Suction Embolectomy Research Articles

Clinical characteristics and treatment of patients with central pulmonary embolism and right heart thrombus.

Right heart thrombus (RHT), also known as clot in transit, is an uncommon finding in pulmonary embolism (PE) that is associated with increased inpatient mortality. To date, there is no consensus on the management of RHT. Therefore, we aim to describe the clinical features, treatments, and outcomes of patients with simultaneous RHT and PE. This is a retrospective, cross-sectional, and single-center study of hospitalized patients with central PE who had RHT visualized on transthoracic echocardiography (TTE) from January 2012 to May 2022. We use descriptive statistics to describe their clinical features, treatments, and outcomes, including mechanical ventilation, major bleeding, inpatient mortality, length of hospital stay, and recurrent PE on follow-up. Of 433 patients with central PE who underwent TTE, nine patients (2%) had RHT. The median age was 63 years (range 29-87), most were African American (6/9), and females (5/9). All patients had evidence of RV dysfunction and received therapeutic anticoagulation. Eight patients received RHT-directed interventions, including systemic thrombolysis (2/9), catheter-directed suction embolectomy (4/9), and surgical embolectomy (2/9). Regarding outcomes, 4/9 patients were hemodynamically unstable, 8/9 were hypoxemic, and 2/9 were mechanically ventilated. The median length of hospital stay was six days (range 1-16). One patient died during hospital admission, and two patients had recurrent PE. We described the different therapeutic approaches and outcomes of patients with RHT treated in our institution. Our study adds valuable information to the literature, as there is no consensus on the treatment of RHT. Right heart thrombus (RHT) was a rare finding in central pulmonary embolism. Most patients with RHT had evidence of RV dysfunction and pulmonary hypertension. Most patients received RHT-directed therapies in addition to therapeutic anticoagulation.

Complications of Penumbra Indigo Aspiration Device in Pulmonary Embolism: Insights From MAUDE Database

BackgroundThe Penumbra Indigo aspiration system (Penumbra Inc., Alameda, CA, USA) is a suction embolectomy device that was cleared by the Food and Drug Administration for use in acute pulmonary embolism (PE). While this device has proven to be safe in clinical trials, real-world data are minimal. MethodsThe “Manufacturer and User Facility Device Experience” MAUDE database was queried for reports of Penumbra indigo system from January 2020 to August 2021. ResultsA total of 2118 reports were found during the study period. After the exclusion of duplicate and incomplete reports as well as reports not related to PE, our final cohort included 67 reports related to Penumbra indigo device failure. The most common failure mode was Lightning unit malfunction (35.8%, n = 24) followed by rotating hemostasis valve malfunction (31.3%, n = 21). Three (4.5%) patients died; two (3%) from fatal pulmonary vessel perforation, and one from fatal right-sided heart failure. There was one case (1.5%) of pericardial effusion, while there were no cases of hemoptysis or blood transfusion. ConclusionThe overall number of reports in the MAUDE registry related to the Penumbra Indigo aspiration system is small (67 reports in 20 months). The most common reported failure mode was Lightning unit malfunction. These data serve to inform operators about potential issues when using the Penumbra Indigo thrombus aspiration system and identify areas on which to focus further device iteration.

AngioVac suction embolectomy using a roller pump: Operative technique.

AngioVac suction embolectomy is recommended by the manufacturer to be performed with a centrifugal pump due to safety considerations. However, roller head pumps are significantly cheaper to use, and thus may be more readily available during shortages and in resource-poor settings. We present the technique of Angiovac suction embolectomy being successfully performed with a roller pump to evacuate a clot-in-transit in the inferior vena cava and right atrium, along with discussion of important safety caveats.

Endovascular Management of Malperfusion Syndromes in Aortic Dissection

Malperfusion Syndrome (MPS) refers to inadequate perfusion of end organs secondary to ongoing arterial obstruction of the aorta and its branches resulting in increased morbidity and mortality.While uncomplicated type B dissection can typically be monitored, type A or type B dissections with malperfusion syndrome are should be considered for hybrid treatment with an endovascular intervention. In addition to pre-procedure CTA and labs, intra-procedure evaluation of the true lumen, false lumen, and branch vessels is performed with intravascular ultrasound (IVUS) and manometry to delineate static versus dynamic obstruction. Dynamic obstruction of the visceral arteries is typically treated first and can be relieved either with supraceliac dissection flap fenestration or exclusion of the entry tear by thoracic endovascular aortic repair, both of which will restore flow to the true lumen.Static obstruction requires stenting or other branch-artery intervention including branch artery fenestration, suction embolectomy, or thrombolysis. Throughout the procedure, IVUS and manometry are used to evaluate results of interventions with respect to continued hemodynamically significant obstruction. Endovascular intervention should be performed in conjunction with a multi-disciplinary team as patients are often complex and may require further procedures such as bowel resection or open aortic repair.

Bedside VA-ECMO Cannulation for a Patient with CTEPH and RV Failure

Introduction Acute pulmonary embolus (PE) in the setting of chronic thromboembolic pulmonary hypertension (CTEPH) with elevated PA pressures and right ventricular (RV) failure is a complex condition associated with increased mortality if left untreated. We demonstrate an alternative bedside veno-arterial extracorporeal membrane oxygenation (VA-ECMO) strategy used to facilitate stabilization and pre-operative optimization. Case Report A 29-year-old female with a history of previous PE (on Lovenox), RV dysfunction with elevated PA pressures, and IVC thrombus requiring VV-ECMO assisted suction embolectomy presented to an outside hospital with shortness of breath, hypoxia and CT demonstrating acute on chronic, bilateral PEs. A transthoracic echocardiogram (TTE) showed worsening RV function. She was normotensive, had a heart rate of 140, and was hypoxic so was placed on BiPAP. She was transferred to our facility for further management. On arrival, the patient was tachypneic and hypoxic. She was started on Epinephrine, Milrinone, and inhaled Epoprostenol but was persistently hypoxic with a rising lactic acid and worsening metabolic acidosis. With evidence of worsening RV failure, the patient was cannulated for VA-ECMO to facilitate optimization for advanced management. Prior to cannulation, bedside ultrasound revealed occlusive thrombus in both femoral and iliac veins. The venous drainage cannula was placed in the right internal jugular vein and the arterial return cannula was placed in the right common femoral artery, with antegrade reperfusion cannula. Bedside TTE was used to aide in cannula placement and cannula position was confirmed with x-ray.The patient was on VA-ECMO for 72 hours. During this time, her acidosis improved, Milrinone was weaned off, and she was diuresed. On ECMO day 3, she was taken to the OR for a pulmonary thromboendarterectomy and decannulated from VA-ECMO. The following day she was extubated and a TTE revealed improved right ventricular function. Summary Stabilization with VA-ECMO in patients with PE can be beneficial. This case illustrates the use of an alternative VA-ECMO cannulation strategy to optimize a patient with CTEPH. Of note, the cannulation occurred at the bedside with the use of ultrasound and without the need for intubation. Though this cannulation strategy is theoretically described in the literature, this case illustrates a concrete example of its use.

Complete percutaneous decannulation from femoral venoarterial extracorporeal membrane oxygenation.

ObjectivesTo evaluate the clinical outcomes and perioperative complications associated with complete percutaneous decannulation of femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) with the MANTA closure device.MethodsThis is a retrospective analysis of a single surgeon consecutive series of 14 patients at a single center who underwent decannulation from VA-ECMO, 10 of whom underwent a percutaneous method of femoral cannula removal.ResultsAfter a mean duration of VA-ECMO support of 7.4 ± 3.8 days, all 10 patients, with arterial cannulas ranging in size from 17 to 21 Fr, underwent percutaneous decannulation with the MANTA closure device, with immediate hemostasis. One patient had acute lower limb ischemia that was recognized intraoperatively and successfully treated with suction embolectomy. Two patients had a pseudoaneurysm at the distal perfusion catheter site recognized on perioperative imaging studies, one resolving with observation and the other necessitating thrombin injection. One patient had a hematoma that resolved with observation.ConclusionsPercutaneous decannulation from VA-ECMO using the MANTA large-bore vascular closure device is feasible and results in immediate hemostasis with excellent angiographic results.

EkoSonic® endovascular system and other catheter-directed treatment reperfusion strategies for acute pulmonary embolism: overview of efficacy and safety outcomes

ABSTRACT Introduction Studies performed in the past decade suggested that evolving reperfusion strategies may improve early outcomes of patients with acute pulmonary embolism (PE) and hemodynamic decompensation. In this regard, catheter-directed treatment (CDT) options are receiving increasing attention. Areas covered A broad spectrum of CDT options exists for the treatment of patients with acute PE. Procedures include catheter-directed local thrombolysis with or without ultrasound assistance, catheter-directed mechanical or suction embolectomy, and combined pharmaco-mechanical approaches. We present here an overview of the available CDT techniques, focusing on the EkoSonic® endovascular system. Expert commentary CDT, particularly local ultrasound accelerated thrombolysis, continues to evolve. Its increasing popularity is the result of accumulating promising results, which suggest a relief of right ventricular (RV) pressure overload and improvement of RV function. These favorable effects on surrogate endpoints were accompanied by a low rate of procedure-related adverse events, notably intracranial hemorrhage. Although the overall risk of serious bleeding appears to be low in CDT, the lack of direct comparisons with other reperfusion options does not allow definitive conclusions. Prospective controlled trials with robust clinical outcomes are urgently needed to establish the postulated benefits of CDT in selected patients with acute PE.

Catheter-directed therapy for acute pulmonary embolism: navigating gaps in the evidence.

Systemic thrombolysis for acute pulmonary embolism (PE) reduces the risk of death and cardiovascular collapse but is associated with an increased rate of bleeding. The desire to minimize the risk of bleeding events has driven the development of catheter-based strategies for pulmonary reperfusion in PE. These catheter-based strategies utilize lower-dose fibrinolytic regimens or purely mechanical techniques to expedite removal of the embolus. Several devices providing mechanical or suction embolectomy and catheter-directed thrombolysis, with or without facilitation by ultrasound, have been tested. Data are inconsistent regarding the efficacy and safety of mechanical and suction embolectomy. The most comprehensive data on catheter-based techniques stem from trials of ultrasound-facilitated catheter fibrinolysis. Ultrasound-facilitated catheter fibrinolysis relieves right ventricular pressure overload with a lower risk of major bleeding and intracranial haemorrhage than historical rates with systemic fibrinolysis. However, further research is required to determine the optimal application of ultrasound-facilitated catheter fibrinolysis and other catheter-based therapies in patients with acute PE.

Novel aspiration catheter design for acute stroke thrombectomy

BackgroundNavigable, large diameter aspiration catheters demonstrate markedly improved recanalization rates over smaller lumen devices in suction embolectomy. We evaluated the performance of a novel aspiration catheter system designed to maximize...

Use of a Modified Cardiopulmonary Bypass Circuit for Suction Embolectomy with the AngioVac Device

The AngioVac suction cannula and circuit were designed for the percutaneous removal of soft thrombus and emboli in procedures requiring extracorporeal circulatory support. We describe a modification of the AngioVac suction catheter and cardiopulmonary bypass (CPB) circuit to effectively remove thrombus while maintaining the ability to rapidly initiate full CPBs during a medical crisis. This article will discuss the design concepts of the modified circuit as well as procedural protocols and considerations. The design modifications of incorporating an oxygenator, reservoir, and bridge allow for an increased flexibility that allows adaption to veno-venous extracorporeal membrane oxygenation or full CPB support when required for oxygenation or hemodynamic support.

Endovascular Procedures for Mesenteric Ischemia

Mesenteric ischemia is a condition caused by compromised blood flow to the small and large intestines. Patients can present with chronic mesenteric ischemia (CMI), most commonly due to atherosclerosis, or acute mesenteric ischemia (AMI), most commonly due to arterial thrombosis or arterial embolism. Endovascular options for CMI include angioplasty and stenting, whereas options for AMI include catheter-directed thrombolysis and suction embolectomy followed by angioplasty and stenting of the underlying lesion. For treatment of CMI, an endovascular approach is associated with lower morbidity and mortality with good immediate technical success rates but may be less durable than surgical intervention, with reported lower long-term patency and a higher recurrence rate. There are no randomized trials comparing open versus endovascular interventions for AMI. Even after successful endovascular treatment, there should be a low threshold for laparotomy to visually inspect the bowel. Postoperative imaging is important, and close follow-up is mandatory. This review contains 8 figures, and 26 references. Key words: acute mesenteric ischemia, angioplasty, catheter-directed thrombolysis, chronic mesenteric ischemia, stenting (balloon versus self-expandable, covered versus bare metal), suction embolectomy

Catheter-Based Reperfusion Treatment of Pulmonary Embolism

Case Presentation: A 76-year-old man with a history of hemicolectomy for colon cancer 10 days previously was admitted because of syncope and severe shortness of breath. On physical examination, the patient was hemodynamically unstable, with a systolic arterial pressure of 80 mm Hg, a heart rate of 124 beats per minute, and distended jugular veins. He was agitated and unable to speak full sentences. His respiratory rate was 28 breaths per minute, and oxygen saturation was 80% on room air. Contrast-enhanced computed tomography showed a filling defect of the left main pulmonary artery, complete occlusion of the left lower lobe pulmonary artery, nonobstructive filling defects of the right lower lobe pulmonary artery, and right ventricular enlargement (right-to-left ventricular dimension ratio of 1.4) (Figure 1). The hemodynamic situation remained unchanged after initiation of treatment with oxygen, intravenous unfractionated heparin, and normal saline. Figure 1. Contrast-enhanced chest computed tomogram from the first case. Left, Complete occlusion of the left lower lobe pulmonary artery (large arrow) and nonobstructive filling defect in the right lower lobe pulmonary artery (small arrow). Right, The subannular right-to-left ventricular dimension ratio was obtained from the reconstructed 4-chamber view.1 Right (47.3 mm) and left (33.9 mm) ventricular dimensions were measured perpendicular to the interventricular septum and 1 cm above the atrioventricular annulus plane. The right-to-left ventricular dimension ratio was calculated as 1.4. Case Presentation: A 55-year-old woman suddenly developed acute shortness of breath 3 weeks after resection of a meningioma. On physical examination, the patient appeared hemodynamically stable, with a systolic arterial pressure of 100 mm Hg, a heart rate of 96 beats per minute, a respiratory rate of 18 breaths per minute, and an oxygen saturation of 89% while receiving 3 L of oxygen via face mask. A contrast-enhanced computed tomography confirmed subtotal filling defects in both main pulmonary …

A Massive Pulmonary Embolism Treatment Protocol: How Trauma Performance Improvement Affects Outcome Throughout the Hospital System

Trauma performance improvement is the hallmark of a mature trauma center. If loop closure is to be complete, preventable deaths must result in significant change in management and the establishment of protocol-driven improvements so such an instance does not recur. The trauma performance improvement committee reviewed a case of a massive pulmonary embolus and determined that this was a preventable death. The hospital performance improvement committee then initiated a root cause analysis, which led to creation of a treatment protocol for patients with massive or submassive pulmonary embolism. A focused review of the first 6 months of the implementation of the protocol was undertaken. Four patients over a 6-month period had massive or submassive pulmonary embolus. All four had sudden death or near sudden death and were appropriately resuscitated. All four sustained right heart failure. Two patients were treated by catheter-directed fibrinolysis, one with catheter-directed suction embolectomy, and one by surgical pulmonary embolectomy. All survived with full neurologic function. Trauma performance improvement is the model by which all hospital performance improvement should be done. Preventable deaths can result in change, which can have a future impact on survival in potentially lethal scenarios.

Catheter-Directed Embolectomy, Fragmentation, and Thrombolysis for the Treatment of Massive Pulmonary Embolism After Failure of Systemic Thrombolysis

The standard medical management for patients in extremis from massive pulmonary embolism (PE) is systemic thrombolysis, but the utility of this treatment relative to catheter-directed intervention (CDI) is unknown. We evaluated the effectiveness of CDI as part of a treatment algorithm for life-threatening PE. A retrospective review was performed on 70 consecutive patients with suspected acute PE over a 10-year period (from 1997 to 2006) who had been referred for pulmonary angiography and/or intervention. The criteria for study inclusion were patients who received CDI due to angiographically confirmed massive PE and hemodynamic shock (shock index, > or = 0.9). CDI involved suction embolectomy and fragmentation with or without catheter thrombolysis. Twelve patients were treated with CDI. There were seven men and five women (mean age, 56 years; age range, 21 to 80 years). Seven patients (58%) were referred for CDI after failing systemic infusion with 100 mg of tissue plasminogen activator, and five patients (42%) had contraindications to systemic thrombolysis. Catheter-directed fragmentation and embolectomy were performed in all patients (100%). Additionally, catheter-guided thrombolysis was performed in eight patients (67%). Technical success was achieved in 12 of 12 cases (100%). There were no major procedural complications (0%). Significant hemodynamic improvement (shock index, < 0.9) was observed in 10 of 12 cases (83%). The remaining two patients (17%) died secondary to cardiac arrest within 24 h. Ten of 12 patients (83%) survived and remained stable until hospital discharge (mean duration, 20 days; range, 3 to 51 days). In the setting of hemodynamic shock from massive PE, CDI is potentially a life-saving treatment for patients who have not responded to or cannot tolerate systemic thrombolysis.

Surgical management of acute carotid thrombosis after carotid stenting: A report of three cases

We report three cases of symptomatic acute carotid thrombosis occurring after carotid artery stenting (CAS). CASE 1: A patient presented with crescendo transient ischemic attacks on the second day after CAS. Ultrasound images demonstrated incomplete in-stent thrombosis due to plaque protrusion. The urgent surgical procedure consisted of stent removal and carotid thromboendarterectomy. CASE 2: A case of complete thrombosis of a carotid stent occurred 4 days after implantation in a patient with essential thrombocythemia diagnosed by chance. The surgical strategy included stent removal and carotid thromboendarterectomy. CASE 3: Cardiac multiple embolisms in a patient with chronic atrial fibrillation caused concomitant leg ischemia and acute carotid stent occlusion 2 hours after CAS. Cerebral reperfusion was established by embolectomy, without removing the stent. At the same time, the right leg ischemia was resolved by a thromboembolectomy with a Fogarty catheter. These three cases demonstrate that acute thrombosis after carotid stenting can be managed successfully with emergent surgical intervention. Thromboendarterectomy with stent removal or in selected cases, simple thromboembolectomy, can minimize neurologic sequelae in patients suffering from acute post-stenting carotid thrombosis.

Endovascular treatment of an internal carotid artery thrombus using reversal of flow: A case report

A case of a symptomatic free-floating thrombus of the internal carotid artery is described. A 51-year-old woman presented with a transient ischemic attack and was placed on anticoagulation after diagnosis with angiography. After medical therapy failed, she underwent suction embolectomy using reversal of flow with the Parodi Anti-Embolism System. Balloon angioplasty was performed, and a stent was placed. The patient tolerated the procedure well. A follow-up carotid ultrasound scan showed resolution of the thrombus.

Applications of percutaneous mechanical thrombectomy in transjugular intrahepatic portosystemic shunt and portal vein thrombosis

Portal vein thrombosis (PVT) is an uncommon cause for presinusoidal portal hypertension. PVT can be caused by one of three broad mechanisms: (1) spontaneous thrombosis when thrombosis develops in the absence of mechanical obstruction, usually in the presence of inherited or acquired hypercoagulable states; (2) intrinsic mechanical obstruction because of vascular injury and scarring or invasion by an intrahepatic or adjacent tumor; or (3) extrinsic constriction by adjacent tumor, lymphadenopathy or inflammatory process. Usually, several combined factors are necessary to result in PVT. The consequences of portal vein thrombosis are mostly related to the extension of the clot within the vein. Gastrointestinal bleeding from gastroesophageal varices is the most frequent presentation. Noninvasive imaging techniques are currently used for the screening of patients and the initial diagnosis of PVT. The invasive techniques are reserved for cases when noninvasive techniques are inconclusive, before percutaneous interventional treatment, or in preoperative assessment of patients who are candidates for surgery. Recanalization of the portal vein with anticoagulation alone may not be consistent or appropriate in highly symptomatic patients. Catheterization of the superior mesenteric artery (SMA) is helpful for diagnosis as well as for therapy by allowing the intra-arterial infusion of thrombolytic drugs in the same setting. Direct transhepatic portography allows precise determination of the degree of stenosis and extension within the portal vein, as well as pressure measurements. Thrombotic occlusions of the portal, mesenteric, and splenic veins can be managed by mechanical thrombectomy (MT) or pharmacologic thrombolysis. Underlying occlusions because of organized or refractory thrombus or fixed venous stenosis are best corrected by balloon angioplasty and stent placement. Access into the portal venous system can also be established through creating a transjugular intrahepatic portosystemic shunt (TIPS). Creating a TIPS is also important in the setting of PVT associated with cirrhosis to decompress portal hypertension and improve portal venous flow. PVT involving the portal, splenic, and/or mesenteric veins can also complicate a preexisting TIPS in which case the shunt can be readily used as therapy access. Several techniques may be used to recanalize the shunt and portal venous system, including thrombolytic therapy, balloon angioplasty/embolectomy, suction embolectomy, basket extraction of clots, and mechanical thrombectomy with a variety of devices. Advantages of MT include the potential to rapidly remove thrombus without the need for prolonged thrombolytic infusions, and reducing the potential life-threatening complications of thrombolytic therapy. Possible drawbacks include the risk of intimal or vascular trauma to the portal vein, which may promote recurrent thrombosis. © 2003 Elsevier Inc. All rights reserved.

Management of Acute Lower Extremity Embolus with Use of the Oasis Thrombectomy Device and Suction Embolectomy

JVIR 2000; 11:1331–1335 IN the clinical setting of acute lower extremity embolus with limb threatening ischemia, there is a need for a reliable method of percutaneous thrombectomy. Percutaneous removal of arterial thrombus with the use of several devices has been reported, with mixed results (1). One promising class of thrombectomy device extracts thrombus using a Venturi effect created by a rapid jet of saline (rheolytic) (2). There is no one device that is universally applicable, and more than one type of device to achieve complete thrombectomy is often necessary (3). We present a case of an acute lower extremity embolus in which a rheolytic thrombectomy catheter and suction embolectomy were used to rapidly revascularize a threatened limb. A simple technique was used to arrest flow while the rheolytic device was activated to allow the device to more completely remove the thrombus and, at the same time, minimize the risk of distal embolization.

Acute Intraoperative Embolic Peroneal Artery Occlusion: Treatment with Suction Embolectomy, Angioplasty, and the Transluminal Extraction Catheter

Acute Intraoperative Embolic Peroneal Artery Occlusion: Treatment with Suction Embolectomy, Angioplasty, and the Transluminal Extraction Catheter