Aspiration Thrombectomy Research Articles

The Short Outcomes and In-Hospital Complications in Patients with STEMI Revascularized with Primary PCI

Context: Primary percutaneous coronary intervention (PCI) is the most effective reperfusion therapy with low complication rate in comparison to thrombolysis. Aims: We aimed to study the short-term outcomes of primary PCI at a large tertiary care center in India. Settings and Design: A prospective cohort of patients with ST-elevation myocardial infarction (STEMI) who underwent primary PCI was enrolled between December 2015 and November 2016. Subjects and Methods: The demographic profile, risk factors, clinical characteristics, inhospital complications, and outcomes at 30 days were assessed. The primary outcome was a composite of death, reinfarction, and repeat revascularization. Acute left ventricular failure (LVF), complete heart block (CHB) or bradyarrhythmia, ventricular tachycardia (VT) or ventricular fibrillation, stroke, and major thrombolysis in myocardial infarction bleeding were the inhospital complications that were considered the secondary outcomes. Results: A total of 237 STEMI patients with primary PCI were enrolled, accounting for 7.5% of all PCI procedures performed during this period. The mean age was 55.4 ± 11.9 years, and 86.5% were male. The mean window period was 5.1 ± 3.18 h, and the mean door-to-balloon time was 58.4 ± 11.5 min. Prior to PCI, the most often administered antiplatelets were clopidogrel in 54.4% of patients and prasugrel in 55.6%. The aspiration thrombectomy was done in 70.8% of patients. Predilatation with balloon was required in 41.8% of patients. Drug-eluting stents were implanted in 98.3% of patients. The primary outcome was found in 3.3% of patients (deaths – 2.9% and reinfarction – 0.4%) and the secondary outcomes were observed in 13%. The common inhospital complication was CHB or bradyarrhythmia in 5.0% followed by acute LVF in 4.6% and then VT in 2.1%. Conclusions: The primary outcome rate is as good as reported in developed Western countries in contemporary treatment practices of STEMI. CHB and acute LVF were the major inhospital complications among patients of STEMI treated with primary PCI.

S2123 Refractory Case of Malignant Eosinophilic Colitis Leading to Ischemic Colitis

Introduction: Eosinophilic colitis (EC) is a rare inflammatory condition involving eosinophilic infiltration of the mucosa in the absence of a secondary cause or peripheral eosinophilia. Clinically, EC presents with non-specific symptoms. We present a case of malignant EC that is refractory to different therapies. Case Description/Methods: A 30 years old male with known EC on azathioprine, pulmonary embolism and superior mesenteric venous (SMV) thrombosis onrivaroxaban, had multiple admissions with abdominal pain and hematochezia secondary to Clostridioides difficile (C. diff). His rivaroxaban and azathioprine were held given his hematochezia and recurrent infections. He presented a month later with worsening symptoms but C. diff was negative. CT abdomen/pelvis showed non-occlusive SMV and portal venous (PV) thrombosis with signs of ischemia of the sigmoid colon (Figure 1b). Patient underwent percutaneous transhepatic SMV/PV aspiration thrombectomy that was complicated by a large right hemothorax, causing hemorrhagic shock. Subsequent flexible sigmoidoscopy showed signs of colonic ischemia (Figure 1a). Colonic biopsies demonstrated active colitis without evidence of chronicity, and 60 eosinophils per high powered field. Patient underwent a subtotal colectomy with end ileostomy with clinical improvement immediately postoperatively. He was discharged on a steroid taper and apixaban. He was started on the interleukin-5 (IL-5) inhibitor benralizumab for his EC. Outpatient follow-up was notable for continued rectal bleeding. Flexible sigmoidoscopy showed diffuse severe erythema, contact bleeding, and friable mucosa throughout the rectal pouch (Figure 1c). Vedolizumab was started in combination with benralizumab, however, on long-term outpatient follow-up, no notable clinical or endoscopic improvements were noted on combination therapy. Multi-disciplinary decision in conjunction with patient resulted in planned proctocolectomy with permanent end ileostomy. Discussion: There are currently no FDA approved management options for EC. The IL-5 inhibitor Benralizumab is FDA approved for treatment of eosinophilic asthma and therefore it was worth a trial in this patient. In a small number of case reports, Vedolizumab has shown some clinical improvement as well as reduction in eosinophilia in EC patients. Due to the rarity of EC diagnosis, data for therapies in EC is severely lacking. To our knowledge, this is the first case of a patient with severe refractory EC that led to the development of ischemic colitis.Figure 1.: (a) shows an endoscopic image of ischemic colitis. (b), the red arrow points at the portal vein thrombosis and (c) shows diffuse severe erythema, contact bleeding, and friable mucosa throughout the rectal pouch.

Right Heart Clot-in-Transit: Endovascular Therapies.

Right heart thrombus is a challenging high mortality disease typically seen in the setting of pulmonary embolism. Traditional treatments have included anticoagulation, thrombolysis, and surgical embolectomy. Advances in recognition and treatment of clot-in-transit have led to the development of endovascular therapies increasingly becoming the preferred method of treatment due to rapid debulking and lower morbidity. Novel endovascular devices are large bore aspiration thrombectomy systems which mitigate the use of concomitant thrombolytics. The article reviews the disease process, relevant literature, and current endovascular devices and strategies for the treatment of right heart thrombus and clot-in-transit.

Pharmacomechanical Aspiration Thrombectomy of Iliofemoral Deep Venous Thrombosis to Salvage the Transplanted Kidney - A Case Report

Ipsilateral acute iliofemoral deep venous thrombosis (DVT) after a renal transplantation, although rare, has a high morbidity, causing complications such as allograft failure, rupture, or death. Treatment modalities are limited due to the risk of bleeding and impaired renal function. We report successful treatment of a case of iliofemoral DVT in a 58-year-old male recipient of a living donor renal transplantation. The immediate postoperative course of the patient was uneventful, and he was discharged on 6th postoperative day (POD) with serum creatinine of 0.8 mg/dl. On POD 26, the patient was admitted with diarrhea, dehydration, and decreased urine output. His serum creatinine rose from 0.8 mg/dl to 2.6 mg/dl and he developed pain and swelling of the right lower extremity. Duplex ultrasonography was suggestive of acute DVT with noncompressible right distal external iliac vein, common femoral, superficial femoral and popliteal veins, absence of color flow from the right femoral vein to the common iliac vein, dilatation of allograft renal vein and an increased renal graft resistive index of 0.97. After inferior vena cava filter insertion, initial treatment with percutaneous balloon angioplasty and catheter-directed thrombolysis could not restore blood flow. Subsequently, percutaneous transluminal pharmacomechanical aspiration was performed with complete removal of the thrombus leading to restored renal allograft vein patency and normalization of allograft function and Duplex findings.

NO CLOT, NO PROBLEM? NOT EXACTLY

NO CLOT, NO PROBLEM? NOT EXACTLY

A patient with pulseless ST elevation myocardial infarction caused by a very late stent thrombosis

Background: Persistent contrast staining is highly associated with stent thrombosis. Case summary: A 75-year-old woman presented with new-onset effort angina. A coronary angiogram revealed a 90% blockage of the distal left main trunk (LMT) and a 99% blockage of the ostial left anterior descending coronary artery (LAD). A 3.0 × 18-mm CYPHER™ the stent had previously been implanted into the dominant proximal circumflex artery (LCx) in 2009 because of unstable angina. The patient developed pulseless ST elevation myocardial infarction after the withdrawal of antiplatelet therapy before a scheduled CABG. The patient recovered with VA-ECMO and PCI using aspiration thrombectomy and urgent CABG. Discussion: This case highlighted that a preoperative patient may develop thrombosis at a previous stent site with peri-stent contrast staining and withdrawal of an antiplatelet regimen in certain settings poses an imminent risk for preoperative deterioration. A bridging strategy using intravenous PY12 inhibitor before CABG should be considered in this setting. The revascularization strategy should be selected based on coronary anatomy, hemodynamic status and baseline risk for CABG. A hybrid revascularization approach should be considered in this patient population.

Mechanical thrombectomy using the Nimbus stent-retriever - initial experiences in a single-center observational study.

The Nimbus stent-retriever (NSR) was developed for mechanical thrombectomy of wall-adherent thrombi in cerebral arteries. It features a novel geometry with a proximal spiral section and a distal barrel section. The new device is designed to retrieve tough clots with a micro-clamping technique. In the first case series reporting on the NSR, we share our initial experience about the first 12 treated cases. In total, 12 patients (5 men, 7 women; mean age 78 years) with occlusion of the internal carotid artery or the middle cerebral artery (M1 or M2 segment) were treated with the NSR, 11 after unsuccessful recanalization attempts with conventional stent-retrievers or aspiration thrombectomy. Retrieving maneuvers with the NSR recovered a thrombus in 7 patients (58%), of which 6 resulted in vessel recanalization mTICI ≥ 2b. Successful recanalization improved the mTICI score by a median of 3 points. In 5 of 7 cases, this required only one thrombectomy maneuver. In 5 cases, no improvement of recanalization could be achieved with the NSR (1-3 attempts). No NSR-related complications occurred in this case series. In our initial experience, the NSR appeared to be a safe and effective second-line stent-retriever after unsuccessful MT with conventional stent-retrievers or aspiration thrombectomy allowing for mTICI ≥ 2b rescue thrombectomy in ab 50% of cases. No NSR associated complications occurred in our case series.

Value of Thrombus Imaging Characteristics as a Guide for First‐Line Endovascular Thrombectomy Device in Patients With Acute Ischemic Stroke

Background It has been suggested that selection of a first‐line endovascular thrombectomy device, that is, contact aspiration (CA) or stent retriever (SR) thrombectomy, could be based on thrombus type. Thrombus composition and mechanical behavior can partially be predicted with thrombus computed tomography (CT) characteristics. We aimed to assess the influence of thrombus CT characteristics on the association between first‐line device and outcomes of endovascular thrombectomy. Methods For patients enrolled in the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) Registry between March 2014 and November 2017, we assessed thrombus density, thrombus length, and presence of hyperdense artery sign on thin‐slice (≤2.5 mm) admission CT. We used regression models to estimate the relationship between first‐line endovascular thrombectomy device (CA versus stent retriever) and first‐pass reperfusion (FPR, expanded Thrombolysis in Cerebral Infarction score 2C‐3 after first attempt), final reperfusion, procedure duration, 24‐hour National Institutes of Health Stroke Scale, and 90‐day modified Rankin scale score and tested for interaction of thrombus characteristics with first‐line device by adding interaction terms. Results Of 703 included patients, 520 (74%) received first‐line stent retriever and 183 (26%) first‐line CA. Overall, the first‐line device was not associated with FPR (adjusted odds ratio [aOR], 1.32 [95% CI, 0.88–1.98]). In patients with thrombus density below the median (<50 Hounsfield units), FPR was more often achieved with CA than with a stent retriever (34% versus 24%, aOR, 1.95 [95% CI, 1.09–3.50]), whereas in patients with thrombus density above the median (≥50 Hounsfield units), first‐line device was not associated with FPR (aOR, 0.90 [95% CI, 0.50–1.62]). The interaction between thrombus density as a continuous variable and first‐line device on outcome was not significant ( P =0.38). There was also no interaction between first‐line device and the other thrombus characteristics for FPR or the other outcomes. Conclusion Our study does not provide evidence that the association between first‐line thrombectomy device and endovascular thrombectomy outcomes depends on thrombus CT characteristics. Based on our results, there are no arguments for thrombectomy device selection based on thrombus CT characteristics. A possible better performance of CA in low‐density, fibrin‐rich clots needs further study.

TCT-587 Radial vs Femoral Access for Continuous Mechanical Aspiration Thrombectomy Before Percutaneous Coronary Intervention for Acute Coronary Syndrome: A Post Hoc Analysis of the CHEETAH Study

TCT-587 Radial vs Femoral Access for Continuous Mechanical Aspiration Thrombectomy Before Percutaneous Coronary Intervention for Acute Coronary Syndrome: A Post Hoc Analysis of the CHEETAH Study

TCT-204 Effect of Baseline TIMI Thrombus Grade on Safety and Performance Outcomes in High Thrombus Burden Acute Coronary Syndrome Patients Treated With Sustained Mechanical Aspiration Thrombectomy Before Percutaneous Coronary Intervention: A Subset Analysis of the CHEETAH Study

TCT-204 Effect of Baseline TIMI Thrombus Grade on Safety and Performance Outcomes in High Thrombus Burden Acute Coronary Syndrome Patients Treated With Sustained Mechanical Aspiration Thrombectomy Before Percutaneous Coronary Intervention: A Subset Analysis of the CHEETAH Study

A comparative study of stent thrombectomy and direct aspiration thrombectomy in the treatment of ischemic stroke caused by acute middle cerebral artery M2 segment occlusion

A comparative study of stent thrombectomy and direct aspiration thrombectomy in the treatment of ischemic stroke caused by acute middle cerebral artery M2 segment occlusion

Aspiration thrombectomy for patients with acute coronary syndromes and culprit lesions located in coronary bypass grafts. Data from the PL-ACS registry.

Aspiration thrombectomy for patients with acute coronary syndromes and culprit lesions located in coronary bypass grafts. Data from the PL-ACS registry.

Cardiac Magnetic Resonance Shows Improved Outcomes in Patients with an ST-Segment Elevation Myocardial Infarction and a High Thrombus Burden Treated with Adjuvant Aspiration Thrombectomy.

There is a discrepancy between epicardial vessel patency and microcirculation perfusion in a third of patients treated with percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). Optimization with aspiration thrombectomy (AT) may reduce distal embolization and microvascular obstruction. The effect of AT in the treatment of STEMI is debatable. The purpose of this study was to use cardiac magnetic resonance (CMR) to determine whether AT influences microvascular obstruction (MVO), infarct size and left ventricular (LV) remodelling in STEMI patients. Sixty STEMI patients with a thrombus-occluded coronary artery were randomized in a 2:1 fashion to receive PCI proceeded by AT (AT + PCI group), or PCI only. MVO, myocardial infarct size and LV remodelling were assessed by CMR during the index hospitalization and 6 months thereafter. The majority of patients had a large thrombus burden (TIMI thrombus grade 5 in over 70% of patients). PCI and AT were effective in all cases. There were no periprocedural strokes. CMR showed that the addition of AT to standard PCI was associated with lesser MVO when indexed to the infarct size and larger infarct size reduction. There were less patients with left ventricle remodelling in the AT + PCI vs. the PCI only group. To conclude, in STEMI patients with a high thrombus burden, AT added to PCI is effective in reducing infarct size, MVO and LV remodelling.

Aspiration versus Stent Retriever Thrombectomy in Posterior Circulation Stroke: A Systematic Review and Meta-Analysis

Introduction: The management of posterior circulation stroke is primarily carried out by endovascular approaches including aspiration or stent retrevier thrombectomy. Existing reviews have attempted to comparatively evaluate their efficacy in terms of morbidity and mortality-related outcomes, however, with several limitations. Therefore, in this review, we attempt to address the gap in the existing literature by evaluating the comparative impact of stent retriever-based and aspiration-based thrombectomy interventions in posterior circulation stroke patients on the following parameters: overall procedure duration, recanalization time, rescue therapy usage, complication risk, and mortality risk. Methods: A systematic search of the academic literature was performed according to PRISMA guidelines across five databases. We conducted a random-effect meta-analysis to evaluate comparative outcomes, including procedural duration, time to recanalization, risk of complications, use of rescue therapy, and risk of mortality in patients with posterior circulation stroke undergoing stent retriever- and aspiration-based thrombectomies. We also performed comparative subgroup analyses to evaluate differences in outcomes between contact and manual aspiration interventions. Results: From 963 studies, we found nine eligible studies containing data on 840 patients. Meta-analysis revealed a large-to-medium size positive effect for stent retriever-based thrombectomy on overall procedure duration and recanalization compared to aspiration-based thrombectomy. Additional analysis revealed higher risk of complications and mortality in posterior circulation stroke patients undergoing stent retriever-based thrombectomy as compared to aspiration-based thrombectomy. We also observed that the use of rescue therapy was elevated in patients undergoing aspiration-based thrombectomy compared to stent retriever-based thrombectomy. Conclusion: This study provides preliminary evidence for improved morbidity and mortality outcomes in posterior circulation stroke patients undergoing aspiration-based thrombectomies as compared to stent retriever-based thrombectomy. The study also provides evidence for improved endovascular outcomes for patients undergoing aspiration-based thrombectomies. The findings from this study can have implications in developing awareness among neurosurgeons for stratifying patients to manage posterior circulation stroke according to the risks associated with aspiration and stent retriever-based thrombectomies.

Impact of aspiration catheter size on clinical outcomes in aspiration thrombectomy

BackgroundDirect aspiration thrombectomy is a well-established method for mechanical thrombectomy in acute ischemic stroke. Yet, the influence of aspiration catheter internal diameter (ID) on aspiration thrombectomy efficacy is incompletely understood.MethodsA...

Catheter-directed interventions for pulmonary embolism.

Pulmonary embolism (PE) is common, life-threatening, and often recurrent among survivors. The clinical manifestations of PE range from incidental detection to sudden death, with approximately one-third of PE deaths occurring suddenly. State-of-the-art management of acute PE relies on early detection, risk stratification based on clinical, imaging, and biomarker criteria, and multidisciplinary decision-making. The primary goal of catheter-directed interventions for acute PE is to interrupt the cycle of right ventricular failure, hypoperfusion, and oxygen supply/demand imbalance by increasing the cross-sectional area of the patent pulmonary vasculature, thereby lowering resistance and alleviating V/Q mismatch. Innovations in percutaneous interventions have led to several approaches described in this review: rheolytic thrombectomy, catheter-directed thrombolysis, and aspiration or mechanical thrombectomy. The central challenge moving forward will be integrating growing clinical trial evidence into multidisciplinary, individualized care pathways meeting the diverse clinical needs of patients presenting with acute PE.

Neurothrombectomy 2022-Extension of indications and technical innovations

For advanced territorial ischemia numerous retrospective and prospective studies have shown a positive effect of mechanical thrombectomy (MT) compared to best medicinal treatment alone. For patients with minor stroke (NIHSS < 6) there is currently alack of evidence for MT. Appropriate study protocols must differentiate between patients with large vessel occlusion with disproportionately mild symptoms and more distal vascular occlusion and therefore correspondingly fewer clinical symptoms. The role of intravenous lysis treatment before MT as bridging lysis also currently retains its general recommendation, as large studies could not show a uniform noninferiority of MT alone. In addition, the use of intra-arterial lysis after successful MT offers a promising approach, which still needs to be evaluated. Novel aspiration catheters and stent-retrievers as well as competing thrombectomy techniques can be compared by the first pass effect, the successful recanalization with only one attempt at thrombectomy. Contact aspiration and stent-retriever thrombectomy under aspiration are equivalent and established thrombectomy procedures. For the latter, several detailed maneuver tactics are described for improvement of thrombectomy success. Also, in retrospective studies the combination with aballoon-guided catheter promises a further improvement of recanalization results. In the case of failure of supra-aortic vessel probing with inguinal access, radial access and direct carotid puncture are alternative access routes. Recent studies on ICA stenting with tandem occlusions showed a benefit of stents without an increased risk for symptomatic intracranial hemorrhage. The retrograde approach, to first treat the intracranial vessel occlusion and then the carotid stenosis, seems to be advantageous.

De novo headache in ischemic stroke patients treated with thrombectomy: a prospective study

Background and aimHeadache attributed to intracranial endovascular procedures is described in the ICHD-3. Our aim was to study the frequency and characteristics of headache specifically related to thrombectomy in patients with ischemic stroke.MethodsProspective evaluation of clinical features of headache after thrombectomy using an ad hoc questionnaire.ResultsOne hundred seventeen patients were included (52.1% females). Most had an anterior circulation artery occlusion (91.5%). 93 (79.5%) received general anaesthesia. 111 (94.9%) required stent retriever, 21 (24.4%) angioplasty and 19 (16.2%) aspiration thrombectomy. 31 (26.5%; 95% CI 18.8–35.5%) had headache related to thrombectomy, and it was associated with a history of primary headache (p = 0.004). No differences about sex, initial NIHSS score, or the type or complexity of the procedure were observed. Headache was usually moderate and oppressive, ipsilateral to the artery occlusion and usually lasted less than 48 hours.ConclusionsAlmost one-third of patients with ischemic stroke who undergo endovascular thrombectomy experience headache in the first 24 hours, occurring more frequently in patients who had a previous history of headaches regardless of the procedure complexity.

Cerebral Venous Sinus Thrombosis Treated with Vacuum Aspiration Thrombectomy without Thrombolysis: A Descriptive and Retrospective Study of 5 Years’ Experience at a Single Center

PurposeCerebral venous sinus thrombosis (CVST) is a rare but life-threatening condition. Mechanical thrombectomy is a treatment option for patients who deteriorate or do not improve despite anticoagulation treatment or those who have a major contraindication to anticoagulation. The purpose of this study was to describe the authors’ 5 years of experience in treating CVST with vacuum aspiration thrombectomy without thrombolysis. Materials and MethodsFor this retrospective study, data were collected from consecutive patients with CVST who received anticoagulation as initial medical treatment and were treated with vacuum aspiration thrombectomy without thrombolysis. Patients were followed up at 3 months and after 1 year. ResultsThe 9 patients included in the study had a median age of 37 years, and 5 were women. All 9 patients had headaches at presentation; 7 had focal neurologic deficits, and 7 had intracranial hypertension. Risk factors for CVST were identified in 8 patients, and poor prognostic factors were identified in 7 patients. In the 9 patients, 24 CVST locations were treated; complete (70.8%) or partial (29.2%) recanalization was achieved in all CVST locations. No procedure-related complications occurred. One patient died of parenchymal hemorrhagic transformation of CVST and vasogenic edema, 6 hours after the procedure. Two patients required neurosurgical intervention. After 1 year (range, 13–30 months), all 8 surviving patients had good functional outcomes (modified Rankin Scale score 0–2). ConclusionsFor appropriately selected patients with CVST, vacuum aspiration thrombectomy without thrombolysis seemed to be an effective therapy.

An Integrated Approach to the Treatment of Pulmonary Embolism: Current State of the Problem

&#x0D; The aim. Treatment of venous thromboembolism remains perhaps the most challenging problem of modern phlebology. The aim of our study was to analyze current data and guidelines on the use of surgical and minimally invasive approaches in the treatment of pulmonary embolism (PE) and to compare these with our own results.&#x0D; Materials and methods. The results of treatment of 168 patients with PE, who underwent inpatient treatment at the clinic from 2009 to 2021, were analyzed. Among them, 162 (96%) patients had deep vein thrombosis, in 6 patients the cause of PE could not be identified. Recurrent PE was observed in 2 patients. PE with a high risk of death was observed in 51 (30.3%) patients, with a medium and low risk of death in 117 patients (69.6%).&#x0D; Systemic thrombolysis was performed in 44 (26%) cases. In 5 (2.9%) cases, vena cava filters were implanted. One (0.6%) patient underwent aspiration thrombectomy of the pulmonary artery using an Aspirex catheter. Two (1.1%) patients underwent pulmonary artery thrombectomy using an artificial circulation device.&#x0D; Results. Significant improvement in patients treated with thrombolytic therapy was observed in 40 (92.8%) cases. After surgical treatment of PE, significant improvement was observed in 100% of cases, 2 patients after PE showed complete de-obstruction of the pulmonary artery. No hemorrhagic complications were observed during the study period. No fatalities were reported. No recurrent PE was observed during the study period.&#x0D; Conclusions. The choice of treatment for PE is determined by the degree of the impact on the pulmonary tract, the stability of the patient’s condition, indicators of dysfunction of the right heart, the period from the onset of the disease, the risk of death.&#x0D; The use of aspiration thrombectomy using an Aspirex catheter (Straub, USA) and pulmonary artery embolectomy in the absence of thrombolytic therapy allows to obtain satisfactory results in patients with PE.