Risk factors for acute kidney injury after pharmacomechanical thrombolysis for acute deep vein thrombosis

Outcomes From Mechanical Thrombectomy for Deep Vein Thrombosis: Insights From the PINC AI Healthcare Database

Background

Mechanical thrombectomy (MT) is playing an increasingly important role in treating deep vein thrombosis (DVT). Although degrees of safety and efficacy have been shown in independent studies, there remains a lack of comparative evidence between MT devices. To address this, we aimed to compare demographics, clinical outcomes, and resource metrics of patients receiving MT for DVT with 3 common devices using a real-world database.

Methods

Patients receiving MT for DVT between January 2018 and March 2022 were identified from the PINC AI Healthcare Database and divided into analysis populations for the AngioJet ZelanteDVT (AJ), the ClotTriever system (CT), and the Indigo system (IN). Rates of in-hospital mortality, resource utilization, and 30-day readmission were compared. Regression modeling was performed to adjust for potential covariates and compare outcomes.

Results

A total of 4455 MT encounters were identified and met inclusion criteria (AJ, 1753; CT, 1344; IN, 1358). In-hospital mortality ranged from 1.0% (CT) to 2.9% (IN), with modeling predicting significantly higher odds for the AJ (odds ratio [OR], 3.42) and IN (OR, 3.38) groups. Similarly, higher rates of resource utilization were predicted in the AJ and IN groups when compared with the reference group (CT). Average costs ranged from $29,549 (CT: SD, $30,705) to $42,705 (IN: SD, $41,114). Thirty-day readmissions ranged from 10.0% (AJ) to 14.6% (IN), while modeling predicted significantly greater odds for the IN group (OR, 1.47).

Conclusions

These results suggest that all MT interventions may be unequal in terms of outcomes and resources, with the CT device associated with lower in-hospital mortality and resource burden.

Comparing post-maturation outcomes of arteriovenous grafts and fistulae

BACKGROUND

Though arteriovenous grafts (AVG) mature more reliably than arteriovenous fistulae (AVF) and require fewer maturation procedures (MP) to obtain functional patency, AVG are thought to have worse function after maturation. We explored differences in post-maturation outcomes between the following groups: AVF patients who did (AS-AVF) and did not (unAS-AVF) require assisted maturation and AVG patients who did (AS-AVG) and did not (unAS-AVG) require assisted maturation.

METHODS

Using the US Renal Data System (2012-2017), we retrospectively identified patients who initiated dialysis with a central venous catheter, underwent AVF or AVG placement and achieved successful two-needle cannulation. Primary patency and access abandonment after maturation were compared across groups using competing risks regression methods, generating sub-hazards ratios (sHR).

RESULTS

We identified 42,664 AVF and 12,335 AVG that met inclusion criteria. A larger proportion of AVFs required interventions: 18,408 AVF (43.2%) versus 2594 AVG (21.0%; p < 0.01). Both AS-AVG and AS-AVF patients experienced patency loss at 1 year more frequently compared with unAS-AVG (67.5% & 57.5% vs 55.2% respectively). Patency loss was lowest in unAS-AVF (38.9%). These trends were robust on adjusted analysis (unAS-AVG reference, AS-AVG sHR = 1.44, p < 0.01; AS-AVF sHR = 1.08, p < 0.01, unAS-AVF sHR = 0.67, p < 0.01). AS-AVGs were more likely to be abandoned than unAS-AVGs (11.7% unAS-AVG vs 17.2% AS-AVG). Fistulae, assisted or not, had lower unadjusted rates of 1-year abandonment than grafts (8.9% AS-AVF vs 7.3% unAS-AVF). On adjusted analysis, AVF usage was protective against abandonment (unAS-AVG, reference; AS-AVF sHR = 0.67, p < 0.01; unAS-AVF sHR = 0.59, p < 0.01) while AS-AVG was not (AS-AVG sHR = 1.32, p < 0.01).

CONCLUSIONS

unAS-AVF have the best long-term outcomes. AS-AVF lose primary patency at a higher rate than unAS-AVG. AVGs may be a better choice than AVFs if veins are marginal and likely to require assisted maturation. Further research is needed to identify anatomic and physiologic factors that affect long-term performance and influence conduit choice.

Restoring Access in a Thrombosed Hemodialysis Reliable Outflow Graft Using the InThrill Thrombectomy System

Arteriovenous grafts (AVGs) provide vascular access for hemodialysis in patients with end-stage renal disease (ESRD). However, vascular access thrombosis often occurs, requiring frequent reinterventions to maintain access patency. This report describes the successful use of the InThrill Thrombectomy System (Irvine, CA: Inari Medical) for macerating and removing thrombus from an occluded and heavily thrombosed AVG. A 47-year-old male was sent to our institute for a thrombosed right upper extremity arteriovenous access with a HeRO graft (South Jordan, UT: Merit Medical). The patient underwent interventions for the thrombosis of the same AVG two weeks prior using an Aspirex catheter (Franklin Lakes, NJ: BD Medical), and again two days prior with a Fogarty balloon catheter (Irvine, CA: Edwards Lifesciences). The patient presented with a recurrent completely occluded AVG. Using the InThrill Thrombectomy System and balloon angioplasty, the stenosis was reduced to less than 20%, resulting in brisk flow. The patient tolerated the procedure well without complication and recovered in the holding area with no acute distress. He was discharged the same day on anticoagulation therapy. This study highlights the successful use of the InThrill Thrombectomy System for the treatment of thrombosed AVG in a hemodialysis-dependent ESRD patient. The device was easy to use and efficient. Device and procedure times are unparalleled when compared with thrombolytic-based procedures. The patient's AVG remained patent at a 14-day follow-up.

AngioJet rheolytic thrombectomy for the treatment of deep vein thrombosis in elderly patients: Increase the risk of acute kidney injury?

Objective

The objective of this study was to investigate the risk of acute kidney injury in elderly patients compared with nonelderly patients undergoing AngioJet rheolytic thrombectomy for treatment of acute deep vein thrombosis.

Methods

A retrospective review of all patients who underwent AngioJet rheolytic thrombectomy for the treatment of acute deep vein thrombosis between November 1, 2014 and August 1, 2022 was conducted. Their baseline demographics, comorbidities, clinical characteristics, procedural details, and postoperative course were reviewed.

Results

A total of 105 eligible patients were reviewed; 45 patients were in the elderly group, and 60 were in the nonelderly group. Except for age (p < 0.001), no significant differences regarding demographics were detected (p >0.05). Transient macroscopic hemoglobinuria occurred in all patients during the first 24 h post-AngioJet rheolytic thrombectomy. The overall morbidity of acute kidney injury in the two groups was 11.4%, and the nonelderly group had a similar rate of acute kidney injury (8.3%) to the elderly group (15.6%). None of the 12 patients progressed to dialysis within the postoperative period, and the mean acute kidney injury recovery time of the elderly group was 5.86 ± 1.57 days, which was longer than the 3.60 ± .89 days of the nonelderly group (p = 0.017).

Conclusion

The use of AngioJet rheolytic thrombectomy for the treatment of patients with acute deep vein thrombosis is associated with a potential risk of acute kidney injury, which seems to have a comparable rate in elderly and nonelderly patients. acute kidney injury in the elderly group tends to need a longer recovery time, which requires postoperative vigilance for this population.

Exploration of risk factors for hemoglobinuria and acute kidney injury following iliofemoral venous mechanical thrombectomy

Objective

To evaluate the risk factors for hemoglobinuria and acute kidney injury (AKI) after percutaneous mechanical thrombectomy (MT) with or without catheter-directed thrombolysis (CDT) for iliofemoral deep vein thrombosis (IFDVT).

Methods

Patients with IFDVT who had MT with the AngioJet catheter (group A), MT plus CDT (group B), or CDT alone (group C) from January 2016 to March 2020 were retrospectively evaluated. Hemoglobinuria was monitored throughout the treatment course, and postoperative AKI was assessed by comparing the preoperative (baseline) and postoperative serum creatinine (sCr) levels from the electronic medical records of all patients. AKI was defined as an elevation in the sCr level exceeding 26.5 ​μmol/L within 72 ​h after the operation according to the Kidney Disease Improving Global Outcomes criteria.

Results

A total of 493 consecutive patients with IFDVT were reviewed, of which 382 (mean age, 56 ​± ​11 years; 41% of them were females; 97 in group A, 128 in group B, and 157 in group C) were finally analyzed. Macroscopic hemoglobinuria was evident in 44.89% of the patients of the MT groups (101/225, 39 in group A, and 62 in group B), with no significant difference between the groups (P ​= ​0.219), but not in the patients in group C. None of the patients developed AKI (mean sCr difference -2.76 ​± ​13.80 ​μmol/L, range ​= ​-80.20 to 20.60 ​μmol/L) within 72 ​h after surgery.

Conclusions

Rheolytic MT is an independent risk factor for hemoglobinuria. A proper aspiration strategy, hydration, and alkalization following thrombectomy are particularly favorable for preventing AKI.

Association Between Different DVT Prevention Methods and Outcomes of Septic Shock Caused by Intestinal Perforation in China: A Cross-Sectional Study

Introduction

Septic shock, largely caused by intestinal perforation, is the most common critical illness in intensive care unit (ICU). As an important quality control strategy in ICU, deep vein thrombosis (DVT) prevention is routinely used in the treatment of septic shock. Nevertheless, the effects of DVT prevention on septic shock are not fully revealed. This study was thus designed to investigate the effects of DVT prevention on septic shock caused by intestinal perforation in China.

Methods

A total of 463 hospitals were enrolled in a survey, led by the China National Critical Care Quality Control Center (China NCCQC) from January 1, 2018 to December 31, 2018. The association between DVT prevention, including pharmacological prophylaxis and mechanical prophylaxis, and outcomes, such as prognosis, complications, hospital stays, and hospitalization costs, was determined in the present study.

Main Results

Notably, the increased rates of DVT prevention were not associated with the onset of complications in patients with septic shock caused by intestinal perforation (p > 0.05). In addition, even though increased DVT prevention did not affect hospital stays, it significantly decreased the discharge rates without doctor's order in patients with septic shock caused by intestinal perforation (p < 0.05). Nevertheless, it should be noted that the rates of pharmacological prophylaxis but not mechanical prophylaxis were significantly associated with the costs of septic shock caused by intestinal perforation (p < 0.05). Although increased total rates of DVT prevention and the rates of mechanical prophylaxis did not reduce the mortality in patients with septic shock caused by intestinal perforation, the higher frequent intervention using pharmacological prophylaxis indicated the lower mortality of these patients (p < 0.05).

Conclusions

DVT prevention by any means is a safe therapeutic strategy for treating septic shock caused by intestinal perforation, and pharmacological prophylaxis reduced the mortality of patients with septic shock caused by intestinal perforation.

Acute Deep Vein Thrombosis Involving the Inferior Vena Cava: Interventional Perspectives

Extension of an iliofemoral thrombosis into the inferior vena cava (IVC), or from the IVC descending into the iliofemoral segments, can confer significant morbidity and mortality. Interventional management of acute deep vein thrombosis (DVT) has been controversial, but there is little doubt that certain subpopulations benefit, such as those with symptomatic IVC thrombosis. When considering an intervention, caval involvement introduces technical difficulties due to its larger diameter, high thrombus burden, bilateral limb clot extension and need for dual access. The frequent coexistence of an IVC filter increases the complexity even more. This review summarises the current indications and treatment modalities available for the management of acute DVT involving the vena cava.

Interim Outcomes of Mechanical Thrombectomy for Deep Vein Thrombosis from the All-Comer CLOUT Registry

OBJECTIVES

The multicenter, prospective, single arm CLOUT registry assesses the safety and effectiveness of the ClotTriever System (Inari Medical, Irvine, CA) for the treatment of acute and non-acute lower extremity deep vein thrombosis (DVT) in all-comer patients. Reported here are the outcomes of the first 250 patients.

METHODS

All-comer patients with lower extremity DVT were enrolled, including those with bilateral DVT, those with previously failed DVT treatment, and regardless of symptom duration. The primary effectiveness endpoint is complete, or near-complete (≥75%) thrombus removal determined by independent core laboratory-adjudicated Marder scores. Safety outcomes include serious adverse events (SAEs) through 30 days and clinical outcomes include PTS severity, symptoms, pain, and quality of life through 6 months.

RESULTS

The median age was 62 years and 40% of patients had contraindications to thrombolytics. A range of thrombus chronicity (33% acute, 35% subacute, 32% chronic) was observed. No patients received thrombolytics and 99.6% were treated in a single session. Median thrombectomy time was 28 minutes. The primary effectiveness endpoint was achieved in 86% of limbs. Through 30 days, one device-related SAE occurred. At 6 months, 24% of patients had PTS. Significant and sustained improvements were observed in all clinical outcomes including rVCSS, NPRS, and EQ-5D.

CONCLUSIONS

6-month outcomes from the all-comer CLOUT registry with a range of thrombus chronicity demonstrate favorable effectiveness, safety, and sustained clinical improvements.

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.