Catheter-directed Thrombectomy Research Articles

Safety and efficacy of catheter-directed thrombectomy without thrombolysis in acute pulmonary embolism: A systematic review and meta-analysis

BackgroundThis meta-analysis aims to investigate the safety and efficacy of catheter-directed thrombectomy (CDT) without using adjunct thrombolysis as reperfusion therapy to manage intermediate and high-risk pulmonary embolism (PE). MethodsA literature search of Ovid MEDLINE, Embase, CiNAHL, Cochrane Library, and Web of Science was conducted from inception to January 2024. Eligible studies reported more than 10 patients treated for acute PE with catheter-directed thrombectomy only, who were over 18 years of age. Primary endpoints were major bleeding, in-hospital mortality, and hemodynamic changes. ResultsEighteen studies (n = 803) were included for quantitative analysis. The pooled estimate of incidences of in-hospital mortality and major bleeding was 1.8 % (95 % CI 0.009, 0.027) and 2.1 % (95 % CI 0.011, 0.031) respectively. A pooled estimate reported a post-procedural increase in oxygen saturation and systolic blood pressure by 8.96 % (95 % CI: 3.54, 14.38) and 15.02 mmHg (95 % CI 6.35, 23.69) respectively. Post-procedural mean pulmonary artery pressure, right ventricle/left ventricle (RV/LV) ratio, and Miller score were reduced by 10.30 mmHg (95 % CI -14.94, −5.66), 0.29 (95 % CI -0.50, −0.08) and 8.09 (95 % CI -10.70, −5.47) respectively. ConclusionCDT without adjunctive thrombolysis may lead to improvements in hemodynamic outcomes and appears to exhibit favorable safety profiles. This meta-analysis provides a rationale for further research comparing CDT alone against using adjunct thrombolysis to determine optimal management strategies for intermediate to high-risk acute PE.

Admitting clinical department effect on outcomes for acute pulmonary embolism

Abstract Background Pulmonary embolism (PE) is the third most fatal cardiovascular disease and its management is often complex requiring multidisciplinary involvement. Aims To investigate whether there are differences between patient populations with acute PE and associated outcomes admitted to different clinical departments based on a German nationwide inpatient population. Methods We used the German nationwide inpatient sample to identify hospitalizations of patients with acute PE within the period 2005-2020. Patients were classified according to the department were they spent the longest duration of hospitalization (cardiology, general internal medicine, or pulmonology/critical care medicine). Patients admitted and treated to other departments were excluded from the analysis. Temporal trends of hospitalizations, as well as the impact of admitting departments on case-fatality were investigated with the cardiology department used as reference and after multivariable adjustment for age, sex, and comorbidities (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005-2020, own calculations). Results During the investigated period a total of 759,115 patients with acute PE were identified; of those 117,501 (15.5%) were admitted to cardiology, 37,726 (5.0%) were admitted to pulmonology/critical care, while the majority of 603,888 (79.5%) were admitted to internal medicine (Table 1). A trend towards increasing number of patients admitted to cardiology in recent years was observed as opposed to being admitted to internal medicine. The number of patients admitted to pulmonology/critical care appeared stable (Figure 1A). Patients admitted to cardiology were more likely to be younger (Figure 1B) and had less risk factors for acute PE, such as cancer and recent surgery. The PE severity indices were higher in patients admitted to cardiology with a higher prevalence of tachycardia, syncope, signs of right ventricular dysfunction and shock (Table 1). There was an overall trend towards decrease in systemic thrombolysis and increase in catheter-directed thrombolysis independent of the admitting department. Catheter-directed thrombectomy has increased when patients were admitted to cardiology and internal medicine, but not when patients were admitted to pulmonology/critical care. Trends for in-hospital mortality were decreasing linearly over time independent of the admitting clinical service. In the multivariable adjustment, admission to cardiology was associated with significantly reduced rates of in-hospital mortality (OR 0.73, 95% CI 0.71-0.74). Conclusion In this nationwide analysis, the majority of patients with PE were hospitalized in an internal medicine ward, while notably, cardiology admissions demonstrated unique patient characteristics compared to other departments and were associated with decreased in-hospital mortality, suggesting specialized care's potential benefits in PE management.Table 1Figure 1

Cellular and enzymatic features of thrombi in humans are vascular bed dependent

AbstractMechanisms behind vascular remodeling following thrombosis are unclear. Although acute arterial thrombosis in the cerebrovascular circulation has devastating consequences and requires immediate attention, the management of venous thromboembolism (VTE) varies significantly. Our goal was to determine the molecular signatures and cellular content of thrombus extracted using a catheter to gain insight into vascular remodeling. Twenty-five patients underwent catheter-directed thrombectomy (CDT); 13 for cerebrovascular accident (CVA), 8 for pulmonary embolism, and 4 for deep vein thrombosis. Protein and RNA were extracted from thrombi to enable immunoblotting, RNA sequencing, and quantification of gene expression. The time from symptom onset to thrombus extraction was 7.7 ± 1.9 hours for CVA and 109 ± 55 hours for VTE. Protein concentration, white blood cell content (monocytes), and red blood cell content were greater in venous thrombus than in arterial thrombus, whereas the platelet content was similar. Both venous and arterial thrombi contained several zinc endopeptidases belonging to the matrix metalloproteinase (MMP) family. MMP9 activity in venous thrombus was greater than arterial thrombus (61 ± 9 ng/mL per μg protein vs 25 ± 6 ng/mL per μg protein; P = .005). Arterial and venous thrombi displayed surprisingly different phenotypes, with biologically active enzymes promoting blood vessel remodeling and enzymatic activity proportional to thrombus age extracted from the veins. These mechanistic data may support the role of early CDT in venous circulation to avoid irreversible vascular remodeling.

Revisiting the Obesity Paradox: Insights from Pulmonary Embolism Patient Outcomes

Background: Obesity is an epidemic in the US and has been associated with increased incidence and severity of cardiovascular disease and increased risk for pulmonary embolism (PE). However, the evidence of its effect on outcomes in PE patients remains equivocal. We aimed to investigate the impact of obesity on adverse in-hospital outcomes in PE. Methods: This study conducted a comprehensive analysis of the National Inpatient Sample (NIS) database, focusing on adult patients (aged ≥18 years) with a discharge diagnosis of PE (ICD-10 code: I26) from 2016 to 2020. We specifically identified obese patients using the Elixhauser comorbidity measure within NIS and compared them to non-obese patients in terms of adverse in-hospital outcomes. Results: Between 2016 and 2020, there were 1,940,294 discharges for PE, with 436,505 patients (22%) identified as obese. A rising trend of obesity among PE patients was observed, increasing from 21.5% in 2016 to 24.3% in 2020. Obese patients, when compared to their non-obese counterparts, were more female (57.4% vs 49.1%, p<0.001), younger (mean age 58.4 ± 15.1 years vs 64.0 ± 17.1 years, p<0.001), and African American (21.2% vs 17.5%, p<0.001). They also had higher rates of comorbid conditions like CHF (25.1% vs 21.2%, p<0.001), hypertension (70.6% vs 58.2%, p<0.001), diabetes (37.2% vs 21.5%, p<0.001), and renal failure (16.2% vs 14.7%, p<0.001). Obese patients were more likely to receive systemic thrombolytics (3.80% vs. 2.31%, p<0.001), undergo surgical thrombectomy or embolectomy (0.24% vs. 0.16%, p<0.001), and receive catheter-directed thrombectomy or thrombolysis (3.04% vs. 1.37%, p<0.001). Paradoxically, despite these comorbidities and complications, obese patients demonstrated lower mortality rates (4.58% vs 7.60%, p<0.001), mechanical intubation (7.71% vs 8.90%, p<0.001), and shock requiring pressor support (1.73% vs 2.14%, p<0.001). After adjusting for demographic factors, all comorbidities, and reperfusion therapies, the analysis consistently showed a reduced adjusted odds ratio for in-hospital mortality among obese patients (OR 0.63, 95% CI 0.61-0.65, p<0.001). Conclusions: Analyzing nearly two million inpatient cases of PE, our study revealed an intriguing association between obesity and reduced in-hospital mortality rates in PE patients. Notably, despite a higher prevalence of comorbidities and more frequent need for reperfusion interventions, obese patients exhibited lower mortality rates and fewer complications, such as the need for mechanical intubation and shock. This survival advantage in obese individuals persisted even after adjusting for potential confounders. These findings align with a similar study conducted on the German nationwide inpatient database and reflect the broader concept of the ‘obesity paradox,’ previously observed in cardiovascular diseases and chronic obstructive pulmonary diseases. However, whether these results indicate a true protective effect of obesity, a ‘lean paradox,’ or are due to unidentified confounders remains a subject for further investigation.

Percutaneous pulmonary thrombectomy with aspiration catheters in patients with high-risk pulmonary embolism and absolute contraindication to systemic thrombolysis

BackgroundHigh-risk Pulmonary Embolism (PE) mortality remains very high. Systemic thrombolysis is effective but carries significant complications and contraindications related to the hemorrhagic risk. Percutaneous thrombectomy using aspiration catheters may be an alternative in patients with a high bleeding risk. ObjectiveThis study aimed to evaluate the results of catheter-directed thrombectomy using aspiration dedicated catheters in patients with high-risk PE and absolute contraindication to systemic thrombolysis, with specific focus on procedural success, safety, and in-hospital outcomes. MethodsA prospective study enrolled all consecutive patients diagnosed with high-risk pulmonary embolism and absolute contraindication to systemic thrombolysis, who underwent percutaneous pulmonary thrombectomy using dedicated aspiration catheters. The study documented the effectiveness and complications of the procedure, as well as patient outcomes at discharge and during the follow-up period. ResultsThirteen patients underwent percutaneous pulmonary thrombectomy using aspiration dedicated catheters. The procedure was successful for all patients, resulting in hemodynamic and respiratory improvement within the first 24 h. No deaths attributable to cardiovascular or respiratory causes occurred during admission or follow-up. Furthermore, no serious adverse events or complications were reported during the procedure or hospitalization. ConclusionsPercutaneous pulmonary thrombectomy with dedicated aspiration catheters in patients with high-risk pulmonary embolism and contraindications to systemic thrombolysis was associated with excellent clinical results and low rate of complications.

Emergency Ultrasound Unveils Intermediate-High Risk Saddle Pulmonary Embolism with Extensive Bilateral Clot Burden, Masquerading as Micturition Syncope: A Case Report

BackgroundIsolated syncope as the manifestation of pulmonary embolism (PE) is a rare and diagnostically challenging presentation that often leads to delayed or missed diagnosis, increasing morbidity and mortality. In spite of emphasizing cardiovascular etiologies of syncope, current guidelines offer essentially no guidance in establishing a diagnostic workup for PE in these patients. By performing bedside echocardiography, emergency physicians can accurately identify concerning features suggestive of PE in patients with syncope. Case ReportA 78-year-old man, receiving ertapenem via a peripherally inserted central catheter for treatment of extended spectrum β-lactamase urinary tract infection, presented to the emergency department for isolated syncope with collapse while urinating. Arriving asymptomatic with normal vital signs and a benign physical examination, a presumptive diagnosis of micturition syncope was made. However, subtle vital sign changes on reassessment prompted performance of a point-of-care echocardiogram, which revealed signs of right heart strain. A computed tomography angiogram confirmed a saddle PE with extensive bilateral clot burden. Catheter-directed thrombectomy was performed via interventional radiology, with successful removal of pulmonary emboli. Why Should an Emergency Physician Be Aware of This?Pulmonary embolism presenting as isolated syncope represents a daunting diagnostic dilemma, as emergency physicians may not consider it, or anchor on more benign etiologies of syncope. Although lacking sufficient sensitivity to rule out PE, point-of-care echocardiography to evaluate for signs of right heart strain can quickly and effectively point toward the diagnosis, while also assessing for other emergent cardiovascular causes of syncope. Given the lack of evidence-based guidance concerning PE presenting as syncope, bedside echocardiography should be highly considered as a part of the emergency physician's diagnostic workup, especially in patients with abnormal vital signs.

Catheter-Directed Thrombectomy in Acute Renal Vein Thrombosis

Catheter-Directed Thrombectomy in Acute Renal Vein Thrombosis

TCT-556 Catheter-Directed Thrombectomy in Patients With Pulmonary Embolism and Signs of Chronic Thromboembolic Pulmonary Hypertension

TCT-556 Catheter-Directed Thrombectomy in Patients With Pulmonary Embolism and Signs of Chronic Thromboembolic Pulmonary Hypertension

Pulmonary Reperfusion Injury After Catheter-Directed Thrombectomy for Acute Pulmonary Embolism

An 82-year-old man had catheter-directed thrombectomy for intermediate-high–risk pulmonary embolism. Shortly after the procedure, the patient developed new alveolar and interstitial infiltrates found on chest computed tomography (CT) as well as life-threatening hemoptysis, likely related to pulmonary reperfusion injury after thrombus removal. Pulmonary reperfusion injury after minimally invasive thrombectomy in acute pulmonary embolism is a rare and life-threatening complication and should be considered in the differential diagnosis of acute pulmonary hemorrhage syndromes.

Salvage of venoarterial extracorporeal membrane oxygenation following prolonged cardiopulmonary resuscitation and failure of catheter-directed thrombectomy for massive pulmonary embolism in a young patient.

Salvage of venoarterial extracorporeal membrane oxygenation following prolonged cardiopulmonary resuscitation and failure of catheter-directed thrombectomy for massive pulmonary embolism in a young patient.

CATHETER-DIRECTED THROMBECTOMY OF A SADDLE PULMONARY EMBOLUS

CATHETER-DIRECTED THROMBECTOMY OF A SADDLE PULMONARY EMBOLUS

Combined catheter-directed thrombectomy and fibrinolysis: early clinical experience.

Combined catheter-directed thrombectomy and fibrinolysis: early clinical experience.

Catheter-Directed Thrombectomy: An Alternative in Massive Pulmonary Embolism

Massive pulmonary embolism (PE) is a life-threatening condition. The mainstay treatment is thrombolysis. Catheter-directed thrombectomy involves a group of new techniques that appear to have relatively low complications and mortality. These techniques have so far been studied mostly in submassive PE. We present a patient with massive PE that was successfully treated with catheter-directed thrombectomy.

National guidelines on the management of venous thromboembolism: Joint guideline of the Turkish Society of Cardiovascular Surgery, National Society of Vascular and Endovascular Surgery, and Phlebology Society.

These evidence-based guidelines from the Turkish Society of Cardiovascular Surgery, National Society of Vascular and Endovascular Surgery, and Phlebology Society intend to support clinicians in best decisions regarding the treatment of venous thromboembolism (VTE). The Editor was selected by the three national societies and was tasked with the recruitment of the recognized panel. All financial support was solely derived from the sponsoring societies without the direct involvement of industry or other external stakeholders. The panel prioritized clinical questions and outcomes according to their importance for clinicians in terms of VTE. The panel agreed on 42 recommendations under 15 headings for the diagnosis, initial management, secondary prevention of VTE, and treatment of recurrent VTE events. Important recommendations included the use of ultrasonography, preference for home treatment over hospital treatment for uncomplicated VTE, preference for direct oral anticoagulants (DOACs) over vitamin K antagonists for primary treatment of cancer and non-cancer-related VTE, extended or indefinite anticoagulation with DOACs in selected high-risk patients. Early catheter-directed thrombectomy was recommended in only young symptomatic patients with a diagnosis of fresh iliofemoral deep vein thrombosis.

THIRD TIME'S A CHARM: TREATING PULMONARY EMBOLISM WITH MECHANICAL THROMBECTOMY AFTER TWO FAILED ATTEMPTS WITH THROMBOLYTIC THERAPY

TOPIC: Procedures TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary embolism (PE) can be a life-threatening condition. Massive PE, characterized by hemodynamic instability with signs of shock, comprises 4.5%-10% of all PE cases and has over 50% mortality rate. When medical therapy fails, aspiration thrombectomy is a treatment option for acute massive or submassive PE in patients with hemodynamic compromise or right ventricular (RV) dysfunction (Dopazo et al, 2018). CASE PRESENTATION: A 61-year-old male presented after an episode of syncope, chest pain, and dyspnea. Due to profound hypoxia, he was intubated. ECG as seen in figure 1 was changed from prior. Troponin was 0.80. In the ED, he was placed on norepinephrine and epinephrine due to hypotension. Bedside echocardiogram (ECHO) showed enlarged RV with severely reduced RV systolic function, hypokinetic RV free wall, and apex. The patient subsequently developed pulseless electrical activity (PEA) arrest. Two cycles of CPR were performed to achieve the return of spontaneous circulation. Due to the possibility of PE, weight-based tPA was administered. He had PEA arrest a second time and CPR was done for 9 minutes. A second dose of weight-based tPA was given after which his hemodynamics transiently improved. Epinephrine drip was discontinued, but norepinephrine drip was continued. He was transferred to ICU for monitoring and was placed on a heparin drip. Over the next 12 hours, despite multiple tPA doses, he progressively decompensated with systolic blood pressure to 40mmHg while on norepinephrine. Vasopressin drip was initiated. Lactic acidosis increased from 3.8 to 6.6 mmol/L, creatinine worsened from 1.6 to 4.0 mg/dL, and Hb 12.2 to 8.5 g/dL. CTA for PE confirmed saddle pulmonary embolism with evidence of RV strain with RV/LV ratio 1.1. He was taken emergently for cardiac catheterization on multiple vasopressors. A bilateral pulmonary artery thrombectomy with a T24 Inari catheter was done successfully, with subsequent improvement in hemodynamics. ECHO after the procedure showed improved RV function and RV size reduction. Within 24 hours of the thrombectomy, vasopressors were titrated off and the patient remained hemodynamically stable. DISCUSSION: Though systemic thrombolytic therapy is typically indicated for hemodynamically unstable patients with suspected pulmonary emboli, it was not effective in our patient, despite multiple doses. Catheter-directed therapies for PE can remove obstructive emboli directly, allowing for rapid patient improvement as seen in our case. Furthermore, though it is an invasive strategy, catheter-directed thrombectomy has the potential to offer both short- and long-term benefits over systemic thrombolysis including early recovery, reduced risk of bleeding, pulmonary hypertension, and reversal of RV failure. CONCLUSIONS: Catheter-directed techniques should be considered on a case-by-case basis, especially in patients who do not improve with thrombolysis. REFERENCE #1: 1.Ciampi-Dopazo, Juan José et al. "Aspiration Thrombectomy for Treatment of Acute Massive and Submassive Pulmonary Embolism: Initial Single-Center Prospective Experience.” Journal of vascular and interventional radiology : JVIR vol. 29,1 (2018): 101-106. doi:10.1016/j.jvir.2017.08.010 REFERENCE #2: 2.Tu, Thomas et al. "A Prospective, Single-Arm, Multicenter Trial of Catheter-Directed Mechanical Thrombectomy for Intermediate-Risk Acute Pulmonary Embolism: The FLARE Study.” JACC. Cardiovascular interventions vol. 12,9 (2019): 859-869. doi:10.1016/j.jcin.2018.12.022 DISCLOSURES: No relevant relationships by Mukul Bhattarai, source=Web Response No relevant relationships by radhika deshpande, source=Web Response no disclosure on file for Abdul Hafiz; No relevant relationships by Cameron Koester, source=Web Response No relevant relationships by Abhishek Kalidas Kulkarni, source=Web Response no disclosure on file for Mohsin Salih; No relevant relationships by Omar Siddiqui, source=Web Response

CATASTROPHIC PULMONARY EMBOLISM SUCCESSFULLY TREATED WITH EXTRACORPOREAL MEMBRANE OXYGENATION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) is increasingly recognized as a modality for cardiopulmonary support in high-risk pulmonary embolism (PE). We report a successful application of VA ECMO to support a patient following cardiac arrest secondary to massive saddle PE. CASE PRESENTATION: A 35 year old woman was admitted with new cranial nerve palsies, concerning for neurosarcoidosis versus lymphoma. On hospital day (HD) 11 she became dyspneic and desaturated to 88% on room air; other vitals remained stable. CT chest revealed bilateral pulmonary artery occlusion with right heart strain. NT-proBNP was 3086 pg/mL (ref <125). Multidisciplinary Pulmonary Embolism Response Team (PERT) stratified her as "intermediate-high risk" PE, and recommended therapeutic heparin infusion, with resultant clinical improvement. On HD16 she developed acute chest pain with new tachycardia (HR 130), hypotension (BP 87/65) and increased oxygen requirements. S1Q3T3 pattern was noted on EKG. PE Severity Index (PESI) was 125 (Class IV), and PERT elected for urgent catheter-directed thrombectomy. Prior to procedure she suffered a cardiac arrest, and received ACLS plus systemic thrombolytics, with return of spontaneous circulation after 20 minutes. Post-arrest suction thrombectomy removed large clot burden, but with persistent hypotension despite inhaled nitric oxide, vasopressor and inotropic support and severe right ventricle (RV) systolic dysfunction on echocardiogram, she was peripherally cannulated for VA-ECMO. Her ECMO course was complicated by renal failure requiring renal replacement therapy and hemoperitoneum requiring blood transfusion. Vasopressors were weaned off on ECMO day 4, and she was decannulated on ECMO day 6. She was discharged on HD42, neurologically intact and with recovered cardiac and renal function. DISCUSSION: High-risk PE, defined by acute PE with hemodynamic instability, shock, or cardiac arrest, is associated with high mortality. VA ECMO allows for maintenance of organ perfusion and oxygenation by mechanically bypassing and decompressing the failing RV and pulmonary circulation, offering hemodynamic and respiratory support to allow for reperfusion strategies or spontaneous thrombolysis on heparin. ECMO is increasingly available, with mobile teams allowing for rapid deployment. The literature on ECMO as a rescue therapy for catastrophic PE is limited to small case series, and recent meta analyses were unable to draw definitive conclusions (1, 2). 2019 European guidelines suggest that mechanical cardiopulmonary support may be helpful for high-risk PE with circulatory collapse (3). CONCLUSIONS: This case adds to reports of successful use of VA-ECMO for high-risk PE. Early ECMO consultation and timely appropriate use may prevent sudden cardiac death. Further research is needed to determine what role ECMO may play as an early intervention rather than a salvage procedure. REFERENCE #1: Pozzi, Matteo, et al. "Efficacy and safety of extracorporeal membrane oxygenation for high-risk pulmonary embolism: A systematic review and meta-analysis." Vascular Medicine 25.5 (2020): 460-467. REFERENCE #2: Baldetti, Luca, et al. "Use of extracorporeal membrane oxygenation in high-risk acute pulmonary embolism." Artificial Organs (2020). REFERENCE #3: Konstantinides, Stavros V., et al. "2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC)." European heart journal 41.4 (2020): 543-603. DISCLOSURES: no disclosure on file for Stephanie Nonas; No relevant relationships by Jonathan Taylor, source=Web Response

Successful Use of Apixaban for Paget-Schroetter Syndrome in a Pediatric Patient.

Paget-Schroetter syndrome (PSS) is a rare syndrome that typically develops in young, healthy males subjected to repetitive overhead motions resulting in compression and thrombosis of the subclavian vein. This "effort thrombosis" typically occurs acutely in patients with specific anatomic variations within the thoracic outlet and is treated by a combination of surgical and pharmacologic interventions. There is a paucity of literature regarding this syndrome, particularly surrounding pharmacotherapy, and in the treatment of pediatric patients. This case report documents the pharmacologic treatment of a 17-year-old, male, baseball player with confirmed PSS. Apixaban was selected as the anticoagulant therapy of choice following the determination of its safety and anticipated efficacy for this pediatric patient. Upon admission, anticoagulation was initiated with intravenous heparin and transitioned to warfarin for 1 dose. On day 2, the patient was discharged with apixaban 10 mg twice daily for 7 days, followed by 5 mg twice daily. One week later, he underwent catheter-directed thrombectomy, followed by thoracic outlet decompression with resection of the first rib. Apixaban therapy was continued for 10 weeks after the procedure to diminish the risk of any further thrombotic events. This pediatric patient with PSS was successfully treated with apixaban in conjunction with surgical management. Treatment with apixaban resulted in continued resolution of thrombus after follow-up, with no complications reported thereafter. Further research is needed to definitively determine the safety and efficacy of apixaban for the use of pediatric anticoagulation, particularly in upper extremity deep vein thrombosis.

Factors associated with the development of post-thrombotic syndrome in patients with iliofemoral deep venous thrombosis who underwent catheter-directed thrombolysis.

To identify predictors of post-thrombotic syndrome in patients with iliofemoral deep venous thrombosis who underwent catheter-directed thrombolysis. Fifty-two consecutive patients who underwent catheter-directed thrombolysis were included in this retrospective study. In addition to catheter-directed thrombolysis, aspiration thrombectomy or stent placement was performed if needed. At six months, duplex ultrasound was performed to assess iliofemoral patency and deep venous reflux. Post-thrombotic syndrome was assessed using the clinical, etiologic, anatomic, and pathophysiologic classification (post-thrombotic syndrome present ≥3 on a scale from 0 to 6). Univariate analysis and multivariate logistic regression were used to identify predictors of post-thrombotic syndrome. Median follow-up was 52 months and post-thrombotic syndrome developed in nine patients (17.3%). In univariate analysis, stent placement (odds ratio 0.16, p = 0.022) was negatively associated with post-thrombotic syndrome, whereas iliofemoral venous obstruction with reflux at six months (OR 6.08, p = 0.037) was positively associated with post-thrombotic syndrome. Multivariate analysis indicated that stent placement was associated with reduced risk of post-thrombotic syndrome (OR 0.17, p = 0.043), and iliofemoral obstruction with reflux was associated with increased risk (OR 6.67, p = 0.046). Stent placement and iliofemoral venous obstruction with reflux, respectively, were important protective and risk factors for post-thrombotic syndrome in patients who underwent catheter-directed thrombolysis.

Successful use of hyperbaric oxygen therapy for limb salvage of acute limb ischemia as a complication of acute carbon monoxide poisoning

Acute limb ischemia (ALI) as a complication of acute carbon monoxide (CO) poisoning is rare. Several reports have utilized hyperbaric oxygen therapy (HBO2) as an adjunctive therapy for peripheral arterial diseases. However, no study has yet described the use of HBO2 for ALI precipitated by CO poisoning. Herein we report successful limb salvage achieved with adjunctive HBO2 and conventional therapies in a patient with CO-induced ALI. A 69-year-old man was admitted with acute CO poisoning; ALI of both lower extremities occurred on hospitalization day 3. Pre-existing risk factors for ALI other than CO were not definite. After conventional treatments including catheter-directed thrombolysis and endovascular thrombectomy, the right-side lesion remained and a left-side lesion was newly developed. In addition to prior therapies, 47 sessions of serial HBO2 were administered as adjunctive therapy, resulting in limb salvage. Acute CO poisoning can cause ALI as a rare complication. HBO2 may be utilized as an adjunctive treatment in ALI.

Comparison of Ultrasound-Accelerated Versus Multi-hole Infusion Catheter-Directed Thrombolysis for the Treatment of Acute Limb Ischemia

Retrospective single-center review between 2006 and 2008 Thrombolysis of thrombosed native arteries and arterial bypasses was performed with Uni-Fuse multihole catheters (AngioDynamics, Latham, NY) in 69 cases and EKOS ultrasound-accelerated catheters (EKOS Corporation, Bothell, Wash) in 22 cases. All patients were initially treated with the power-pulse feature of an AngioJet catheter (Boston Scientific, Marlborough, Mass) administering 10 mg of alteplase (tissue plasminogen activator [tPA]) followed 20 minutes later by rheolytic catheter-directed thrombectomy. Residual thrombus was treated with either Uni-Fuse or EKOS catheters with tPA infused at 0.5 to 2.0 mg/h overnight. The mean duration of thrombolysis, mean volume of tPA, technical success, and complications were similar in both groups. The standard multihole infusion catheter demonstrates similar clinical safety and efficacy as the ultrasound-accelerated EKOS system to treat acute arterial limb ischemia.