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Chamseddine H, Shepard A, Kabbani L, Nypaver T, Weaver M, Kavousi Y, Peshkepija A, Lee A, Dandu C, Kafri O, Onofrey K. Single-center experience with the JETi Hydrodynamic Thrombectomy System for acute limb ischemia. J Vasc Surg 2024:S0741-5214(24)01486-1. [PMID: 38972364 DOI: 10.1016/j.jvs.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/27/2024] [Accepted: 07/01/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVE Acute limb ischemia (ALI) remains a vascular emergency with high morbidity and mortality. While the JETi Hydrodynamic Thrombectomy System (Abbott) offers a percutaneous approach to fragment and aspirate the thrombus in patients with arterial occlusions, data on its efficacy and safety are limited. This study reports our early experience using the JETi device to treat ALI at our institution. METHODS This is a single-center, retrospective review of patients with ALI treated with the JETi device between September 2020 and December 2022. Patients were included if the JETi device was used either as a primary intervention or as an adjunct procedure. The primary endpoint was technical success defined as <50% residual thrombus after intervention. Secondary endpoints included achieving complete resolution of the thrombus on angiogram, acute kidney injury (AKI), major bleeding, 30-day major amputation, and 30-day mortality. RESULTS A total of 59 JETi procedures for ALI (median age 62 years [interquartile range: 56-71 years]) were performed on 39 male and 20 female patients. The median time from onset of symptoms to hospitalization was 24 hours (interquartile range: 4-168 hours). Rutherford classifications were I (10), IIa (27), IIb (14), and undocumented (8). Etiology of ALI was native vessel thrombosis (27), embolism (16), graft/stent thrombosis (14), and iatrogenic (2). A total of 124 vessels were treated, with an average of 2.1 vessels per procedure. The primary outcome was achieved in 86% (107/124) of the arteries, with 82% (102/124) successfully opened using the JETi device alone without the need for any adjunctive therapy. Complete resolution of the thrombus using JETi was achieved in 81% (101/124) arteries, with or without the use of adjunctive therapy. A total of 6.7% (4/59) patients required a major limb amputation within 30 days despite successful recanalization, and one 30-day mortality was recorded. Complications included distal embolization (5), access site hematoma (2), and AKI (4). No major bleeding, hemolysis-induced AKI, or vessel dissection or perforation was observed. CONCLUSIONS The JETi device appears to be a safe and effective percutaneous treatment option in the management of ALI. It provides definitive treatment with a high technical success rate of 86% and a good safety profile.
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Affiliation(s)
- Hassan Chamseddine
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Alexander Shepard
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Loay Kabbani
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Timothy Nypaver
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Mitchell Weaver
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Yasaman Kavousi
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Andi Peshkepija
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Alice Lee
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Chaitanya Dandu
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Omar Kafri
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - Kevin Onofrey
- Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI.
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Dobesh K, Natour AK, Kabbani LS, Rteil A, Lee A, Nypaver TJ, Weaver M, Shepard AD. Patients with Acute Lower Limb Ischemia Continue to Have Significant Morbidity and Mortality. Ann Vasc Surg 2024; 108:127-140. [PMID: 38848889 DOI: 10.1016/j.avsg.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 02/11/2024] [Accepted: 03/13/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND The treatment of acute lower limb ischemia (ALLI) has evolved over the last several decades with the availability of several new treatment modalities. This study was undertaken to evaluate the contemporary presentation and outcomes of ALLI patients. METHODS We retrospectively analyzed data from a prospectively collected database of all patients who presented to our tertiary referral hospital with acute ischemia of the lower extremity between May 2016 and October 2020. The cause of death was obtained from the Michigan State Death Registry. RESULTS During the study period, 233 patients (251 lower limbs) were evaluated for ALLI. Seventy-three percent had thrombotic occlusion, 24% had embolic occlusion, and 3% due to a low flow state. Rutherford classification of ischemia severity was 7%, 49%, 40%, and 4% for Rutherford grade I, IIA, IIB, and III, respectively. Five percent underwent primary amputations, and 6% received medical therapy only. The mean length of stay was 11 ± 9 days. Nineteen percent of patients were readmitted within 30 days of discharge. At 30 days postoperatively, mortality was 9% and limb loss was 19%. On multivariate analysis, 1 or no vessel runoff to the foot postoperatively was associated with higher 30-day limb loss. Patients with no run-off vessels postoperatively had significantly higher 30-day mortality. Cardiovascular complications accounted for most deaths (48%). At 1-year postoperatively, mortality and limb loss reached 17% and 34%, respectively. CONCLUSIONS Despite advances in treatment modalities and cardiovascular care, patients presenting with ALLI continue to have high mortality, limb loss, and readmission rates at 30 days.
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Affiliation(s)
- Kaitlyn Dobesh
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI.
| | | | - Loay S Kabbani
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Ali Rteil
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Alice Lee
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | | | - Mitchell Weaver
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
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Wainwright BS, Chihade DB, Costanza MJ, Feghali AC, Shaw PM. Paradigm Shift of Interventional Strategies and Outcomes for Acute Limb Ischemia Post-Pandemic. J Endovasc Ther 2024:15266028241246162. [PMID: 38606923 DOI: 10.1177/15266028241246162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
PURPOSE We performed a large-scale comparison of patients treated for acute limb ischemia (ALI) in the pre-COVID (2017-2019) and COVID (2020-2022) eras to evaluate changes in interventional strategies and compare factors associated with adverse outcomes. We sought to characterize patient outcomes in an evolving ALI treatment algorithm in response to pandemic-associated presentation delays and rapid technological advancements in mechanical thrombectomy (MT). METHODS Using the TriNetX global research network, we conducted a multicenter query across 80 health care organizations (HCOs) spanning 4 countries for patients treated for ALI. Propensity score matching was performed to account for comorbidities. Risk of adverse outcomes within 30 days was calculated for each era, including re-intervention (RI30), major/minor amputation, and death. Patients were then stratified by initial intervention: open revascularization (OR), MT, or catheter-directed thrombolysis and adjunctive endovascular procedures alone (CDT/EP). Risk of adverse outcomes was compared between treatment groups of the same era. RESULTS After propensity score matching, the pre-COVID era and COVID era cohorts included 7344 patients each. COVID era patients experienced a statistically significant higher risk of 30-day mortality (RR=1.211, p=0.027). Mechanical thrombectomy interventions were performed more frequently in the COVID era (RR=1.314, p<0.0001). Comparing outcomes between treatment groups, MT patients required RI30 more than OR patients (pre-COVID: RR=2.074, p=0.006; COVID: RR=1.600, p=0.025). Open revascularization patients had higher 30-day mortality (pre-COVID: RR=2.368, p<0.0001; COVID: RR=2.013, p<0.0001) and major amputations (pre-COVID: RR=2.432, p<0.0001; COVID: RR=2.176, p<0.0001) than CDT/EP. Pre-COVID CDT/EP patients were at higher risk for RI30 (RR=1.449, p=0.005) and minor amputations (RR=1.500, p=0.010) than OR. The MT group had higher major amputation rates than CDT/EP (pre-COVID: RR=2.043, p=0.019; COVID: RR=1.914, p=0.007). COVID-era MT patients had greater 30-day mortality (RR=1.706, p=0.031) and RI30 (RR=1.544, p=0.029) than CDT/EP. CONCLUSION Significant shifts toward an MT-based approach have been observed in the last 3 years. Although MT required more RI30 than OR, there was no associated consequence of mortality and limb salvage. The increased mortality seen among COVID-era patients could be explained by delayed presentation, as well as poorly understood pro-thrombogenic or pro-inflammatory mechanisms related to the first waves of COVID. More research is necessary to determine an optimal treatment algorithm. CLINICAL IMPACT Comorbid risk factors and severity of ischemia must be carefully considered before selecting an interventional strategy to prevent adverse outcomes and maximize limb salvage. Open revascularization strategies are associated with increased mortality and limb loss compared to less-invasive thrombolytic therapy alone. Mechanical thrombectomy (MT)-based approaches have been increasingly used in the last 3 years. Patients receiving MT are more likely to require reintervention within 30 days.
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Affiliation(s)
- Brandon S Wainwright
- Norton College of Medicine, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Deena B Chihade
- Division of Vascular Surgery & Endovascular Services, Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Michael J Costanza
- Division of Vascular Surgery & Endovascular Services, Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Anthony C Feghali
- Division of Vascular Surgery & Endovascular Services, Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Palma M Shaw
- Division of Vascular Surgery & Endovascular Services, Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY, USA
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Maldonado TS, Powell A, Wendorff H, Rowse J, Nagarsheth KH, Dexter DJ, Dietzek AM, Muck PE, Arko FR, Chung J. Safety and efficacy of mechanical aspiration thrombectomy for patients with acute lower extremity ischemia. J Vasc Surg 2024; 79:584-592.e5. [PMID: 37931885 DOI: 10.1016/j.jvs.2023.10.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/17/2023] [Accepted: 10/22/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE Acute limb ischemia (ALI) is associated with high rates of amputation and consequent morbidity and mortality. The objective of this study is to report on the safety and efficacy of aspiration thrombectomy using the Indigo Aspiration System in patients with lower extremity (LE) ALI. METHODS The STRIDE study was an international, multicenter, prospective, study that enrolled 119 participants presenting with LE-ALI. Patients were treated firstline with mechanical thrombectomy using the Indigo Aspiration System, before stenting or angioplasty, or other therapies as determined by treating physician. The primary end point was target limb salvage at 30 days after the procedure. Secondary end points within 30 days included technical success, defined as core laboratory-adjudicated Thrombolysis in Myocardial Infarction (TIMI) 2/3 flow rate immediately after the procedure, changes in modified Society for Vascular Surgery runoff score, improvement of Rutherford classification compared with before the procedure, patency, rate of device-related serious adverse events, and major periprocedural bleeding. Secondary end points that will be evaluated at 12 months include target limb salvage and mortality. RESULTS Of the 119 participants enrolled at 16 sites, the mean age was 66.3 years (46.2% female). At baseline (n = 119), ischemic severity was classified as Rutherford I in 10.9%, Rutherford IIa in 54.6%, and Rutherford IIb in 34.5%. The mean target thrombus length was 125.7 ± 124.7 mm. Before the procedure, 93.0% (of patients 107/115) had no flow (TIMI 0) through the target lesion. The target limb salvage rate at 30 days was 98.2% (109/111). The rate of periprocedural major bleed was 4.2% (5/119) and device-related serious adverse events was 0.8% (1/119). Restoration of flow (TIMI 2/3) was achieved in 96.3% of patients (105/109) immediately after the procedure. The median improvement in the modified Society for Vascular Surgery runoff score (before vs after the procedure) was 6.0 (interquartile range, 0.0-11.0). Rutherford classifications also improved after discharge in 86.5% of patients (83/96), as compared with preprocedural scores. Patency at 30 days was achieved in 89.4% of patients (101/113). CONCLUSIONS In the STRIDE (A Study of Patients with Lower Extremity Acute Limb Ischemia to Remove Thrombus with the Indigo Aspiration System) study, aspiration thrombectomy with the Indigo System provided a safe and effective endovascular treatment for patients with LE-ALI, resulting in a high rate (98.2%) of successful limb salvage at 30 days, with few periprocedural complications.
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Affiliation(s)
| | | | | | - Jarrad Rowse
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | - Frank R Arko
- Sanger Heart and Vascular Institute, Charlotte, NC
| | - Jayer Chung
- Division of Vascular Surgery & Endovascular Therapy, Baylor College of Medicine, Houston, TX
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Bastian MB, Nadjiri J, Wessendorf J, Scheschenja M, König AM, Jedelska J, Mahnken AH. Safety and efficacy of interventional treatment of acute limb ischemia in Germany 2021. CVIR Endovasc 2023; 6:43. [PMID: 37632599 PMCID: PMC10460325 DOI: 10.1186/s42155-023-00393-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/18/2023] [Indexed: 08/28/2023] Open
Abstract
PURPOSE Interventional procedures have become a mainstay in the therapy of acute limb ischemia caused by embolism or arterial thrombosis. Treatment options include pharmacological thrombolysis (PT) and mechanical thrombectomy (MT). The aim of this study was to evaluate success and major complication rates of interventional radiological treatments of arterial embolism and thrombosis in Germany in 2021 and to compare their results with accepted international quality standards. MATERIALS AND METHODS Data for PT and MT for 2021 was obtained from the quality management system of the German interventional radiological society (DeGIR). 2431 PT and 1582 MT procedures were documented for 2021, with 459 combinations of PT and MT. Data was analysed for technical and clinical success rates, as well as major complication rates such as intracranial bleeding, major bleeding, distal embolization, aneurysm formation, organ-failure and cardiac-decompensation. RESULTS PT alone had technical and clinical success rate of 90.21% and 81.08%, respectively. MT alone had technical and clinical success rates of 97.41% and 95.39%, respectively. MT&PT had technical and clinical success rates of 91.07% and 84.75%, respectively. Major complications were: distal embolization (PT:2.02%; MT:1.74%; PT&MT:2.61%), major bleeding (PT:0.94%; MT:1.14%; PT&MT:0.87%), aneurysm formation (PT:0.33%;MT: 1.14%;PT&MT: 0%), intracranial bleeding (PT:0.16%;MT:0%;PT&MT:0.22%), cardiac-decompensation (PT:0.21%;MT: 0.06%;PT&MT:0%) and organ-failure (PT:0%;MT:0.06%;PT&MT:0.22%). Technical and clinical success rates were higher, while complication rates were lower than the corresponding threshold recommended by the Society of Interventional Radiology for percutaneous management of acute lower-extremity ischemia. CONCLUSION Treatment of arterial embolism and thrombosis performed by interventional radiologists in Germany is effective and safe with outcomes exceeding internationally accepted standards.
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Affiliation(s)
- Moritz B Bastian
- Department of Diagnostic and Interventional, Radiology University Hospital Marburg, Philipps-University of Marburg, Baldingerstrasse 1, 35043, Marburg, DE, Germany.
| | - Jonathan Nadjiri
- Department of Interventional Radiology, Klinikum rechts der Isar, Technische Universität München, Munich, DE, Germany
| | - Joel Wessendorf
- Department of Diagnostic and Interventional, Radiology University Hospital Marburg, Philipps-University of Marburg, Baldingerstrasse 1, 35043, Marburg, DE, Germany
| | - Michael Scheschenja
- Department of Diagnostic and Interventional, Radiology University Hospital Marburg, Philipps-University of Marburg, Baldingerstrasse 1, 35043, Marburg, DE, Germany
| | - Alexander M König
- Department of Diagnostic and Interventional, Radiology University Hospital Marburg, Philipps-University of Marburg, Baldingerstrasse 1, 35043, Marburg, DE, Germany
| | - Jarmila Jedelska
- Department of Diagnostic and Interventional, Radiology University Hospital Marburg, Philipps-University of Marburg, Baldingerstrasse 1, 35043, Marburg, DE, Germany
| | - Andreas H Mahnken
- Department of Diagnostic and Interventional, Radiology University Hospital Marburg, Philipps-University of Marburg, Baldingerstrasse 1, 35043, Marburg, DE, Germany
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Meng XH, Xie XP, Liu YC, Huang CP, Wang LJ, Liu HY, Fang X, Zhang GH. Observation of the effect of angiojet to treat acute lower extremity arterial embolization. World J Clin Cases 2023; 11:3491-3501. [PMID: 37383913 PMCID: PMC10294201 DOI: 10.12998/wjcc.v11.i15.3491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/25/2023] [Accepted: 04/13/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Through significant advances in the treatment of peripheral arterial occlusive disease, acute ischemia of the lower extremity is still associated with significant morbidity, limb threat and mortality. The two main causes of acute ischemia in lower extremities are arterial embolism and atherosclerotic arteries. Timely recognition and treatment of acute limb ischemia in emergency situations is essential in order to minimize the duration of ischemia.
AIM To investigate the application effect of angiojet thrombolysis in the treatment of acute lower extremity arterial embolization.
METHODS Sixty-two patients with acute lower extremity arterial embolization admitted to our hospital from May 2018 to May 2020 were selected. Among them, the observation group (twenty-eight cases) had received angiojet thrombolysis, and the control group (thirty-four cases) had received femoral artery incision and thrombectomy. After thrombus clearance, significant residual stenosis of the lumen was combined with balloon dilation and/or stent implantation. When the thrombus removal was not satisfactory, catheter-directed thrombolysis was performed. The incidence of postoperative complications, recurrence rate and recovery of the two groups were compared.
RESULTS There were no significant differences in postoperative recurrence (target vessel reconstruction rate), anklebrachial index and the incidence of postoperative complications between the two groups (P > 0.05); there were statistically significant differences in postoperative pain score and postoperative rehabilitation between the two groups (P < 0.05).
CONCLUSION The application of angiojet in the treatment of acute lower limb artery thromboembolism disease is safe and effective, minimally invasive, quicker recovery after operation, less postoperative complications, which is more suitable for the treatment of femoral popliteal arterial thromboembolism lesions. If the thrombus removal is not satisfactory, the combination of coronary artery aspiration catheter and catheterized directed thrombolysis can be used. Balloon dilation and stent implantation can be considered for obvious lumen stenosis.
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Affiliation(s)
- Xiao-Hu Meng
- Department of Vascular Surgery, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Xu-Pin Xie
- Department of Vascular Surgery, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Yong-Chang Liu
- Department of Vascular Surgery, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Chang-Pin Huang
- Department of General Surgery, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310022, Zhejiang Province, China
| | - Lin-Jun Wang
- Department of Vascular Surgery, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Han-Yi Liu
- Department of Vascular Surgery, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Xin Fang
- Department of Vascular Surgery, The Affiliated Hangzhou Cancer Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
| | - Guo-Hui Zhang
- Department of General Surgery, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310022, Zhejiang Province, China
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Xu J, Yu Q, Zhu G, Zhao Z, Xiao Y, Bao J, Yuan L. Sex-related differences in the effect of rotational thrombectomy for thrombus-containing lower limbs ischemic lesions. Thromb J 2022; 20:78. [PMID: 36527031 PMCID: PMC9758767 DOI: 10.1186/s12959-022-00437-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/04/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND To assess the immediate effect and factors affecting the efficacy of rotational thrombectomy (RT) in patients with thrombus-containing lower-limb ischaemic lesions. METHODS Patients were retrospectively divided into two groups: RT and RT+ CDT (Catheter-directed thrombolysis). The RT group included patients in whom intraoperative thrombus aspiration was successful, while the RT + CDT group included patients in whom intraoperative thrombus aspiration was less effective and remedial CDT treatment was used. The primary outcome was the immediate effect of RT on thrombus-containing lower-limb ischaemic lesions. RESULTS From May 2015 to July 2021, 170 patients (113 men, 57 women; mean age, 74.0 years) with thrombus-containing lower-limb ischaemic lesions were treated in our centre. Of these patients, 113 received RT only, while 57 received RT + CDT. There were no significant intergroup differences in terms of age, disease duration, or comorbidities, but a higher proportion of male patients and higher preoperative plasma D-dimer levels (1.23 vs. 0.84; p = .017) was observed in the RT + CDT group. There were no significant intergroup differences in terms of diagnosis, lesion characteristics, lesion location, or lesion length. Multivariate logistic regression analysis revealed that male sex (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.098-6.410; p = .030) and poor distal runoff (OR, 2.94; 95% CI, 1.439-5.988; p = .003) were associated with higher rates of additional CDT. Male patients also had a significantly longer onset time, more thrombotic occlusions, and a greater frequency of in-stent restenosis. CONCLUSIONS RT alone or with CDT is a feasible primary treatment option for thrombus debulking. Sex significantly influences the effect of RT on thrombus-containing lower-limb ischaemic lesions.
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Affiliation(s)
- Jinyan Xu
- grid.411525.60000 0004 0369 1599Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, 168 Changhai Road, Shanghai, 200433 People’s Republic of China
| | - Qingyuan Yu
- grid.411525.60000 0004 0369 1599Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, 168 Changhai Road, Shanghai, 200433 People’s Republic of China
| | - Guanglang Zhu
- grid.8547.e0000 0001 0125 2443Department of Vascular Surgery, Qingpu Branch of Zhongshan Hospital, Affiliated to Fudan University, Shanghai, 201700 China
| | - Zhiqing Zhao
- grid.411525.60000 0004 0369 1599Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, 168 Changhai Road, Shanghai, 200433 People’s Republic of China
| | - Yu Xiao
- grid.411525.60000 0004 0369 1599Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, 168 Changhai Road, Shanghai, 200433 People’s Republic of China
| | - Junmin Bao
- grid.411525.60000 0004 0369 1599Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, 168 Changhai Road, Shanghai, 200433 People’s Republic of China
| | - Liangxi Yuan
- grid.411525.60000 0004 0369 1599Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, 168 Changhai Road, Shanghai, 200433 People’s Republic of China
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Gupta R, Siada SS, Bronsert M, Al-Musawi MH, Nehler MR, Yi JA. High Rates of Recurrent Revascularization in Acute Limb Ischemia - a National Surgical Quality Improvement Program Study. Ann Vasc Surg 2022; 87:334-342. [PMID: 35817385 DOI: 10.1016/j.avsg.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/17/2022] [Accepted: 06/24/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to review outcomes of acute limb ischemia (ALI) patients following open surgical intervention for ALI. METHODS A previously validated tool was used to identify ALI patients in NSQIP undergoing open surgical revascularization from 2012-2017. Multivariable analysis was performed for the primary outcome of reoperation and secondary outcome of readmission and infection. RESULTS 2,878 ALI patients underwent open revascularization; 35.7% were transfers from another acute care hospital. 13.8% required reoperation and 7.9% required readmission within 30 days. 32% of reoperations were recurrent revascularization, representing 4.4% of all ALI patients. 58.7% of patients were female and either overweight or obese. Younger age (OR 0.991 [0.984-0.999], p=0.02), underweight patients (OR 1.159 [0.667-2.01], p=0.05), pre-operative steroid use (OR 1.61 [1.07-2.41], p=0.02), and perioperative transfusion (OR 2.02 [1.04-3.95], p=0.04) predicted reoperations. CONCLUSIONS This registry series demonstrates all-cause ALI patients are a different population than PAD with different risk factors. Despite being a time-critical condition, ALI has higher interhospital transfer rates than ACS or ruptured aneurysm. Following open revascularization, ALI outcomes are worse than ACS but better than ruptured AAA. These outcomes do not appear related to patient factors in contrast to revascularization for chronic PAD.
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Affiliation(s)
- Ryan Gupta
- Department of Surgery, University of Colorado Anschutz School of Medicine, Aurora, CO
| | - Sammy S Siada
- Division of Vascular Surgery, University of California San Francisco Fresno Hospital, Fresno, CA
| | | | | | - Mark R Nehler
- Division of Vascular Surgery, University of Colorado Anschutz School of Medicine, Aurora, CO
| | - Jeniann A Yi
- Division of Vascular Surgery, University of Colorado Anschutz School of Medicine, Aurora, CO.
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Yang X, Li X, Yin M, Wang R, Ye K, Lu X, Li W, Cheng Y, Qin J. Percutaneous Mechanical Thrombectomy for Acute Limb Ischemia With Aorto-iliac Occlusion. Front Surg 2022; 9:831922. [PMID: 35599798 PMCID: PMC9116458 DOI: 10.3389/fsurg.2022.831922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Xinrui Yang
- Department of Vascular Surgery, School of Medicine, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, Shanghai, China
- Vascular Center of Shanghai JiaoTong University, Shanghai, China
| | - Xiangxiang Li
- Department of Vascular Surgery, People's Hospital of Fuyang, Fuyang, China
| | - Minyi Yin
- Department of Vascular Surgery, School of Medicine, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, Shanghai, China
- Vascular Center of Shanghai JiaoTong University, Shanghai, China
| | - Ruihua Wang
- Department of Vascular Surgery, School of Medicine, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, Shanghai, China
- Vascular Center of Shanghai JiaoTong University, Shanghai, China
| | - Kaichuang Ye
- Department of Vascular Surgery, School of Medicine, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, Shanghai, China
- Vascular Center of Shanghai JiaoTong University, Shanghai, China
| | - Xinwu Lu
- Department of Vascular Surgery, School of Medicine, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, Shanghai, China
- Vascular Center of Shanghai JiaoTong University, Shanghai, China
| | - Weimin Li
- Department of Vascular Surgery, School of Medicine, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, Shanghai, China
- Vascular Center of Shanghai JiaoTong University, Shanghai, China
- *Correspondence: Weimin Li
| | - Yong Cheng
- Department of Vascular Surgery, School of Medicine, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, Shanghai, China
- Vascular Center of Shanghai JiaoTong University, Shanghai, China
- Yong Cheng
| | - Jinbao Qin
- Department of Vascular Surgery, School of Medicine, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, Shanghai, China
- Vascular Center of Shanghai JiaoTong University, Shanghai, China
- Jinbao Qin
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Araujo ST, Moreno DH, Cacione DG. Percutaneous thrombectomy or ultrasound-accelerated thrombolysis for initial management of acute limb ischaemia. Cochrane Database Syst Rev 2022; 1:CD013486. [PMID: 34981833 PMCID: PMC8725191 DOI: 10.1002/14651858.cd013486.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Acute limb ischaemia (ALI), the sudden and significant reduction of blood flow to the limb, is considered a vascular emergency. In the general population, the incidence is estimated as 14 per 100,000. Prognosis depends on the time it takes to diagnose the condition and begin appropriate treatment. Standard initial interventional treatments include conventional open surgery and endovascular interventions such as catheter-directed thrombolysis (CDT). Percutaneous interventions, such as percutaneous thrombectomy (PT, including mechanical thrombectomy or pharmomechanical thrombectomy) and ultrasound-accelerated thrombolysis (USAT), are also performed as alternative endovascular techniques. The proposed advantages of PT and USAT include reduced time to revascularisation and when combined with catheter-directed thrombolysis, a reduction in dose of thrombolytic agents and infusion time. The benefits of PT or USAT versus open surgery or thrombolysis alone are still uncertain. In this review, we compared PT or USAT against standard treatment for ALI, in an attempt to determine if any technique is comparatively safer and more effective. OBJECTIVES To assess the safety and effectiveness of percutaneous thrombectomy or ultrasound-accelerated thrombolysis for the initial management of acute limb ischaemia in adults. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, the World Health Organization (WHO) International Clinical Trials Registry Platform, and ClinicalTrials.gov to 3 March 2021. We searched reference lists of relevant studies and papers. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared PT (any modality, including mechanical thrombectomy (aspiration, rheolysis, rotation) or pharmomechanical thrombectomy) or USAT with open surgery, thrombolysis alone, no treatment, or another PT modality for the treatment of ALI. DATA COLLECTION AND ANALYSIS Two review authors independently selected the studies, assessed risk of bias, extracted data, performed data analysis, and assessed the certainty of evidence according to GRADE. Outcomes of interest were primary patency, amputation rate, major bleeding, clinical success, secondary patency, and adverse effects. MAIN RESULTS We included one RCT in this review. This study had a total of 60 participants and compared USAT with standard treatment (CDT). The study included 32 participants in the CDT group and 28 participants in the USAT group. We found no evidence of a difference between USAT and CDT alone for the following evaluated outcomes: amputation rate (risk ratio (RR) 1.14, 95% confidence interval (CI) 0.17 to 7.59); major bleeding (RR 1.71, 95% CI 0.31 to 9.53); clinical success (RR 1.00, 95% CI 0.94 to 1.07); and adverse effects (RR 5.69, 95% CI 0.28 to 113.72). We rated the certainty of the evidence as very low for these outcomes. We downgraded the certainty of the evidence for amputation rate, major bleeding, clinical success, and adverse effects by two levels due to serious limitations in the design (there was a high risk of bias in critical domains) and by two further levels due to imprecision (a small number of participants and only one study included). The study authors reported 30-day patency, but did not report primary and secondary patency separately. The patency rate in the successfully lysed participants was 71% (15/21) in the USAT group and 82% (22/27) in the CDT group. The study authors did not directly report secondary patency, which is patency after secondary procedures, but they did report on secondary procedures. Secondary procedures were subdivided into embolectomy and bypass grafting. Embolectomy was performed on 14% (4/28) of participants in the USAT group versus 3% (1/32) of participants in the CDT group. Bypass grafting was performed on 4% (1/28) of participants in the USAT group versus 0% in the CDT group. As we did not have access to the specific participant data, it was not possible to assess these outcomes further. We did not identify studies comparing the other planned interventions. AUTHORS' CONCLUSIONS There is insufficient evidence to assess the safety and effectiveness of USAT versus CDT alone for ALI for our evaluated outcomes: amputation rate, major bleeding, clinical success, and adverse effects. Primary and secondary patency were not reported separately. There was no RCT evidence for PT. Limitations of this systematic review derive from the single included study, small sample size, short clinical follow-up period, and high risk of bias in critical domains. For this reason, the applicability of the results is limited. There is a need for high-quality studies to compare PT or USAT against open surgery, thrombolysis alone, no treatment, or other PT modalities for ALI. Future trials should assess outcomes, such as primary patency, amputation rate, major bleeding, clinical success, secondary patency, and adverse effects.
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Affiliation(s)
- Samuel T Araujo
- Division of Vascular and Endovascular Surgery, Department of Surgery, UNIFESP - Escola Paulista de Medicina, São Paulo, Brazil
| | - Daniel H Moreno
- Division of Vascular and Endovascular Surgery, Department of Surgery, UNIFESP - Escola Paulista de Medicina, São Paulo, Brazil
| | - Daniel G Cacione
- Division of Vascular and Endovascular Surgery, Department of Surgery, UNIFESP - Escola Paulista de Medicina, São Paulo, Brazil
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[Application of Rotarex mechanical thrombectomy system in acute lower limb ischemia]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021. [PMID: 34916698 PMCID: PMC8695157 DOI: 10.19723/j.issn.1671-167x.2021.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and safety of Rotarex mechanical thrombectomy system in treating acute lower limb ischemia. METHODS From December 2017 to December 2019, the clinical data of 23 acute lower limb ischemia cases treated with Rotarex mechanical thrombectomy system were retrospectively analyzed. There were 14 males and 9 females from 53- to 84-year-old patients and the mean age was (69.1±9.1) years. Duration of symptoms was 6 hours to 14 days (median time 7 days). In the study, 8 acute thromboembolism cases and 15 acute thrombosis cases were included (In which, there was one thromboangiitis obliterans case and two in-stent restenosis cases). In 5 cases, the lesions were located above the groin; in 16 cases, the lesions were located below the groin, and in the other 2 cases, the lesions were located both above and below the groin. All the cases were treated with Rotarex mechanical thrombectomy system. When residual stenosis was greater than 50%, percutaneous transluminal angioplasty (PTA) was used, and stent was used only when it was necessary. Heparin was used 24 h after the procedure, and after that, antiplatelet agents were used in acute thrombosis cases, and oral anti-coagulants were used in acute thromboembolism cases. Doppler ultrasonography was taken during the follow-up. RESULTS In all the 23 cases, there were 22 successful cases and 1 unsuccessful case, the mean procedure time was (68.2±15.6) min. Percutaneous transluminal angioplasty was used in 18 cases, 7 of which were implanted stents (3 stents were implanted in iliac artery and 4 in superficial femoral artery). There were 3 procedure related complications. The first one was arterial wall injury which resulted in contrast medium extravazation, and in this case, we solved it with prolonged balloon inflation. The second one was distal embolism. We took out the thrombus with guiding catheter. The last one was acute occlusion in a stent, and thrombectomy was applied urgently, and the result was good. Mean hospital stay were (3.6±1.7) days. The ankle brachial index (ABI) increased from 0.25±0.10 to 0.85±0.16 after treatment (t=12.901, P < 0.001). All the patients were followed up for 4.0-28.0 months, and the median time was 12.0 months. One patient stopped antiplatelet agents, which resulted in acute thrombosis 2 months later. Another percutaneous mechanical thrombectomy and PTA were taken. In the failed case, the patient suffered amputation above the knee 3 months later and in another case, the patient died of heart failure 8 months after the procedure. Two target lesion restenosis occurred during the follow-up. Because the patients' symptom was not sever, no procedure was taken. CONCLUSION Percutaneous mechanical thrombectomy using Rotarex catheter is safe and effective in treating acute lower limb ischemia. For one side, it can restore blood flow to the affected limbs quickly, and for the other, it has the characteristics of minimally invasive and good repeatability. So it should be considered that this me-thod can be widely used for acute lower limb ischemia.
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Loffroy R, Falvo N, Galland C, Fréchier L, Ledan F, Midulla M, Chevallier O. 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. Front Cardiovasc Med 2020; 7:557420. [PMID: 33195452 PMCID: PMC7642033 DOI: 10.3389/fcvm.2020.557420] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/24/2020] [Indexed: 01/14/2023] Open
Abstract
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.
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Affiliation(s)
- Romaric Loffroy
- ImViA Laboratory-EA 7535, Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
| | - Nicolas Falvo
- ImViA Laboratory-EA 7535, Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
| | - Christophe Galland
- ImViA Laboratory-EA 7535, Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
| | - Léo Fréchier
- ImViA Laboratory-EA 7535, Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
| | - Frédérik Ledan
- ImViA Laboratory-EA 7535, Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
| | - Marco Midulla
- ImViA Laboratory-EA 7535, Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
| | - Olivier Chevallier
- ImViA Laboratory-EA 7535, Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
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Araujo ST, Moreno DH, Cacione DG. Percutaneous thrombectomy for initial management of acute limb ischaemia. Hippokratia 2019. [DOI: 10.1002/14651858.cd013486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Samuel T Araujo
- UNIFESP - Escola Paulista de Medicina; Division of Vascular and Endovascular Surgery, Department of Surgery; São Paulo Brazil
| | - Daniel H Moreno
- UNIFESP - Escola Paulista de Medicina; Division of Vascular and Endovascular Surgery, Department of Surgery; São Paulo Brazil
| | - Daniel G Cacione
- UNIFESP - Escola Paulista de Medicina; Division of Vascular and Endovascular Surgery, Department of Surgery; São Paulo Brazil
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