Pitfalls of embolic protection

Protrieve Sheath embolic protection during venous thrombectomy: early experience in seventeen patients

PURPOSE

The Protrieve Sheath (Inari Medical; Irvine, CA) is designed for embolic protection during venous thrombectomy. This report describes experience with its use.

MATERIALS AND METHODS

Between November 2022 and December 2023 (13 months), seventeen patients, including nine (52.9%) females and eight (47.1%) males (mean age 58.8 ± 13.3 years, range 37-81 years), underwent deep venous thrombectomy following the Protrieve Sheath placement for embolic protection. Gender, age, presenting symptoms, procedural indications, obstructed venous segments, the Protrieve Sheath access and deployment sites, thrombectomy devices utilized, need for stent reconstruction, technical success, clinical success, adverse events (the Protrieve Sheath maldeployment or clinically significant embolic events), removed thrombi analyses, and mortality were recorded. Technical success was defined as successful deployment of the Protrieve Sheath funnel central to the thrombectomy site. Clinical success was defined as improvement in presenting venous occlusive symptoms without procedure-related venous thromboembolism.

RESULTS

The most common presenting symptom was extremity swelling (n = 15; 88.2%). Nine (52.9%) patients had malignant and eight (47.1%) had benign etiologies of venous obstruction. Obstructed venous segments included the inferior vena cava (IVC) and lower extremity (n = 9; 52.9%), isolated lower extremity (n = 4; 23.5%), isolated IVC (n = 2; 11.8%), thoracic central veins and superior vena cava (n = 1; 5.9%), and isolated thoracic central vein (n = 1; 5.9%). The Protrieve Sheath access sites included the right internal jugular vein (n = 15; 88.2%) for IVC and lower extremity obstructions and the right common femoral vein (n = 2; 11.8%) for thoracic central vein and superior vena cava obstructions. The Protrieve sheath funnel deployment locations included intrahepatic IVC in 13 patients (n = 13; 76.5%), suprarenal IVC in two (n = 2; 11.8%), and inferior cavoatrial junction in two (n = 2; 11.8%). Thrombectomy devices used included the ClotTriever System (Inari Medical) (n = 15; 88.2%), the InThrill Thrombectomy System (Inari Medical) (n = 4; 23.5%), the FlowTriever System (Inari Medical) (n = 2; 11.8%), the Lightning Flash 16 Aspiration System (Penumbra; Salt Lake City, UT) (n = 2; 11.8%), the Cleaner Rotational Thrombectomy System (Argon; Plano, TX) (n = 1; 5.9%), and the RevCore Thrombectomy System (Inari Medical) (n = 1; 5.9%). Ten (58.8%) patients required stent reconstruction following thrombectomy. Technical success was achieved in all patients. Clinical success was achieved in 16 (94.1%) patients. No immediate adverse events, including the Protrieve Sheath maldeployment or clinically significant embolic events, occurred.

CONCLUSION

Use of the Protrieve Sheath during large-bore venous mechanical thrombectomy resulted in favorable technical and clinical outcomes without device-related adverse events or clinically significant thromboembolic events.

Extended Use of Distal Embolic Protection Devices in Treatment of Distal Embolism During Lower Extremity Arterial Endovascular Interventions

There is no consensus on the best treatment modality for acute distal embolization complications during endovascular interventions for peripheral arterial diseases. We report on 3 patients who underwent mechanical embolectomy using a distal embolic protection device (EPD). All patients showed angiographic evidence of distal embolism, which occurred during lower extremity limb salvage endovascular procedures. After embolectomy, all had complete recanalization of the involved vessel on completion angiogram, and none had any device-related complications or adverse outcomes from the embolization. This initial experience suggests that EPD can be used for both the prevention and treatment of intraoperative distal embolization during endovascular intervention of lower extremity arterial disease.

Use of Embolic Protection Devices in Peripheral Interventions

The use of embolic protection devices (EPDs) when treating coronary saphenous vein bypass grafts, performing carotid arterial stenting and treating acute coronary syndromes is well accepted. We will review currently available devices and approaches to reduce distal embolisation, first discussing their uses in carotid interventions and then in vertebral and peripheral vascular interventions.

Clinical significance of embolic events in patients undergoing endovascular femoropopliteal interventions with or without embolic protection devices

OBJECTIVE

The purpose of this study was to evaluate the incidence and clinical significance of embolic events in patients undergoing endovascular femoropopliteal interventions with or without embolic protection devices (EPDs).

METHODS

We reviewed the clinical data of 566 patients treated by 836 endovascular femoropopliteal interventions for lower extremity claudication (46%) or critical limb ischemia (54%) from 2002 to 2012. Outcomes were analyzed in 74 patients/87 interventions performed with EPDs (Spider Rx; Covidien, Plymouth, Minn) and 513 patients/749 interventions performed without EPDs. TransAtlantic Inter-Society Consensus (TASC) II classification, runoff scores, and embolic events were analyzed. End points were morbidity, mortality, reintervention, patency, and major amputation rates.

RESULTS

Both groups had similar demographics, indications, cardiovascular risk factors, and runoff scores, but patients treated with EPDs had significantly (P < .05) longer lesions (109 ± 94 mm vs 85 ± 76 mm) and more often had occlusions (64% vs 30%) and TASC C/D lesions (56% vs 30%). Embolic events occurred in 35 of 836 interventions (4%), including two (2%) performed with EPD and 33 (4%) without EPD (P = .35). Macroscopic debris was noted in 59 (68%) filter baskets. Embolic events were not associated with lesion length, TASC classification, runoff scores, treatment type, or indication but were independently associated with occlusion. Patients who had embolization required more reinterventions (20% vs 3%; P < .001) and major amputations at 30 days (11% vs 3%; P = .02). There was no difference in hospital stay (2.4 ± 4 days vs 1.6 ± 2 days; P = .08), reintervention (2% vs 4%), and major amputation (1% vs 4%) among patients treated with or without EPD, respectively. The two patients who developed embolization with EPDs had no clinical sequela and required no reintervention. Most emboli were successfully treated by catheter aspiration or thrombolysis, but eight patients (24%) treated without EPD required prolonged hospital stay, seven (21%) had multiple reinterventions, one (3%) had unanticipated major amputation, and one (3%) died from hemorrhagic complications of thrombolysis. Median follow-up was 20 months. At 2 years, primary patency and freedom from reintervention was similar for TASC A/B and TASC C/D lesions treated with or without EPDs.

CONCLUSIONS

Rates of embolization are low in patients undergoing endovascular femoropopliteal interventions with (4%) or without (2%) EPD. Embolization is more frequent in patients with occlusions. While emboli in patients with EPD had no clinical sequel, those treated without EPD required multiple reinterventions in 21% or resulted in major amputation or death in 3%. Late outcomes were similar in patients treated with or without EPDs.

Bowel necrosis following endovascular revascularization for chronic mesenteric ischemia: a case report and review of the literature

Background

Endovascular revascularization has recently been established as a less invasive treatment method for chronic mesenteric ischemia. However, intestinal necrosis caused by distal embolization following this procedure has not been emphasized.

Case presentation

The present report describes a 59-year-old man who was treated with endovascular revascularization for chronic mesenteric ischemia. After the procedure, he was diagnosed with intestinal necrosis caused by distal embolization. Despite emergent bowel resection, he died on postoperative day 109.

Conclusion

Although endovascular revascularization for chronic mesenteric ischemia is less invasive and may be suitable for high-risk patients, attention should be paid to avoid embolic complications that can cause intestinal infarction possibly leading to a fatal condition.

Non-invasive embolus trap using histotripsy-an acoustic parameter study

Free-flowing particles in a blood vessel were observed to be attracted, trapped and eroded by a histotripsy bubble cloud. This phenomenon may be used to develop a non-invasive embolus trap (NET) to prevent embolization. This study investigates the effect of acoustic parameters on the trapping ability of the NET generated by a focused 1.063 MHz transducer. The maximum trapping velocity, defined by the maximum mean fluid velocity at which a 3-4 mm particle trapped in a 6 mm diameter vessel phantom, increased linearly with peak negative pressure (P-) and increased as the square root of pulse length and pulse repetition frequency (PRF). At 19.9 MPa P-, 1000 Hz PRF and 10 cycle pulse length, a 3 mm clot-mimicking particle could remain trapped under a background velocity of 9.7 cm/s. Clot fragments treated by NET resulted in debris particles <75 μm. These results will guide the appropriate selection of NET parameters.

Initial experience with a reversal-of-flow cerebral protection device in carotid angioplasty

PURPOSE: To report initial findings with the GORE Flow Reversal System®, with a focus on major/minor adverse events in the 30 first postoperative days. METHODS: The first 24 patients submitted to carotid angioplasty using the GORE system, from June 2010 to May 2012, were retrospectively assessed with regard to indications, anatomic details, technical difficulties, and early clinical outcomes, including major (stroke, death, acute myocardial infarction) and minor (hematoma) adverse events. RESULTS: Systemic hypertension was present in 100% of the patients, diabetes mellitus in 58.3%, and coronary disease in 37.5%. Type II aortic arch was encountered in 62.5% of the patients and atherosclerotic lesion predominantly at the carotid bifurcation affecting the internal and common carotid arteries in 79.2%. Angiographic data revealed contralateral carotid arteries with <50% stenosis in 95.8% of cases and preservation of cerebral blood flow in 95.8%. All procedures but one were technically successful. Mean cerebral flow reversal time was 14.9 minutes, with a statistically significant difference between the first 12 (17.9 minutes) and the last 12 patients treated (11.6 minutes) (p<0.001). Intolerance to flow reversal was observed in 17.4% of the cases. Technical difficulties were experienced in 1 patient (4.2%). Clinical outcomes included 4.2% of stroke and 12.5% of hematomas at arterial puncture sites. CONCLUSION: The system was technically effective. A significant reduction in cerebral flow reversal time was observed, and the rates of early major/minor adverse events were within acceptable limits, suggesting that the device is safe and effective.