Graft Thrombectomy Research Articles

A Novel Use of JETi Thrombectomy Device Mediates Embolic Complication during Graft Thrombectomy

A Novel Use of JETi Thrombectomy Device Mediates Embolic Complication during Graft Thrombectomy

PRESENTATIONS AND OUTCOMES OF AORTOFEMORAL BYPASS GRAFTING

Objectives: The aim of the study is to study presentations and clinical outcomes in patients undergoing Aortofemoral Bypass Grafting Surgery (AFB). Design: This was a Hospital based prospective study. Materials And Methods: During 18 months period , 20 patients (mean age = 56 years) underwent AFB. Indications comprised of occlusive disease with Intermittent Claudication (IC) (n=10), Critical Limb Ischaemia (CLI)(n=4), Resting Pain (RP) (n=4) and Tissue Loss (TL) (n=2). Results: From Jan 2023 to June 2024, AFB was performed more frequently for IC (50%) vs rest of other indications. 30 day observations / follow up showed infection in 5%, Graft occlusion in 5% for which patient underwent emergency graft thrombectomy, Amputation in 10% due to gangrenous changes and 15% mortality. Graft patency was found to be triphasic in 90% cases. Hypertension was leading risk factor (85%) followed by Diabetes Mellitus(70%) and smoking (65%). Predictors of morbidity included CKD (25%), CAD (25%), COPD (20%), CVA (20%).90% Patients were operated via thoracotomy approach and 10% were operated via abdominal approach depending on level of aortic thrombus. 20% of patients had previous history of endovascular interventions followed by stent occlusion. Conclusion: In era of endovascular intervention, Aortofemoral Bypass Surgery is more likely to be performed for Intermittent Claudication and graft patency has a better outcome.

Utility of a ML analytics on real time risk stratification and re-intervention risk prediction on AV access outcomes and cost.

Vascular access is the lifeline for patients on hemodialysis. The average survival rates of dialysis dependent patients have been improving over the last 5 years and hence their dialysis access needs longevity for uninterrupted optimal dialysis. With the lack of genomic vascular access failure predictors, there is an unmet need for predicting an event and the appropriate approach to mitigate recurrence of the event that could have cost and outcome implications. We performed a single center experience that extracted relevant clinical (access flow, laboratory data and CKD details), access intervention (prior interventions, type & location of lesion, type of balloon used, use of stents etc.) and demographic (age, vintage on dialysis, sex, social determinants, other medical conditions) data in real time and feeds it into validated ML algorithms to predict risk of reintervention. (Plexus EMR LLC). About 200 prevalent hemodialysis patients with a AV graft or AV fistula were included for this analysis. Need for re-intervention and use of stent/ flow reduction/new access creation were the outcomes analyzed. Plexus EMR is a licensed Azure based platform. R software was used to develop the ML algorithms. Regression factors were developed to assess and test the validity of individual attributes across all the data attributes. Each patient had a real time risk calculator available to the interventionalist on risk of reintervention/ year. Of the 200 patients, 148 had a AV fistula and the remaining 52 had a AV graft. Mean interventions in the year prior to analysis was 1.8 in patients with AV fistulas and 3.4 in AV grafts which decreased to 1.1 in AV fistulas and to 2.4 in AV grafts (p < 0.01) post tool deployment. There were 62 AV graft thrombectomies done in the observation year and 62% of those were repeat thrombectomies. Stent utilization increased to 37 (22 in AV grafts and 15 in AV fistulas) and 2 patients had AV access flow reduction surgery. The cumulative cost (predicted) preintervention was $712,609 and decreased to $512,172 post intervention. Stent utilization increased by 68% in the evaluation year and 89% of the stents used were PTFE coated stents. Utilizing AI with ML based algorithms that includes clinical, demographic and patency maintenance variables could become new standards of care to optimally manage AV accesses and lower cost of care.

Bilateral rectus femoris myocutaneous flaps to salvage exposed axillo-bifemoral graft of bilateral groins

Exposed prosthetic grafts are a challenge to vascular specialists. Groin dissections in vascular surgery can lead to local tissue breakdown, especially in patients who have multiple comorbidities and poor nutritional status. In this report, we describe a patient with exposed prosthetic bypass conduits in the groin region which was successfully covered with bilateral myocutaneous flaps. A 75-year-old Sri Lankan male with diabetes, hypertension and Parkinson's disease presented with bilateral non-healing wound and rest pain for 3 months. Since his premorbid status precluded the aortic cross-clamping and aorto-bifemoral graft, a decision was made to perform a right axillo-bifemoral bypass using a prosthetic graft. Re-operation was required for graft thrombectomy on the same day of surgery. His post-operative period was complicated with lymph leak and surgical site infection of bilateral groin wounds which ultimately led to exposed prosthetic graft which was fortunately patent. After optimizing his nutritional status and comorbidities, he underwent bilateral rectus femoris myocutaneous flaps to cover the soft-tissue defect over the exposed prosthetic grafts. His initial post-operative period was unremarkable except for a small area of skin breakdown. Myocutaneous flaps are preferred as they are more resilient to breakdown compared to facio-cutaneous flaps, especially in a patient with compromised blood supply. The type of loco-regional flap should be carefully selected in an individualized manner depending on the regional vascularity. The rectus femoris flap is a suitable option in terms of ease of surgical technique and durability. Comorbidities and local factors should be optimized prior to definitive reconstruction to maximize the chances for optimal wound healing.

Trans-stent graft thrombectomy for the treatment of long stent graft thrombosis in the femoropopliteal artery.

At present, no consensus has been reached regarding the optimal management of stent graft thrombosis in the femoropopliteal artery. We present a case of long thrombosis of a Viabahn stent graft implanted in the superficial femoral artery that was successfully treated by thrombectomy using a trans-Viabahn approach at the mid-thigh segment. The advantages of this approach include that it preserves the common femoral artery and popliteal artery untouched without scarring, allowing for a future site of surgical anastomosis. This technique could be a reasonable approach when performing surgical thrombectomy for stent graft thrombosis in the femoropopliteal artery.

Iatrogenic tibial arteriovenous fistula after Fogarty balloon catheter graft thrombectomy.

A 75‐year‐old male presented with an immediately threatened grade IIb acute ischemia of the left leg due to thrombosis of a femoro‐infrapopliteal prosthetic bypass graft. After an urgent Computed Tomography Angiography, an urgent graft thrombectomy was performed using a 5 Fr Fogarty catheter, which had a troublesome distal passage, causing a tibial A‐V fistula.

Comparison of Clinical Outcomes in Patients Undergoing a Salvage Procedure for Thrombosed Hemodialysis Arteriovenous Grafts.

BackgroundThe major limitation of arteriovenous graft access is the high incidence of thrombotic occlusion. This study investigated the outcomes of our salvage strategy for thrombosed hemodialysis arteriovenous grafts (including surgical thrombectomy with balloon angioplasty) and evaluated the efficacy of intragraft curettage.MethodsSalvage operations were performed for 290 thrombotic occluded arteriovenous grafts with clinical stenotic lesions from 2010 to 2018. Of these, 117 grafts received surgical thrombectomy and balloon angioplasty from 2010 to 2012 (group A), and 173 grafts received surgical thrombectomy and balloon angioplasty, with an additional salvage procedure using a curette and a graft thrombectomy catheter, from 2013 to 2018 (group B). Outcomes were described in terms of post-intervention primary patency and secondary patency rates.ResultsThe post-intervention primary patency rates in groups A and B were 44.2% and 66.1% at 6 months and 23.0% and 38.3% at 12 months, respectively (p=0.003). The post-intervention secondary patency rates were 87.6% and 92.6% at 6 months and 79.7% and 85.0% at 12 months, respectively (p=0.623). Multivariate Cox regression analysis demonstrated that intragraft curettage was a positive predictor of post-intervention primary patency (hazard ratio, 0.700; 95% confidence interval, 0.519–0.943; p=0.019).ConclusionSurgical thrombectomy and balloon angioplasty showed acceptable outcomes concerning post-intervention primary and secondary patency rates. Additionally, intragraft curettage may offer better patency to salvage thrombotic occluded arteriovenous grafts with intragraft stenosis.

Acute hepatitis post arteriovenous graft thrombectomy of hemodialysis vascular access.

The following paper reports the case of a woman on in-center hemodialysis through an arteriovenous graft, who attended with an acute vascular access thrombosis. Post percutaneous thrombectomy, the patient presented a rare case of self-limited acute hepatitis secondary to the revascularization procedure. We explain the probable trigger for this complication, its pathophysiology, management, and evolution.

Successful Expectant Management of Nonocclusive Thrombosis in Simultaneous Pancreas-Kidney Transplantation

BackgroundSimultaneous pancreas-kidney (SPK) transplantation can be complicated by thrombosis in the early post-transplant period. MethodsWe performed a single-center retrospective study examining risk factors, management, and outcomes of modern era SPK transplants. We reviewed 235 recipients over 10 years (January 1, 2008, to September 1, 2017). We used multivariate analysis to examine donor, recipient, and operative risk factors for thrombosis. ResultsForty-one patients (17%) had a thrombosis diagnosed on postoperative imaging, but 61% of these patients (n = 25/41) did not lose their graft secondary to the thrombosis. Nine patients (22%) were managed with watchful waiting and serial imaging, 12 (29%) were managed with therapeutic anticoagulation, and 4 (10%) required laparotomy and graft thrombectomy. Sixteen of 235 pancreas grafts (6.8%) required pancreatectomy, and 10 of these cases occurred in the first half of the study, before 2012. The risk of thrombosis leading to graft loss increased 11.2-fold in recipients with a body mass index (calculated as weight in kilograms divided by height in meters squared) > 25 compared with others (odds ratio, 11.2; 95% CI, 1.1-116.7; P = .043). ConclusionsThe majority of SPK transplants (61%) complicated by thrombosis of the pancreatic graft were salvaged by use of imaging, anticoagulation, and in select cases, laparotomy and graft thrombectomy.

Impella flow pump reinsertion after axillary graft thrombectomy: Technical points in replacing axillary Impella

Axillary Impella devices are increasingly employed for long-term support of patients with systolic heart failure and shock. Axillary access allows for awake support and ambulation, which carries an inherent risk of disconnection or malposition. We report a series of two cases where device replacement due to dysfunction and malposition can be completed safely through the original axillary graft using axillary graft thrombectomy, given that the clot burden could be a major source of morbidity to the patient.

Comparison between endovascular versus hybrid thrombectomy for arteriovenous graft under complete ultrasound guidance.

Endovascular treatment of acute thrombosed arteriovenous grafts performed completely under ultrasound guidance has rarely been reported. We compared the efficacy of a new endovascular thrombectomy technique (percutaneous manual thromboaspiration through the introducer sheath) with classical hybrid thrombectomy (minimally invasive surgical thrombectomy combined with high-pressure angioplasty) performed completely under ultrasound guidance, for arteriovenous graft thrombosis. This was a retrospective cohort study involving patients receiving hemodialysis who underwent arteriovenous graft thrombectomy between January 2014 and December 2017. We divided 130 participants into an intervention (endovascular) group (N.=65) and a control (classical hybrid) group (N.=65) according to the thrombectomy technique. The procedural success rate, immediate outcomes and patency were compared between the groups. There was no significant difference in the procedural success rate (92.31% vs. 89.23%, P=0.55) between the intervention and control groups, respectively. No major complications were noted, but two cases of vessel rupture occurred in the control group and three cases of vessel rupture occurred in the intervention group. The procedure time in the intervention group was significantly shorter than that in the control group (74±14.21 min vs. 109.05±19.20 min, respectively; P<0.05). During the 6-month follow-up, we found no significant difference in the postintervention primary patency rate (48.33% vs. 55.17%; P=0.51) or the postintervention second patency rate (83.33% vs. 84.49%; P=0.79) between the intervention and control groups, respectively. Dialysis clearance and ≥50% stenosis were predictors of postintervention primary patency (hazard ratio, 7.80; 95% confidence interval: 1.75-34.81; P=0.01; and hazard ratio, 6.43; 95% confidence interval: 2.43-17.03; P<0.001), respectively. Completely ultrasound-guided percutaneous manual thromboaspiration through the introducer sheath can be used for thrombosed arteriovenous grafts. This approach has the advantage of shorter operative time compared with hybrid treatment.

Long-Term Impact of Vascular Surgery Stress on Frail Older Patients

Frailty is a syndrome where the ability to cope with acute physiological stress is compromised, although it is unclear what impact this stress has on long-term outcomes. Vascular-Physiological and Operative Severity Score for enumeration of Mortality and Morbidity is a validated method for calculating levels of stress associated with vascular procedures. We designed this study to evaluate the long-term impact of different levels of surgical stress among frail older patients undergoing vascular surgery procedures. We identified all independently living patients who underwent prospective frailty assessment followed by an elective vascular surgery procedure captured in the Vascular Quality Initiative registry (endovascular abdominal aortic aneurysm [AAA] repair, thoracic endovascular aortic repair, suprainguinal and infrainguinal bypass, peripheral vascular intervention, carotid endarterectomy, and open AAA) at an academic institution between January 2016 and July 2018. Patient- and procedure-level data were obtained from our institutional data warehouse and Vascular Quality Initiative database, and used to calculate Vascular-Physiological and Operative Severity Score for enumeration of Mortality and Morbidity scores. The association between frailty and composite outcome of any major complications (surgical site infection; graft thrombectomy; major amputation; adverse cardiac, pulmonary, or neurologic event; acute renal insufficiency; and/or reoperation related to the index procedure), nonhome living status, or death within 1year after low-, medium-, and high-stress vascular procedures was evaluated using bivariate and logistic regression models. A total of 163 patients were identified (70% male, mean age 67.8years) who underwent open AAA repair (6%), endovascular AAA repair (21%), thoracic endovascular aortic repair (7%), suprainguinal bypass (5%), infrainguinal bypass (18%), carotid endarterectomy (18%), or peripheral vascular interventions (25%), which included 44 (27%) patients diagnosed with frailty before surgery. Overall, frail patients had significantly higher rates of the 1-year composite outcome (48% frail versus 27% nonfrail; P=0.012) when compared with nonfrail patients, with a significant dose-dependent effect as the level of stress increased. In comparison, increasing levels of surgical stress had a negligible effect on long-term outcomes among nonfrail patients. The interaction between frailty and high surgical stress was found in adjusted regression models to be a significant predictor of adverse outcomes within 1year after vascular surgery (odds ratio, 3.3; 95% confidence interval, 1.3-8.6; P<0.01). Frail patients who undergo high-stress vascular procedures have a significantly higher rate of complications leading to loss of functional independence and mortality within the year after their surgery. These data suggest that estimates of surgical stress should be incorporated into clinical decision making for frail older patients before and after surgery.

Comparative Long-term Outcomes of Patients with Aortoiliac Occlusive Disease Limited to Common Iliac Arteries Who Underwent Endarterectomy versus Bypass Grafting

The objective of this study was to compared outcomes of patients with aortoiliac occlusive disease (AIOD), limited to the common iliac artery, who underwent either aortoiliac thromboendarterectomy (AIE) or aortobiiliac bypass grafting (ABIB). A single-center, retrospective analysis of consecutive patients with AIOD who underwent either AIE or ABIB between 2010 and 2019 from a prospective database. Patients with disease extending to the external iliac or common femoral arteries were excluded. Data collected included demographics, cardiovascular risk factors, indication for surgery, preoperative and postoperative ankle brachial indexes (ABIs), estimated blood loss, major adverse events (MAEs), and long-term patency. The study end point was clinical success, defined as improvement in ABIs with resolution of symptoms. MAEs included return to the operating room for any reason, postoperative myocardial infarction, stroke, pneumonia, or venous thromboembolism. Thirty-three patients, who met inclusion criteria, underwent repair for AIOD (AIE: 13; ABIB: 20) at our institution during this time. In both groups, there were more women than men (AIE: 11, ABIB: 10) with a mean age of 55±7 years and 58±6 years in the AIE and ABIB group, respectively. Indication for surgery included disabling claudication in 19 patients, ischemic rest pain in 13 patients, and tissue loss in one patient. No difference in cardiovascular risk factors or AIOD severity was noted between groups. Patients in the AIE group had slightly higher body mass index (30±5 vs. 26±6, P=0.06). Two patients in each group required concomitant renal/mesenteric artery endarterectomy. One patient in the AIE group required bilateral femoral artery exposure and external iliac thrombectomy. MAEs (4 vs. 0) were higher in the ABIB group including, pneumonia in one patient, myocardial infarction in another, return to the operating room for evacuation of hematoma in the third and bypass graft thrombectomy with lower extremity angiography in the fourth patient. There were no differences in the intensive care unit or hospital length of stay between groups. Patients in both groups achieved return of normal ABI and complete resolution of their symptoms. At mean follow-up time of 43.4±25.2 and 52.9±35.4months in the AIE and ABIB group, respectively, there was no symptomatic recurrence or need for reintervention while two patients in the ABIB group died of non-aortic-related issues. Both procedures were safe, effective, and conferred high long-term primary patency with no need for reintervention in patients with AIOD limited to the common iliac arteries.

Aortic anastomotic pseudoaneurysm repaired with iliac branched endoprosthesis

A 75-year-old man undergoing surveillance imaging for a known pseudoaneurysm of the aortic anastomosis of an aortobifemoral bypass graft placed 20 years prior for occlusive disease was found to have increase in pseudoaneurysm size to 6 cm (A/Cover). The patient has a history of chronic obstructive pulmonary disease and non-small cell lung cancer with right upper lobectomy. He is of very thin habitus, and a pulsatile mass was visible in his left mid abdomen. Previously, the patient had undergone multiple cutdowns to the right and left groin for graft thrombectomies, pseudoaneurysm repair, as well as distal bypass and revision of the distal bypass with the last intervention 5 years previously.

Perioperative and Long-term Outcomes of Percutaneous Arteriovenous Graft Thrombectomy

Perioperative and Long-term Outcomes of Percutaneous Arteriovenous Graft Thrombectomy

PC136. Procedural and Long-term Outcomes of Percutaneous Arteriovenous Graft Thrombectomy

PC136. Procedural and Long-term Outcomes of Percutaneous Arteriovenous Graft Thrombectomy

A study on surgical intervention outcomes in chronic aorto iliac occlusion

Background: Aorto-iliac occlusion is an advanced and late manifestation of the atherosclerotic vascular disease. Patients with this complicated and frequently multi-level disease can present with debilitating symptoms ranging from life-limiting claudication to limb-threatening ischemia. To study the results of Surgical management and complications of Aortic surgery in a patient with chronic, aortoiliac occlusion.Methods: Our study of 22 cases, 12 patient underwent aortic bi femoral bypass, 08 cases underwent aortobi-iliac bypass and 2 of them aortic endarterectomy. This entire patient had a 64 slice CT angiogram of aorto with bilateral lower limb and offered surgical treatment after explaining the risk and complication of surgery. All patients followed post op with the clinical examination, ABI, duplex once a month.Results: 19 patients had a patent graft at the end of the study period. The primary patency of 86%. 2 patient had graft thrombectomy, 1 patient had graft thrombectomy with extension bypass, hence the secondary patency was 95%.Conclusions: The spectrum of aortoiliac occlusive disease ranges from short, simple stenosis to long, complete occlusions, with treatment options that vary accordingly from minimally invasive endovascular procedures to major open surgical intervention.

Endovascular management of aortic endograft occlusion

Endovascular aortic repair is becoming the standard of care for abdominal aortic aneurysm. Despite aorta being a high flow system, there is still a definite risk of endograft occlusion. Management of occluded aortic endograft is highly controversial. Successful endovascular relining in aortic endograft occlusion is a technically demanding and forthcoming secondary intervention, not been studied extensively. We are reporting a case of aortic endograft thrombosis in a morbidly obese, 64-year-old gentleman with multiple comorbidities presenting with lifestyle-limiting claudication. The patient had a history of abdominal aortic aneurysm repair with aorto-uni-iliac device and femorofemoral bypass. The patient was managed by relining of aortic endograft with graft thrombectomy and snorkeling of the left renal artery. Postoperative course was uneventful. After 1 year of follow-up, the patient is free of symptoms with patent endograft. More empirical evidence is yet required to make the standard guidelines for the management of aortic endograft occlusion.

Surgical Interventions for Organ and Limb Ischemia Associated With Primary and Secondary Antiphospholipid Antibody Syndrome With Arterial Involvement.

The association of antiphospholipid antibody syndrome (APS) and hypercoagulability is well known. Arterial compromise leading to ischemia of organs and/or limbs in patients with APS is uncommon, frequently unrecognized, and rarely described. We evaluated our institutional experience. Retrospective review was conducted. From August 2007 to September 2016, 807 patients with diagnosis of APS were managed in our Institution. Patients with primary and secondary APS who required interventions were examined. Demographics, comorbidities, manifestations, procedures, complications, and other factors affecting outcomes were recorded. Fourteen patients (mean age 35 years old, standard deviation ±14) were evaluated and treated by our service. Six (43%) of them had primary APS and 8 (57%) had secondary APS; 11 (79%) were female. Two (14%) experienced distal aorta and iliac arteries involvement, 3 (21%) visceral vessels disease, 2 (14%) in upper and 7 (50%) in the lower extremity vasculatures. Thirteen (93%) patients underwent direct open revascularization and 1 with hand ischemia (Raynaud disease) underwent sympathectomy. During the mean follow-up period of 48 months, reinterventions included a revision of the proximal anastomosis of an aortobifemoral bypass graft, 1 (7%) abdominal exploration for bleeding, 1 (7%) graft thrombectomy, and 4 (29%) amputations (2 below the knee, 1 above the knee, and 1 transmetatarsal). One (7%) death occurred secondary to sepsis in a patient who had acute mesenteric ischemia. Significant differences in clinical manifestations and outcomes were not observed among patients with primary and secondary APS. All patients remained on systemic anticoagulation. APS is a prothrombotic disorder that may lead to arterial involvement with less frequency than the venous circulation but has significant morbidity and limb loss rate. Arterial reconstruction seems feasible in an attempt to salvage organs and limbs; however, research is necessary to establish the optimal anticoagulation regime and long-term management following surgical interventions.

Результаты хирургического лечения тромбоза постоянного сосудистого доступа, сформированного синтетическим протезом, при его динамическом наблюдении методом ультразвукового дуплексного сканирования

Результаты хирургического лечения тромбоза постоянного сосудистого доступа, сформированного синтетическим протезом, при его динамическом наблюдении методом ультразвукового дуплексного сканирования