Percutaneous Pharmacomechanical Thrombectomy Research Articles

Role of Antiplatelet Therapy in Hemodialysis Arteriovenous Graft Secondary Patency Following Successful Percutaneous Thrombectomy.

The purpose of this study was to elicit the relationship of antiplatelet therapy (AP) in maintaining arteriovenous graft (AVG) patency after successful percutaneous pharmacomechanical thrombectomy ("declot"). This was an institutional review board-approved retrospective review of AVG declot procedures between July 2019 and August 2020. AVG characteristics, bleeding complications, anticoagulation and antiplatelet medication regimens, and thrombosis free survival were evaluated. Recurrent time-to-event analysis was performed using a Prentice-Williams-Peterson Gap time model was performed to evaluate AVG thrombosis free survival. A total of 109 declots were technically successful and performed in 63 individual patients. The majority of procedures were performed in upper arm grafts (71%, n = 45). Dual antiplatelet (DAPT) was prescribed after 52 declots (48%), single antiplatelet was prescribed after 36 declots (33%), and anticoagulation was prescribed after 31 declots (28%). Median thrombosis free survival was 37days (range 1-412days) in the no antiplatelet group, 84days (range 1-427days) in the single antiplatelet group, and 93days (range 3-407days) in the DAPT group. Anti-platelet medications trended towards protective of AVG thrombosis in multivariate analysis (hazard ratio 0.84, 95% confidence interval 0.60-1.19); however, this did not reach statistical significance (P = 0.33). A total of 4 major and 5 minor bleeding events occurred. The results of this study support further evaluation of AP therapy in preventing secondary rethrombosis of dialysis AVG.

Combined pharmacomechanical thrombectomy with selective catheter-directed thrombolysis in patients with acute proximal deep vein thrombosis.

Background The aim of this study was to evaluate the characteristics and the outcomes of combined percutaneous pharmacomechanical thrombectomy with selective catheter-directed thrombolysis for acute iliofemoral deep vein thrombosis. Methods Between March 2018 and February 2020, a total of 37 patients (21 males, 16 females; mean age: 55±13.8 years; range, 21 to 79 years) with symptomatic acute iliofemoral vein thrombosis who underwent combined percutaneous pharmacomechanical thrombectomy and catheter-directed thrombolysis were retrospectively analyzed. All patients received a three-step therapy: (i) insertion of a temporary inferior vena cava filter, (ii) percutaneous pharmacomechanical thrombectomy via rotational mechanical thrombectomy device with an adjuvant 0.15 mg/kg recombinant tissue-type plasminogen activator alteplase, and (iii) catheter-directed thrombolysis with continuous 1 mg/h tissue-type plasminogen activator alteplase. Data including demographic characteristics of the patients, bleeding complications, technical success, and adjuvant angioplasty rates were analyzed. The Kaplan-Meier analysis was used to evaluate freedom from re-thrombosis at 3, 6, and 12 months of follow-up was calculated. Results The majority of the patients had left-sided (n=22, 59.4%) proximal deep vein thrombosis. Successful insertion of the inferior vena cava filter was achieved in 97.2% (n=36) of patients. The technical success rate was 89.1% (n=33). Adjuvant venous angioplasty was performed in four patients (10.8%) and no venous stents were used. No major bleeding was occurred, while minor bleeding was observed mostly in the form of hematuria (n=12, 32.4%). No mortality was observed. The 3, 6, and 12-month freedom from re-thrombosis rates were 96.3%, 92.6%, and 86.0%, respectively. Conclusion Combined percutaneous pharmacomechanical thrombectomy and catheter-directed thrombolysis seems to be an effective and safe treatment of the iliofemoral acute deep vein thrombosis with acceptable minor bleeding complications post-interventionally.

Effect of Perioperative Hydration After Rheolytic Thrombectomy for Iliofemoral Deep Vein Thrombosis

Percutaneous pharmacomechanical thrombectomy is a preferred treatment for certain patients with acute thrombosis. Various devices have been approved for this purpose, including a rheolytic thrombectomy device (rPMT). Reported studies have noted an association between the use of an rPMT and acute kidney injury (AKI) and acute renal failure. Our objective was to determine whether an aggressive perioperative hydration strategy would minimize the potential for deleterious renal outcomes, especially in the setting of acute iliofemoral deep vein thrombosis (IF-DVT).

Mid-term and short-term efficacy of percutaneous pharmacomechanical thrombectomy in deep venous thrombosis

Mid-term and short-term efficacy of percutaneous pharmacomechanical thrombectomy in deep venous thrombosis

Recurrence of Paget-Schroetter Syndrome: A Rare Case Report and Review of Literature

Paget-Schroetter syndrome (PSS) is a primary upper extremity deep vein thrombosis (DVT) that occurs with no significant risk factors, mostly in a young and healthy patient. Treatment of this disease is discussed heavily in the literature and the optimal treatment method is still being debated. Here, we present a patient with PSS treated with balloon angioplasty, thrombolysis and treatment with an oral thrombin inhibitor (apixaban) who developed recurrence of PSS. A 38-year-old white male with no past medical history, presented to an urgent care center with sudden onset axillary pain and an axillary lump that was treated with outpatient antibiotics. Extensive deep venous thrombosis was diagnosed with computed tomography (CT) and ultrasound. He underwent percutaneous pharmacomechanical thrombectomy. Postprocedural angiogram showed significant improvement in the caliber of the axillary and subclavian veins where they crossed the first rib. He was discharged on apixaban and underwent removal of his first rib 1 month later. He returned 3 weeks later with recurrence of right arm pain and swelling. Repeat ultrasound showed thrombus in the right arm and venogram confirmed 80% stenosis at the subclavian vein as it enters the innominate vein. He was again treated with placement of a thrombolytic catheter and overnight thrombolysis of the central venous circulation on the right-side upper extremity balloon angioplasty of the subclavian vein, axillary vein, and basilic vein. He is disease-free for 6 months. Recurrence of PSS after surgical removal of rib, thrombectomy, thrombolysis while using apixaban is very rare. This is the first case to our knowledge presented with recurrent PSS treated with apixaban, early rib resection, balloon angioplasty and thrombectomy. J Med Cases. 2020;11(1):22-25 doi: https://doi.org/10.14740/jmc3416

Analysis of the Safety and Efficacy of the Endovascular Treatment for Acute Limb Ischemia with Percutaneous Pharmacomechanical Thrombectomy Compared with Catheter-Directed Thrombolysis

To evaluate the rates of limb salvage, survival, and perioperative mortality in patients with acute limb ischemia (ALI) submitted to endovascular revascularization with pharmacomechanical thrombectomy (PMT) and catheter-directed thrombolysis (CDT). This was a retrospective consecutive cohort study of patients with ALI who were submitted to endovascular treatment with PMT or fibrinolysis at the Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual (São Paulo, Brazil), between July 2015 and December 2018. The limb salvage rate and survival rate at 720days were analyzed in both the PMT (group 1) and CDT treatment (group 2), as well as the perioperative mortality rate (PMR) at 30days after surgery. One hundred twelve patients were admitted to the emergency department with ALI between July 2015 and December 2018. Seventeen patients diagnosed with Rutherford III irreversible ALI and 46 patients submitted to open surgery were excluded. Thus, 49 patients were submitted to endovascular surgery; 18 (36.7%) were classified into group 1, and 31 (63.3%) were classified into group 2. The clinical data were equal between the 2 groups, but there was a higher prevalence of thrombophilia in group 1 (3 cases; P<0.001). The limb salvage rate and the overall survival rate at 720days were similar between groups 1 and 2 (87.8% vs. 89.7%, P=0.78 and 84.7% vs. 69.2%, P=0.82, respectively). There was no statistical difference regarding secondary patency rates at 720days between groups 1 and 2 (group 1, 81.9% and group 2, 78.8%; P=0.66). The PMR was 16.7% (8 patients) within the first 30days. Group 2 had a higher overall mortality rate (OMR) (6 patients, 19.3%, P=0.03). Regarding the PMT group, there was a higher rate of complications such as myoglobinuria, hematuria, acute renal failure, and death in the subgroup of patients in whom there were performed more than 150 cycles/sec during the surgery (P < 0.001). In the present study, the PMT and CDT endovascular procedures had similar limb salvage, overall survival, and secondary patency rates. However, the OMR was higher in the CDT group. Another important finding was related to the number of cycles/sec performed in the PMT group, in whom patients with more than 150 cycles/sec have presented with higher rates of hematuria, myoglobinuria, acute renal failure, and death.

Percutaneous Pharmaco-Mechanical Thrombectomy of Acute Symptomatic Superior Mesenteric Vein Thrombosis

PurposeTo evaluate the safety and the efficacy of percutaneous pharmaco-mechanical thrombectomy (PPMT) of acute superior mesenteric vein (SMV) thrombosis.MethodsA database of patients treated between 2011 and 2018 with acute venous mesenteric ischemia (VMI) was reviewed. VMI was diagnosed in the presence of SMV thrombosis and CT evidence of jejunal thickening. All patients presented with mild to moderate peritonism, which allowed surgery to be postponed. Initial treatment consisted of heparinization. PPMT was indicated in case of worsening abdominal pain despite anticoagulation and was performed via a transjugular or transhepatic approach, using a rotational aspiration thrombectomy catheter, followed by transcatheter thrombolysis. Clinical success was defined as symptoms resolution. Technical success was defined as patency of > 50% of SMV at venography and resolution of jejunal thickening. Patients were discharged on lifelong oral anticoagulation (INR 2.5–3.5). Follow-ups were performed using CT and color Doppler ultrasound.ResultsPopulation consisted of eight males, aged 37–81 (mean 56.5 years). Causes for thrombosis were investigated. Urokinase infusion time ranged from 48 to 72 h (3,840,000–5,760,000 IU). Clinical and technical success was obtained in all cases. One patient experienced bleeding from the superior epigastric artery and was treated with embolization. One patient died of multi-organ failure after 35 days, despite resolution of SMV thrombosis. In no case was surgery required after PPMT; mean hospitalization was 14.1 days (9–24). Mean follow-up of remaining seven patients was 37.7 months (12–84 months).ConclusionPPMT of acute SMV thrombosis seems safe and effective, with an 87.5% long-term survival rate and a 12.5% major complication rate.

Increased risk of acute kidney injury with percutaneous mechanical thrombectomy using AngioJet compared with catheter-directed thrombolysis

ObjectiveThe objective of this study was to investigate the risk of postoperative acute kidney injury (AKI) in patients with acute iliofemoral deep venous thrombosis (IFDVT) who underwent percutaneous pharmacomechanical thrombectomy (PMT) using AngioJet (Boston Scientific, Marlborough, Mass) or catheter-directed thrombolysis. MethodsElectronic medical records of patients with acute IFDVT from January 2014 to September 2017 were reviewed. Those who received PMT with AngioJet (AJ-PMT group) or catheter-directed thrombolysis (CDT group) were included in this study. Baseline characteristics were recorded and compared. Postoperative serum creatinine concentration was compared with baseline serum creatinine concentration to determine the occurrence of postoperative AKI. Hemolysis was diagnosed on the basis of the decrease of hematocrit (HCT) and the occurrence of hematuria. The incidence of postoperative AKI in the two groups was analyzed. Univariable analysis and logistic regression analysis were used to determine risk factors that contribute to postoperative AKI. ResultsA total 198 patients with acute IFDVT were included (79 in the AJ-PMT group, 119 in the CDT group). Baseline data of the two groups were of no statistical difference. The AJ-PMT group suffered more from acute hemolysis (P = .018). Compared with baseline HCT, the absolute HCT reduction of each group was of statistical significance (P < .01). The percentage change of absolute HCT of the two groups was of statistical significance (P < .01). Univariate analysis and multivariate analysis demonstrated that percutaneous AJ-PMT (odds ratio [OR], 2.82; 95% confidence interval [CI], 1.16-6.82; P = .02), history of major surgery within 3 months of endovascular intervention (OR, 8.51; 95% CI, 2.90-24.94; P < .01), and HCT drop >14% (OR, 2.73; 95% CI, 1.08-6.87; P = .03) are independent risk factors that raise the odds of postoperative AKI. ConclusionsIn patients with acute IFDVT, AJ-PMT will raise the risk of postoperative AKI compared with CDT, especially in patients with a history of major surgery within 3 months of endovascular intervention. AJ-PMT causes more hemolysis and hematuria. An HCT drop >14% may indicate upcoming AKI.

Risk of Acute Kidney Injury after Percutaneous Pharmacomechanical Thrombectomy Using AngioJet in Venous and Arterial Thrombosis

Percutaneous mechanical thrombectomy is commonly used to treat acute thrombotic syndromes. AngioJet (AJ) forcibly sprays fibrinolytics to fragment and aspirate thrombus. It is known to cause hemolysis and gross hematuria, yet potential consequences to renal function after AJ remain unstudied. We sought to determine the risk of acute kidney injury (AKI) after AJ when compared with other lysis techniques. We retrospectively reviewed patients treated with thrombolysis over 5years. We identified those treated with AJ or catheter-directed thrombolysis (CDT). Demographics, indications, procedures, and laboratory values within 3days were recorded. AKI was defined as an increase >25% above the baseline creatinine within 72hr of the procedure. IN total, 102 patients (52 AJ, 50 CDT) had no statistical difference in mean age (50 and 51), indication (arterial thrombosis 65% and 88%), or baseline creatinine (0.9 and 1.0mg/dL), respectively. AKI occurred in 15 (29%) patients treated with AJ versus 4 (8%) of CDT (P=0.007). Similar numbers of AJ and CDT patients underwent additional open surgical procedures (21% and 30%, respectively, P = not significant). Multivariable analysis demonstrated that the oddsof AKI were only increased by AJ (odds ratio [OR] 8.2, 95% confidence interval [CI]1.98-34.17, P=0.004), open surgery (OR 5.4, 95% CI 1.43-20.17, P=0.013), or a>10% drop in hematocrit (OR 4.0, 95% CI 1.15-14.25, P=0.03). In our observational study, AJ is an independent risk factor for AKI. Concomitant open surgery and drop in hematocrit also raise the odds of AKI. Renal injury after AJ is under-reported in the literature, and may be related to hemolysis from the device.

Percutaneous Pharmacomechanical Thrombectomy Offers Lower Risk of Post-thrombotic Syndrome than Catheter-directed Thrombolysis in Patients with Acute Deep Vein Thrombosis of the Lower Limb

Despite optimal anticoagulant therapy, patients with proximal deep vein thrombosis (DVT) will often develop post-thrombotic syndrome (PTS). Early thromboreduction can potentially decrease the risk of PTS by restoring venous patency and preserving valvular function. This study was undertaken to compare the efficacy and treatment outcomes of patients with acute proximal DVT of the lower limb who underwent either catheter-directed thrombolysis (CDT) or percutaneous pharmacomechanical thrombectomy (PMT). Thirty-nine patients with acute proximal DVT of the lower limb who were diagnosed by Wells' Score, PMT or CDT was chosen depending on the patient. They underwent early thromboreduction, and 3 died postoperatively in less than 12 months, while 2 were removed for not following-up. Thirty-four patients, 16 in PMT and 18 in CDT, were followed up for more than 1 year. Venous Registry Index (VRI) was used to evaluate the postprocedural patency, while PTS was assessed using the Villalta scale. The technical success was 100% in both the groups, without any 30-day mortality. VRI changed from 13.1 ± 4.3 preoperatively to 2.4 ± 1.5 postoperatively in the PMT group, and from 11.8 ± 2.4 to 3.6 ± 2.2 in the CDT group. Thrombolysis rate was 81.5 ± 8.5% and 67.7 ± 21.0% in the PMT and CDT groups, respectively (P = 0.059). There were no differences in complications, thrombus score, and VRI between the 2 groups. Primary patency rate at 1 year was 93.8% in the PMT group and 88.9% in the CDT group (P = 0.648). The Villalta scale was 2.1 ± 3.0 in the PMT group and 5.1 ± 4.1 in the CDT group (P = 0.030). Both PMT and CDT are effective treatment modalities in patients with acute proximal DVT. Compared with CDT, PMT provides similar treatment success, but with lower risk of PTS at 1-year follow-up.

Percutaneous pharmacomechanical thrombectomy for acute iliofemoral deep vein thrombosis: A suitability study

Percutaneous pharmacomechanical thrombectomy is an emerging therapy for acute deep vein thrombosis and may reduce long-term incidence of post-thrombotic syndrome. This study investigates the proportion of patients presenting with lower limb deep vein thrombosis who are potentially suitable for percutaneous pharmacomechanical thrombectomy. A retrospective review of all duplex ultrasound scans for lower limb deep vein thrombosis over two-year period at a regional vascular unit was conducted. All acute occlusive iliofemoral deep vein thrombosis were screened for percutaneous pharmacomechanical thrombectomy suitability according to predefined criteria. There were 2513 duplex ultrasound scans for suspected lower limb deep vein thrombosis in the two-year period. There were 120 cases of acute occlusive iliofemoral deep vein thrombosis. After application of inclusion and exclusion criteria 48 out of 120 (40%) patients were identified as potential candidates for percutaneous pharmacomechanical thrombectomy. This indicates that a large randomised trial of percutaneous pharmacomechanical thrombectomy is feasible given expected recruitment rates in a multicentre study.

Midterm results of percutaneous endovascular treatment for acute and chronic deep venous thrombosis.

Treatment of deep venous thrombosis (DVT) with therapeutic anticoagulation has been increasingly challenged by aggressive percutaneous treatment using ultrasound-accelerated catheter-directed thrombolysis (US-CDT) or percutaneous pharmacomechanical thrombectomy (PMT). These techniques have been promoted to improve thrombus removal, prolong venous patency, prevent venous insufficiency, and reduce postthrombotic syndrome. This study reviews midterm results using these endovascular techniques for both acute and chronic DVT. A retrospective chart review was performed on patients treated for acute or chronic DVT with US-CDT and/or PMT. Charts were reviewed for patient demographics, medical history and treatment, operative details, and postoperative outcomes. Intraoperative venography and intravascular ultrasound quantified clot response to therapy. Duplex ultrasound defined the pre- and postoperative extent of venous thrombosis, venous patency, and valvular function. Between October 1, 2002 and September 30, 2010, 80 patients were treated for iliofemoral (n= 48), iliofemoropopliteal (n= 15), or femoropopliteal (n= 17) venous thrombosis. Mean age was 45.8 years (range, 15-78 years), and 24 patients (30%) had a documented history of hypercoagulable state. Intravascular ultrasound confirmed May-Thurner syndrome in 34 patients (42.5%). Fifty-two patients (65%) were treated for acute DVT; the mean time to intervention from symptom onset was 8.7 ± 4.5 days (range, 1-14 days). The remaining 28 patients (35%) had chronic symptoms and were treated at a mean of 8.6 ± 10.9 months (range, 1.5-36 months) after DVT diagnosis was made. Patients were treated with PMT (n= 43, 53.8%), US-CDT (n= 14, 17.5%), or both (n= 32, 28.7%). Clot lysis (>90%) was achieved in 72 of 80 patients (90%). Tenecteplase was used for all cases, and the mean dose was 8.6 ± 4.3 mg. Adjunctive procedures, including angioplasty with or without stent placement, were required in 90% (n= 47) of acute patients and in 96% (n= 27) of chronic patients (P= .33). Three patients (3.8%) had postoperative bleeding events requiring blood transfusion; there were no occurrences of intracranial hemorrhage or clinically significant pulmonary embolism. At a mean follow-up of 3.8 years (range, 1-8.9 years), venous patency was present in 49 of 52 acute patients (94%) and in 23 of 28 chronic patients (82%) (P= .12). Valve function was preserved in 41 of 52 (79%) acute patients vs 11 of 28 (39%) chronic patients (P < .001). US-CDT and PMT can effectively remove acute and chronic thrombus in the lower extremity deep venous system. Vein patency and valvular function is better preserved at midterm follow-up after treatment for acute DVT, howeverintervention should be considered in patients with chronic DVT as well.

Midterm Results of Percutaneous Treatment for Acute and Chronic Deep Venous Thrombosis

Traditional treatment of deep venous thrombosis (DVT) with therapeutic anticoagulation has been increasingly challenged by aggressive percutaneous treatment using ultrasound-accelerated catheter directed thrombolysis (US-CDT) or percutaneous pharmacomechanical thrombectomy (PMT). These techniques have been promoted to improve thrombus removal, prolong venous patency, prevent venous insufficiency, and reduce postthrombotic syndrome. This study reviews midterm results using these endovascular techniques for both acute and chronic DVT. A retrospective chart review was performed on patients treated for acute or chronic DVT with US-CDT and/or PMT. Charts were reviewed for patient demographics, symptoms and time course of venous thrombosis, anticoagulation regimen, underlying prothrombotic disorders, operative details, and postoperative outcomes. Intraoperative venography and intravascular ultrasound (IVUS) quantified clot response to therapy. Duplex ultrasound defined the pre- and postoperative extent of venous thrombosis, venous patency, and valvular function. Between October 1, 2002 and September 30, 2010, eighty-seven patients were treated for iliofemoral (n = 48), iliofemoropopliteal (n = 15), femoropopliteal (n = 17), or subclavian (n = 7) venous thrombosis. Mean age was 45.8 years (range, 15-78 years) and 27 patients (31%) had a documented history of hypercoaguable state. IVUS confirmed May-Thurner syndrome in 34 patients (39%). Fifty-nine patients (68%) were treated for acute symptoms; the mean time to intervention from symptom onset was 7.0 days (range, 1-14 days). The remaining 28 patients (32%) had severe chronic symptoms and were treated at a mean of 8.6 months (range, 1.5-36 months) after DVT diagnosis was made. Patients were treated with PMT (n = 52, 58%), US-CDT (n = 14, 16%), or both (n = 22, 25%). Adjunctive procedures, including percutaneous transluminal angioplasty alone or with stent placement, were required in 59% (n = 35) of acute patients and in 96% (n = 27) of chronic patients (P =.09). A significant decrease in clot burden (>50%) or complete clot lysis was achieved in 79 of 87 patients (91%). Three patients (3.4%) had postoperative bleeding events requiring blood transfusion; there were no occurrences of intracranial hemorrhage or clinically significant pulmonary embolism. At a mean follow-up of 3.8 years (range, 1-8.9 years), venous patency was present in 55 of 59 acute patients (93%) and in 23 of 28 chronic patients (82%)( P = .14). However, of the 80 lower extremities treated, valve function was preserved in 41 of 52 (79%) acute patients versus only 11 of 28 (39%) chronic patients (P < .001). Ultrasound-accelerated thrombolysis or percutaneous mechanical thrombectomy used alone or in tandem for treatment of acute and chronic deep venous thrombosis improves symptoms in the involved limb and maintains venous patency at midterm follow-up. Valvular function in the lower extremity is better preserved when sufficient treatment is provided acutely after the onset of symptoms. However, a beneficial symptomatic response is achievable in patients with chronic deep venous thrombosis or post phlebitis syndrome and should be considered in this population.

Acute renal artery thrombosis treated with t-PA power-pulse spray rheolytic thrombectomy

To describe a new application of tissue plasminogen activator (t-PA) power-pulse spray rheolytic (pharmacomechanical) thrombectomy in the treatment of acute renal artery thrombosis. Acute renal artery thrombosis is a relatively rare, but serious condition in which it is imperative to restore perfusion as quickly as possible. Percutaneous pharmacomechanical thrombectomy technique was utilized to provide an effective means of restoring renal flow and function. We therefore present two unique cases of spontaneous and iatrogenic renal artery thromboses that were treated successfully with t-PA power-pulse spray rheolytic thrombectomy. t-PA Power-pulse spray rheolytic (pharmacomechanical) thrombectomy has the potential to be a useful means to restore perfusion and function in the setting of acute renal artery thrombosis.