Mechanical Thrombectomy to Treat Intra-Procedural Distal Embolization Caused During Percutaneous Revascularization

Abstract

Purpose Periprocedural acute distal embolization is a complication that occurs during percutaneous revascularization of the femoro-popliteal and below-the-knee arteries. To date, limited research has been done and no standard of treatment has been established. Material and Methods Three cases using mechanical thrombo-aspiration to treat distal embolization complications from limb salvage treatment are reported. Each case was treated using a novel mechanical thrombectomy device, the Penumbra System (Penumbra Inc., Alameda, California), traditionally used during acute ischemic stroke therapy. It involves a trackable catheter connected to a dedicated aspiration pump (Penumbra MAX Pump, Penumbra, Inc.). In addition, the Penumbra Separator wire technology was available to help prevent the catheter tip from clogging for the duration of the thrombectomy procedure. Thromboemboli and debris extracted from the body was collected from the suction, and could be drained for visual confirmation and further clot analyses at the end of the procedure. Results Of the 3 cases, pre-procedural angiography showed indications of proximal steno-obstructions in the tibial artery in 2 and obstruction of the proximal third of the superficial femoro-popliteal artery in the other. After percutaneous transluminal angioplasty with a balloon catheter was performed, post angiography imaging revealed distal embolization caused by the angioplasty procedure. Mechanical thromboaspiration was used with Penumbra System (3MAX was used in 2 cases, and 4MAX in 1 case) connected to the aspiration pump. Final angiographic imaging showed complete recanalization and occluded arteries were restored to normal flow. A healing ulcer was observed at the 4- to 6-month follow-up, and all 3 patients were asymptomatic at the 12-month follow-up. Conclusions Our initial experience using the Penumbra System in the peripheral vasculature demonstrates a rapid and effective approach to address intra-procedural distal embolization and avoid possible grave clinical sequelae. Follow up in a larger cohort is warranted with this system.