for the treatment of acute thrombotic and critical limb ischaemia in the femoropopliteal segment

Introduction

Mechanical thrombectomy is an alternative to local thrombolysis for the treatment of severe ischaemia in the femoropopliteal segment, but stent implantation is usually required after this procedure. The use of drug-eluting balloons (DEBs) may overcome long-term problems associated with stents, but it remains unclear how often such a treatment is technically feasible and efficient.

Aim

This post hoc single-centre study was aimed at assessment of the feasibility, safety and efficacy of mechanical thrombectomy followed by application of DEBs.

Material and methods

Fifty-one patients, aged 69.1 ±11.6 years, were managed for acute thrombotic or chronic critical ischaemia in the femoropopliteal segment using the Rotarex device. Following mechanical thrombectomy, on condition that there was no significant residual stenosis or dissection, lesions were managed with paclitaxel-coated DEBs, which was a desired strategy (24 patients). The remaining 25 patients underwent stent implantations, which was regarded as bailout treatment. Final follow-up was scheduled 12 months after the procedure.

Results

The primary-assisted patency rate after mechanical rotational thrombectomy with additional balloon angioplasty and/or stenting was 97.1% (49 patients). The early mortality rate was 2.0% (1 patient) and the amputation rate was 4.1% (2 patients). There were no late mortalities or limb amputations at 12-month follow-up, but significant restenoses occurred in 13 (27.1%) patients. These restenoses were more frequent in patients who underwent stent implantation (45.5%) than those managed with DEBs (12.5%), and in patients managed for secondary lesions.

Conclusions

In selected patients mechanical rotational thrombectomy in the femoropopliteal segment followed by application of DEB is a safe, effective and long-lasting method of revascularisation.

Acute on chronic limb ischemia: From surgical embolectomy and thrombolysis to endovascular options

After the invention of the balloon catheter by Fogarty in 1963, surgical thromboembolectomy was considered the gold standard treatment for many years in patients with acute lower limb ischemia (ALLI). ALLI is a dramatic event, carrying a high risk of amputation and perioperative morbidity and mortality. The evolution of endovascular technologies has resulted in a variety of therapeutic options to establish arterial patency. In the 1970s, Dotter first introduced the idea of clot lysis in the treatment of ALLI, which was modified to catheter-directed thrombolysis, and now clot aspiration techniques. Currently, the majority of ALLI (about 70%) is arterial thrombosis, which generally occurs in the setting of preexisting vascular lesion. This condition is very common in patients with diabetes. Clinical presentation in case of thrombosis on atherosclerotic stenosis (so called "acute on chronic ischemia") may be less severe, but treatment is generally more challenging than ALLI due to embolism, considering the complexity in device trackability through the diseased vessels, potential vessel injury, incomplete revascularization, and need of correction of underlying vascular lesions. Although surgery is still a treatment option, especially for ALLI, endovascular interventions have assumed a prominent role in restoring limb perfusion. In this review, the treatment options for ALLI are detailed from surgical thromboembolectomy to thrombolysis and current endovascular techniques, including mechanical fragmentation, rheolytic thrombectomy, and aspiration thrombectomy. The evolution to endovascular therapies has resulted in improved clinical outcomes and lower rates of morbidity.

Rotarex Mechanical Debulking in Acute and Subacute Arterial Lesions

Introduction:

Data regarding the effectiveness and safety of percutaneous mechanical thrombectomy (PMT) in contemporary routine care are scarce.

Materials and Methods:

Consecutive patients undergoing PMT of native lower limb acutely/subacutely occluded arteries were included.

Results:

In all, 525 consecutive patients were available for analysis with a mean age of 66.7 ± 10.7 years. Almost two-third (n = 324; 61.7%) were men with acutely (n = 211; 40.2%) or subacutely (n = 314; 59.8%) occluded lesions presenting mostly in Rutherford-Becker category (RBC): 3 (30.3%) and 4 (47.6%). Mean lesion length was 159 mm (range 22-279 mm), with moderate and severe calcification in 119 (23.3%) lesions. PMT was performed solely in 161(27.2%), PMT + balloon angioplasty in 232 (39.1%), provisional stenting in 169 (28.4%), and thrombolysis in 77 (13.9%) interventions. Procedural technical success rate was 97.7%, with improvement in RBC persisting in 74.1% of patients after 12 ± 2.4 months mean time follow-up. Overall 30 days major adverse events (MAEs) was 6.9% with a mortality rate of 1.1%. No death was directly related to the device. After 12 months, a promising overall target lesion revascularization (TLR; 10.1%), non-TLR (6.6%), and major amputation rates (2.3%) were found. One-year mortality was 8%.

Conclusion:

Treatment with PMT resulted in clinic and hemodynamic improvement in the majority of patients, thereby reducing the need for thrombolysis in a significant proportion of patients. Prospective studies in this issue are recommended.