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

Percutaneous Aortoiliac Thromboendarterectomy for Acute Limb Ischemia

Aortoiliac occlusive disease (AIOD) can occur from either chronic, progressive atherosclerotic disease, acute on chronic thrombosis or acute arterial embolism, and can all result in limb ischemia. Bypass surgery had long been the gold standard for treatment for AIOD, however, with advances in endovascular techniques, minimally invasive treatment of aortoiliac lesions has become the first line choice of management in many cases. Herein, we describe a case of utilizing the Inari ClotTriever to perform aortoiliac mechanical thrombectomy and the ARTIX thrombectomy system to perform an embolectomy the superficial femoral artery, highlighting new therapies to treat AIOD.

PATIENTS WITH ACUTE LOWER LIMB ISCHEMIA CONTINUE TO HAVE SIGNIFICANT MORBIDITY AND MORTALITY

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, one or no vessel runoff to the foot post-operatively was associated with higher 30-day limb loss. Patients with no run-off vessels post-operatively 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.

CONCLUSION

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.

Percutaneous mechanical thrombectomy using the Rotarex®S device for the treatment of acute lower limb artery embolism: A retrospective single-center, single-arm study

Objective

Acute limb embolism (ALE) is a challenging, highly morbid, and frequently fatal vascular emergency. Percutaneous mechanical thrombectomy (PMT) devices are an alternative treatment to restore perfusion by removing emboli in the limb arterial system. We evaluated the outcomes of treatment of ALE patients using PMT devices in our center.

Methods

A retrospective review of ALE patients treated with Rotarex S (Straub Medical) at a single institution from 2018 to 2022 was performed. The primary outcome was technical success, defined as complete recanalization of the occluded segment with satisfactory outflow and good capillary filling of the distal parts of the foot without any major or obstructing residual emboli or thrombi either in the treated segment or in the outflow tract without the need for additional catheter-directed thrombolysis (CDT) or conversion to open surgery. Embolized segments treated, treatment outcomes, and perioperative complications were reviewed.

Results

A total of 17 ALE patients (29% men, 71% women; mean age, 73 years) underwent PMT procedures. The femoral arteries and popliteal arteries are the most commonly treated vessels, with both present in 59% of the patients. The technical success rate was 100%, but the majority of cases (82%) had concurrent percutaneous transluminal angioplasty or stent grafting, and two patients were treated with urokinase during the operation. There was one thrombotic recurrence that required amputation. There were no 30-day deaths. Complications included extravasation after PMT (two), intraoperative embolization of the outflow tract (one), access site hematoma (one), target artery thrombosis (one), and acute kidney injury (one). There were no severe bleeding complications.

Conclusions

The Rotarex S device has a satisfactory success rate, although complementary use of various adjunctive techniques is frequently required. It seems to be a moderately effective tool for treating ALE to avoid CDT or open surgery. The device appears safe, with low risks of amputation and mortality rates, but special attention should be given to the potential for extravasation and distal embolism.

Sex-related differences in the effect of rotational thrombectomy for thrombus-containing lower limbs ischemic lesions

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.

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.

Key Points: 

Citation Format

[Efficacy of percutaneous mechanical thrombectomy for proximal deep vein thrombosis]

OBJECTIVE

To study the efficacy and safety of percutaneous mechanical thrombectomy and long-term anticoagulation with rivaroxaban for proximal deep vein thrombosis.

MATERIAL AND METHODS

We analyzed the effectiveness of treatment in 60 patients with proximal deep vein thrombosis divided into 2 homogeneous groups by 30 people. Standard therapy was performed in the first group, therapy with percutaneous mechanical thrombectomy was applied in the second group. Patients received rivaroxaban in preoperative, perioperative and 6-month postoperative period. We considered complications of endovascular treatment and anticoagulation. Ultrasound and clinical examination were carried out after 12 months to analyze restoration of deep vein patency and venous outflow disorders. Recovery of vein lumen was assessed as follows: <50% - minimal, 50-99% - partial, 100% - complete.

RESULTS

Recurrent deep vein thrombosis was found in 2 (6.7%) patients of the second group. Hemorrhagic complications following rivaroxaban therapy occurred in 8 (13.3%) patients (equally in both groups). In the first group, complete restoration of vein lumen was found in 16.7% of patients, partial recovery - in 40%, minimal recovery - in 43.3% of patients. In the second group, these values were 16.7%, 60% and 23.3%, respectively. Severe venous outflow impairment developed in 43.3% of patients in the first group and 23.3% of patients in the second group. Moderate impairment occurred in 30% and 20% of patients, mild disorders - in 10% and 40% of patients, respectively.

CONCLUSION

Percutaneous mechanical thrombectomy on the background of long-term anticoagulation with rivoroxaban improves treatment outcomes in patients with proximal deep vein thrombosis.

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.

Percutaneous Mechanical Atherectomy Plus Thrombectomy Using the Rotarex®S Device Followed by a Drug-Coated Balloon for the Treatment of Femoropopliteal Artery In-stent Restenosis: A Prospective Single-Center, Single-Arm Efficacy Trial (PERMIT-ISR Trial)

Background: Studies investigating debulking devices with drug-coated balloons (DCBs) in the treatment of femoropopliteal (FP) artery in-stent restenosis (ISR) are limited. We aimed to evaluate the safety and midterm outcome of percutaneous mechanical atherectomy plus thrombectomy (MATH) using the Rotarex®S (Straub Medical, Wangs, Switzerland) catheter followed by a DCB in the treatment of FP-ISR.

Methods: This study was a single-center single-arm trial. Patients with symptomatic (Rutherford category 2–5) de novo restenosis lesions of FP-ISR were treated with MATH and subsequent DCB. From June 2016 to May 2018, 59 patients with FP-ISR were enrolled. The primary endpoint was target lesion revascularization (TLR) and changes in the Rutherford category of the target limb at 12 months. Secondary endpoints included primary and secondary patency at 12 months, technical success rate, major adverse events, and ankle-brachial index (ABI). Risk factors for TLR were analyzed using Cox proportional hazard model.

Results: The average follow-up time was 33 ± 8 months. The rate of technical success was 88.1% (52/59). Nine patients received bailout stenting. The rate of freedom from TLR was 84.7% (50/59) at 1 year, the Rutherford category changed at 12 months were significantly improved from baseline (p < 0.01). The primary patency rates and the secondary patency at the 12-month follow-ups were 82.5 and 92.5%, respectively. The ABI changed at 12 months were significantly improved from baseline (p < 0.01). Global limb anatomic staging system (GLASS) classification III [hazard ratio (HR) 18.44, 95% CI (1.57–215.99), p = 0.020] and postoperative Rutherford classification ≥4 [HR 8.28, 95% CI (1.85–37.06), p = 0.006] were identified as independent predictors of TLR.

Conclusion: Our preliminary data suggested that MATH using a Rotarex®S catheter combined with DCB angioplasty is a safe, minimally invasive, and effective treatment for FP-ISR with favorable, immediate, and midterm outcomes.

Clinical Trial Registration:http://www.chictr.org.cn, identifier [ChiCTR2000041380].

Mechanical rotational thrombectomy in long femoropopliteal artery and stent occlusion in COVID-19 patient: Case report

Introduction

Coronavirus disease-19 (COVID-19) has been increasingly associated with thromboembolic complications. COVID-19 infection has a thrombogenic potential for stents. Herein, we report a case of stent thrombosis in diabetic obese patient COVID-19 positive where was previously released a Multilayer Flow Modulator stent (MFM) for large popliteal aneurysm.

Case report

A 78-year-old male was referred to our hospital for fever and acute pain in the left leg. At history, the same patient had endovascular procedure for a large symptomatic popliteal aneurysm, treated through release of three MFM. The pulmonary CT scan showed COVID-19 infection with confirm of rhino-laryngeal swab. Duplex ultrasound and CT-angiography showed complete thrombosis of stents. The treatment consisted of mechanical thrombectomy using an 8Fr catheter Rotarex plus release of Vibahn stent-graft.

Discussion

COVID-19 patients can present arterial occlusion. In literature are not reported cases about thrombosis peripheral stent. Minimally invasive approaches in redo-procedure reduce risk of infection. Rotarex device was used in revascularization of acute and subacute iliac and femoropopliteal arteries. The goal is to have a debulking, to avoid an incomplete deployment of stent-graft. In our precedent experience, MFM and stent-graft to treatment of popliteal aneurism were safe. It is important to monitor these patients for early identification of failure and rapprochement. In this case, the COVID-19 infection was determinant in promoting thrombosis.

Conclusions

COVID-19 increases risk of thrombosis stent. In our experience debulking through Rotarex and stenting, were decisive factors for revascularization and limb salvage.