Surgical Thrombectomy Research Articles

Post-traumatic giant thrombosis of inferior vena cava induced right-sided blunt traumatic diaphragmatic injury: a case report

BackgroundInferior vena cava thrombosis is a severe disease as it carries a higher risk of developing pulmonary embolism associated with a high mortality rate. The incidence of inferior vena cava thrombosis is extremely low and is commonly associated with outflow obstruction of the inferior vena cava. The frequency of traumatic diaphragmatic injuries is less than 1% of all traumatic injuries. In addition, it was not a typical cause of inferior vena cava obstruction. We report the case of the patient who presented with giant thrombosis of the inferior vena cava, which required surgical treatment-induced right-sided blunt traumatic diaphragmatic injury.Case presentationA 60-year-old male presented to the emergency department with pelvic and lower leg pain. He was working on a dump truck with the bed raised position. Suddenly, the bed came down, and his body was crushed and injured. Primary CT showed a right lung contusion and elevation of the right diaphragm but no apparent liver injury. The right pleural effusion gradually worsened after admission, as the traumatic diaphragmatic injury was highly suspected. Repeat CT showed aggravation of elevation of the right-sided diaphragm, narrowing of the inferior hepatic vena cava due to left cephalic deviation of the liver, and formation of a giant thrombus in the inferior vena cava. No adverse hemodynamic effects were observed due to thrombus formation, and we performed thrombolytic therapy. The day after starting thrombolytic therapy, the patient developed pulmonary embolism due to a dropped in SpO2 needed oxygen, and dyspnea triggered by coughing. Thrombolytic therapy was continued after the diagnosis of pulmonary embolism. However, thrombolytic therapy was ineffective, so we decided on surgical thrombectomy and inferior vena cava filter placement. The postoperative course was not eventful, and an anticoagulant was started. The patient was transferred to the hospital on the 62nd day for rehabilitation.ConclusionsWhen a diaphragmatic hernia is suspected of causing hepatic hernia and narrowing of the inferior vena cava, it may be necessary to consider emergency surgical treatment to prevent secondary inferior vena cava thrombosis and fatal pulmonary embolism.

Outcomes in high-risk pulmonary embolism patients undergoing FlowTriever mechanical thrombectomy: the FLAME study in perspective.

Pulmonary embolism (PE) is a common and life-threatening acute cardiovascular problem. In some patients, an abrupt increase in right ventricular (RV) afterload and impaired gas exchange result in acute RV failure, hypoperfusion, and severe hypoxemia due to V/Q mismatch. State-of-the-art management of acute PE includes early detection, risk stratification based on clinical, imaging, and biomarker criteria, and multidisciplinary decision-making regarding therapy.1,2 The European Society of Cardiology guidelines for management of PE recommend selection of therapy based on clinical severity of the presentation with class I recommendations for anticoagulation and systemic thrombolysis in patients with high-risk PE and for surgical thrombectomy in such patients in whom thrombolysis is contraindicated or has failed.3 Catheter-directed interventions for acute PE are aimed at increasing the cross-sectional area of patent pulmonary vasculature, thereby lowering resistance and alleviating V/Q mismatch.1,2 Percutaneous catheter-directed treatments are recommended as a reasonable alternative (Class IIa) in patients for whom thrombolysis is contraindicated or has failed.

Clinical case of surgical treatment of pulmonary embolism

Pulmonary embolism is a disease associated with significant prevalence. Incidence of venous thromboembolism in countries of Europe is 100–200 cases per 100 thousand per year. Annual morbidity for venous thromboembolism in the United States is 71–117 cases per 100 000. Surgical pulmonary thrombectomy is an effective method of treatment, however, remains ambiguous due to the small number of multicenter studies. In this case report the result of surgical treatment of patient with acute massive pulmonary embolism is presented.

Surgical Thrombectomy for Complete Portal Vein Thrombosis Induced by Blunt Abdominal Trauma

Background: Blunt abdominal injury is a known, but very rare cause of portal vein thrombosis.In most cases, full anticoagulant therapy is sufficient. Surgical thrombectomy is an extremely rare procedure in the treatment of acute portal thrombosis. Materials and Methods: We present a case of a young patient with portal vein thrombosis and its branches after a blunt abdominal injury resulting from the sport. Due to severe infarction of the intestinal loops, we chose surgical thrombectomy as the only causal treatment option. This procedure is generally rarely reported in the scientific literature. However, it has not yet been described with a blunt abdominal injury. The patient was subsequently shown to have a Leiden mutation in a heterozygous form. The interplay of all factors including blunt abdominal injury, Leiden mutation, and intestinal malrotation could lead to acute thrombosis of the portal vein and its branches. Conclusions: We successfully used direct surgical thrombectomy from portal vein and its branches for the patient with portal vein thrombosis and severe small intestine infarction after a blunt abdominal trauma as the only available treatment option, because other treatment options were not suitable in this patient.In our case, early diagnosis, right decision to choose surgical treatment, and direct surgical trombectomy resulted in success and the patient has fully returned to normal life.

Functional outcome of arterial thoracic outlet syndrome treatment.

The low prevalence of Arterial Thoracic Outlet Syndrome (ATOS) and diffuse symptomatology have resulted in limited data on optimal treatment strategies and long-term outcome. The aim of this study was to report and evaluate a single center experience with the treatment of ATOS including midterm patient reported outcome. All patients treated for ATOS from 2004 to 2020 were retrospectively identified. Patients were divided into two groups based on presenting symptoms; ATOX group (Acute arterial occlusion with ischemia) and ATOS group (claudication symptoms). Baseline characteristics and treatment details were extracted from electronic patient files. A telephone survey was conducted to collect patients' follow-up data including a functional disability score using the Quick Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The primary endpoint of this study was symptom-free survival. Secondary endpoints were median QuickDASH scores during follow-up, postoperative complications and possible re-interventions. A total of 20 patients (mean age 44.6 years, median follow-up 50.5 months) were included and divided into two groups (ATOX N = 9, ATOS N = 11). In the ATOX group, eight patients were primarily treated with catheter directed thrombolysis (CDT; N = 5) or surgical thrombectomy (N = 3). All patients received staged thoracic outlet decompression surgery (TOD). In the ATOS group, 10 patients primarily received TOD and one patient was treated conservatively with physiotherapy. Seven ATOX patients and nine ATOS patients were symptom free at follow-up with a median QuickDASH score of 2.3 (IQR 12.5) and 2.3 (IQR 16.5) respectively. Ten complications occurred in the ATOX group; three bleeding complications, five re-occlusions, one arterial dissection and one occipital infarction. In the ATOS group five complications occurred; one perioperative bleeding complication, three re-occlusions and a stent fracture. Seven vs. five re-interventions were required in the ATOX and ATOS groups respectively. The mid-term self-reported symptom free survival in both the ATOX as well as ATOS group seems acceptable while median QuickDASH scores in both groups indicate a very good functional outcome. This however comes at the cost of treatment related bleeding complications in especially the ATOX group presumably due to thrombolysis, and re-interventions required in almost one out of three patients.

Histologic and Immunohistochemical Features of Antemortem Thrombus Compared to Postmortem Clot: Updating the Definition of Lines of Zahn.

Distinguishing true antemortem thrombus (AMT) from artifactual postmortem clot (PMC) can occasionally be challenging at autopsy. Lines of Zahn are cited as pathognomonic of AMT, but review of literature reveals heterogeneous definitions of the term. Neutrophil karyorrhexis and CD61 immunohistochemistry can also be used to define AMT, but there has been no systematic study determining the specificity of these features. To identify features that distinguish AMT from PMC, and to clarify the definition of lines of Zahn. PMC from the heart was collected in 50 hospital autopsies. Fifty arterial and 50 venous surgical thrombectomy specimens were reviewed for comparison. The microscopic features with hematoxylin-eosin staining, phosphotungstic acid-hematoxylin (PTAH) staining, and CD61 immunohistochemistry were documented. Thin curvilinear strands of fibrin and clumps of fibrin were frequently observed in both AMT and PMC. Thick bands of nested platelets wrapped in fibrin were nearly exclusive to AMT. Neutrophil karyorrhexis was readily apparent on low power in AMT but was seen in 40 of 50 PMCs (80%) only sparsely on high-power examination. Bone marrow elements were identified in 38 of 50 PMCs (76%). CD61 staining showed a geographic pattern in AMT and a speckled pattern in PMC. PTAH staining confirmed features seen with hematoxylin-eosin. Thin curvilinear strands of fibrin are found in both AMT and PMC and can be misinterpreted as lines of Zahn. We define lines of Zahn as thick bands formed by nested platelets wrapped in fibrin. Diffuse neutrophil karyorrhexis is common in AMT; in contrast, bone marrow elements are often seen in PMC.

A Case of Giant Thrombosed Vertebral Artery Aneurysm Treated by Endovascular Treatment and Surgical Thrombectomy

A Case of Giant Thrombosed Vertebral Artery Aneurysm Treated by Endovascular Treatment and Surgical Thrombectomy

Asymptomatic pulmonary thromboembolism due to hemodialisys catheter thrombosis: case series and literature review.

Right atrial thrombus is commonly associated to catheters. Catheter-related right atrial thrombus (CRAT) in hemodialysis patients frequently presents as pulmonary embolism. Although CRAT is sometimes asymptomatic, even in these cases it is associated with worse prognosis. The management strategy for CRAT is not well established, however, along with catheter removal, anticoagulation, thrombolysis, and surgical thrombectomy may be performed. Suspicion of asymptomatic pulmonary embolism associated to CRAT is important in order to perform proper treatment. The authors of this article report two cases of asymptomatic pulmonary thromboembolism due to CRAT in hemodialysis patients and perform a review of the literature.

Advances in the therapy of cerebral ischemia-reperfusion injury with natural product-based nanoparticles

Stroke is a serious acute cerebrovascular disease attributable to disruptions in the blood supply to the brain tissue as a result of vascular obstruction or sudden rupture of blood vessels in the brain, which further result in hypoxia of the brain and reduction of necessary nutrients, apoptosis of neurons, and damage to brain tissue. The majority of stroke patients are ischemic stroke. The main clinical treatments for ischemic stroke include medical thrombolysis in the early stage of onset and surgical thrombectomy or stent implantation in the late stage of onset, all of which have their own indications, advantages, and disadvantages, and show limited clinical application. For cerebral ischemia-reperfusion injury with an extremely poor prognosis, there is currently no effective prevention and treatment method in the clinic. Therefore, timely and effective treatment is needed to treat cerebral ischemia-reperfusion injury. An increasing number of studies have shown that natural products have a good curative effect on cerebral ischemia-reperfusion injury. However, due to their low solubility, low bioavailability, and short half-life, many natural products cannot optimally exert their curative effects on cerebral ischemia-reperfusion injury. Natural products-based nanoparticles modified with specific ligands have attracted much attention because of their high-efficiency permeation through the blood–brain barrier, targeted delivery abilities, and the protection of the active components from degradation. Therefore, this review focused on the prevention and treatment of cerebral ischemia-reperfusion injury in the natural product-based nanoparticles.

Abstract 11687: Diagnosis and Management of High-Risk Pulmonary Embolism in a Term Neonate

Case Presentation: A 5 day old, term infant born to a 39-year-old G1P0 with a history of diet-controlled gestational diabetes mellitus presented with hypernatremic dehydration in the setting of poor feeding. On hospital day 2, the infant suffered a bradycardic cardiac arrest requiring 2 minutes of CPR prior to return of spontaneous circulation. An echocardiogram (Figure 1A) revealed moderately depressed right ventricular (RV) function, elevated RV pressure and a large mobile mass extending from the main pulmonary artery (PA) into the left PA with obstruction of flow. D-dimer was markedly elevated at 2740 ng/mL. A subsequent CT angiogram revealed acute pulmonary emboli in the distal left and right branch PAs (Figure 1B). Additional imaging was obtained and showed dural venous sinus, left portal vein and right cephalic vein thromboses. The infant was managed with a heparin infusion and supportive therapy for the RV dysfunction and pulmonary hypertension including mechanical ventilation, inhaled nitric oxide as well as epinephrine and milrinone infusions. Over the course of two weeks, the infant improved clinically with normalization of RV function. Discussion: Neonatal pulmonary arterial thrombosis is an exceedingly rare phenomenon. The majority of cases described in the literature are associated with either an inherited thrombophilia or with underlying congenital heart disease, which were not found to be present in this case. However, this patient presented with severe dehydration and a history of maternal diabetes, both of which are risk factors for neonatal thrombosis. Fortunately, this patient responded to treatment with anticoagulation alone and did not require more invasive therapies, such as surgical thrombectomy or systemic and catheter-directed thrombolysis. Although rare, neonatal pulmonary arterial thrombosis can occur and delays in recognition and treatment may lead to significant RV dysfunction, morbidity, and even death.

Abstract 15639: Infected Thrombus - An Unusual Etiology of Acute Coronary Syndrome in a Patient With New Onset Atrial Fibrillation

Background: Coronary embolism (CE) is an uncommon (3%) cause of acute coronary syndromes (ACS) and is often missed. Case Presentation: A 68-year-old woman with a h/o hypertension & breast cancer post lumpectomy 10 yrs ago, presented with generalized weakness, fever (101F), & vomiting without chest pain, dyspnea, or palpitations. She was afebrile, tachycardic (158 beats/min), tachypneic (26 breaths/min) with BP of 98/64 mmHg. Cardiac exam revealed irregularly irregular rhythm, 5 cm jugular venous distension & 3+ bilateral pretibial edema. Labs revealed thrombocytopenia, lactic acidosis, & hyponatremia. High sensitivity-Troponin was 1023 & NT-pro-BNP 19854. EKG showed atrial fibrillation (AF), diffuse ST elevations in the precordial leads & aVR, poor R wave progression & inferior Q waves. Her cardiac cath revealed a large thrombus from mid-left main extending into the LAD with minimal atherosclerotic burden. Intraoperative transesophageal echocardiogram for emergent surgical resection of the thrombus revealed a highly mobile thrombus 2.32x0.6 cm on the aortic aspect originating between L and R coronary cusps and a left atrial appendage thrombus (1.1 cm) with marked spontaneous contrast in LA appendage & LA which was surgically resected. Blood cultures & of coronary thrombus grew Methicillin sensitive Staphylococcus Aureus (MSSA) . Anticoagulation & appropriate antibiotics were initiated. but after a protracted, complicated ICU stay, patient was made comfort care. Discussion/Conclusion: CE should be considered in cases of recurrent coronary thrombus or in the setting of heavy thrombus burden despite a relatively normal coronary vessel. AF is the most common underlying cause of CE causing ACS. Aspiration or surgical thrombectomy should be performed with a high thrombus burden. Thrombus should be sent for pathology to further delineate the source of thrombus.

Abstract 14401: A Rare Case of Patent Foramen Ovale Thrombus Caught in Transit

Introduction: Patent foramen ovale (PFO), seen in about 20-25% of the population, is linked with paradoxical embolism. However, a paradoxical thrombus seen in transit through a PFO is an extremely rare finding. Case: An 80-year-old-female with a history of stroke, atrial fibrillation (AF), and diabetes presented with a complaint of dizziness. She had a history of non-compliance with her anticoagulation for AF. EKG showed AF with rapid ventricular rate. An echocardiogram showed a large mobile thrombus in both atria representing a paradoxical embolus in transit caught in PFO (Figure A). Right ventricular systolic function was noted to be severely reduced. A transesophageal echocardiogram confirmed a paradoxical embolus in transit with a large amount of mobile thrombus in the left atrium (Figure B, C). Large saddle acute pulmonary embolus, extending bilaterally into main, lobar, and segmental pulmonary arteries, was seen on the CT chest (Figure D). Lower extremity ultrasound revealed right popliteal vein thrombosis extending to the peroneal vein. Due to a high risk of paradoxical systemic embolism patient underwent emergent surgical thrombectomy along with the closure of PFO. Conclusion: Paradoxical thrombus in transit through PFO carries a high risk of systemic embolism. Therapeutic options for patients include cardiac surgery with thrombectomy, thrombolysis, or systemic anticoagulation, with no clear consensus regarding the best treatment option.

Outcomes of Surgical and Mechanical Thrombectomy in Massive Saddle Pulmonary Embolism: A National Perspective.

Introduction Saddle pulmonary embolism (PE) is a type of central PE that involves the bifurcation of the pulmonary arteries. First-line treatment is usually systemic thrombolytics, but surgical and mechanical thrombectomy (ST and MT) are used for patients with contraindications to thrombolytics or right heart strain. This study compares surgical and mechanical thrombectomy trends and outcomes in patients with saddle PE. Methods The data was extracted from the National In-Patient Sample (NIS) from 2016-2018 using the International Classification of Diseases-10-Clinical Modification (ICD-10-CM) diagnosis codes. We used the Cochrane-Armitage trend test to analyze the trends of ST and MT and the chi-square test for statistical analyses. A two-tailed p-value of <0.05 was considered statistically significant. Results The overall trend of MT in saddle PE rose from 2016 to 2018, while ST remained stable. Around 95% of patients undergoing ST/MT were emergent admissions, with 82.5% occurring in teaching hospitals. Patients of age >65 years and more with comorbidity burdens were more likely to undergo MT over ST. In-hospital mortality after ST was 15.1%, and after MT was 11.1% (p:<0.001). The most common complications after ST were congestive heart failure (CHF) and atrial fibrillation (AF), and after MT were vascular events and CHF. Conclusion The use of mechanical thrombectomy has steadily increased during the study period. ST is more common in large/teaching hospitals, weekend admissions, and patients transferred from other facilities. MT is more common in elderly patients with a higher comorbidity burden. Patients who underwent MT had lowermortality, length of hospital stay, and post-procedural complications.

Pulmonary embolism response team implementation and its clinical value across countries: a scoping review and meta-analysis

Abstract Background Over the last years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has been developed to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE), but data on the use and the benefit of PERT are sparse. Purpose We aimed to systematically investigate the composition of PERT and its clinical value in clinical routine across different countries. Methods We searched PubMed, CENTRAL and Web of Science until January 2022 for full-text, prospective and retrospective observational studies, which included patients with acute PE who were evaluated by a PERT. Eligible articles were designed to either describe the structure and function of PERTs and/or to investigate outcomes related to the implementation of PERT. We performed a random-effects meta-analysis of controlled studies (PERT vs. pre-PERT era) to investigate the impact of PERTs on clinical outcomes and use of advanced therapies. Results We included 22 original studies and four surveys. Overall, 31.5% of patients with PE were evaluated by PERT referred mostly by emergency departments (59.4%). In total, PERT involved a median of 6 (range 2–10) specialties for guiding further diagnostic and treatment modalities. Patients evaluated by a PERT had a mean age of 60 years; of them, 48.7% were females, and 23.5% suffered from malignancy. Right ventricular dysfunction was present in 55% of the patients. In total, 74.5% were classified as intermediate-risk PE and 16% as high-risk PE. In eleven single-arm studies, 1,532 patients with intermediate- and high-risk PE were evaluated by PERT with a mortality rate of 10% and a bleeding rate of 9%. The mean length of stay was 7.3 days and the use of advanced therapy was reported in 30% of all cases. From these, catheter-directed treatment (CDT) was performed in 22% and inferior vena cava filter was inserted in 15%, while systemic thrombolysis was administered in only 6%, surgical thrombectomy in 2% and ECMO in 3% of all cases. When comparing PERT and pre-PERT era no difference in mortality (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.67–1.19, I2=63%) was observed based on nine controlled studies, while mortality tended to be lower when including only intermediate and high-risk patients in the analysis (RR 0.71, 95% CI 045–1.12) (Figure 1). The use of advanced therapies was more common (RR 2.67, 95% CI 1.29–5.50) and the in-hospital stay as well as the duration of treatment in intensive care unit was shorter (mean difference −1.6 days and −1.8 days, respectively) in the PERT era. Conclusion PERT implementation tended to reduce the mortality rate in patients with intermediate- and high-risk PE and resulted in a shorter in-hospital stay. Large prospective studies are needed to further explore the impact of PERTs on clinical outcomes. Funding Acknowledgement Type of funding sources: None.

WHERE ARE YOU GOING: EMERGENCY MANAGEMENT OF A THROMBUS-IN-TRANSIT WITH PERCUTANEOUS MECHANICAL THROMBECTOMY AT A COMMUNITY HOSPITAL

WHERE ARE YOU GOING: EMERGENCY MANAGEMENT OF A THROMBUS-IN-TRANSIT WITH PERCUTANEOUS MECHANICAL THROMBECTOMY AT A COMMUNITY HOSPITAL

Pediatric Abdominal Malignancies and Intravascular Extension: Contemporary Single-Center Experience

IntroductionInferior vena cava (IVC) thrombus is an uncommon and challenging complication of abdominal malignancies in the pediatric population, which significantly influences the treatment options and clinical outcomes in this population. MethodsIn this review, we present the presentation, treatments, interventions, and outcomes with this clinically and technically challenging oncological finding from a free-standing children's hospital from 2006 to 2017. ResultsFourteen patients with IVC thrombus were identified as having an associated abdominal malignancy. The abdominal malignancies consisted of eight Wilms tumors (63% stage III and 37% stage IV), and one spindle cell sarcoma, neuroblastoma (stage III), kidney clear cell sarcoma (stage III), sclerosing epithelioid fibrosarcoma, hepatoblastoma-epithelial (stage IV), and hepatic embryonal sarcoma (stage IV). 50% of patients were male, 71% White, 29% Black, 7% Hispanic; mean age at diagnosis was 4.09 (SD 2.43) years. CT imaging identified IVC tumor thrombus for 79% of patients, US abdomen complete recorded 14%, and MRI lumbar 7%. 3Out of 14 patients, 13 patients were taken to the operating room with 12 patients undergoing concurrent tumor resection and IVC thrombectomy. Of the remaining patients, one had IVC thrombectomy via femoral cutdown by interventional radiology, and one was noted to have resolution of IVC thrombus with neoadjuvant chemotherapy. Of patients who underwent resection, one required IVC ligation, and one patient required IVC interposition vein graft reconstruction using a right IJ conduit. 60% of patients undergoing thrombectomy received neoadjuvant chemotherapy. Mean time from the diagnosis of IVC tumor thrombus to surgical thrombectomy was 46 (SD 44) days. No operative mortalities were reported. There were five major complications (hemothorax, pulmonary embolisms, seroma, and sepsis) and two minor complications (pneumonia and UTI). With exclusion of patient who underwent IVC ligation, no patients developed signs of IVC compression or recurrent thrombosis after thrombectomy. ConclusionsIVC tumor thrombus can significantly alter the clinical treatment, surgical options, and outcomes of malignant abdominal tumors. Treatment of IVC tumor thrombus included adjuvant chemotherapy, segmental IVC resection with or without reconstruction, thrombectomy with intimal stripping, or resection of the thrombus with part of the IVC wall. Evidence for standard treatment practices for IVC tumor thrombus in the setting of abdominal malignancy is lacking due to the rarity of this finding and the varied clinical presentations.

Percutaneous Right Atrial Thrombectomy Using Flow Triever (Inari) and En Snare Endovascular System : A Safe Alternative to Surgical Approach - Report of Two Cases

Surgical thrombectomy is considered the gold standard approach for removal of thrombotic disease within the right heart (RiTH), however some patients have prohibitive surgical risk and the percutaneous approach has been increasingly popular in the past few years. In this manuscript, we present two case reports of patients with both acute and chronic right atrial thrombi; in whom elevated surgical risk deemed them not surgical candidates and both successfully underwent mechanical thrombectomy with Flow Triever suction catheter and En snare endovascular system. To our knowledge, these are the first reported cases of the use of both of these devices for treatment of RiTH.

MO785: Balancing the Covid-19 Pandemic Impact on the Maintenance of Haemodialysis Vascular Access

BACKGROUND AND AIMSThe new coronavirus disease, named by World Health Organization (WHO) as COVID-19 brought great challenges to patients with end-stage renal disease (ESRD). In general, ESRD patients have a higher number of comorbidities and are at risk for the severe presentation of this disease.As a lifeline of haemodialysis patients, vascular access (VA) care has a profound impact on the patient's quality of dialysis and life but the ideal management of VA during the pandemic is currently unknown.Many centres differed on their approach and referral criteria to minimize COVID-19 risk but the impact on VA and patient survival is unknown.In this multicentre retrospective cross-sectional study, we analysed the impact of the pandemic on VA maintenance in Vascular Access Centres of Nephrocare Portugal.METHODThe authors collected VA data from haemodialysis patients treated at three Vascular Access Centers of NeproCare Portugal from January 2019 to July 2021 and compared the year before and after the pandemic.RESULTSOf the 14 352 haemodilaysis patients included, with a mean age of 68 ± 14 years, 7.161 procedures were analysed.A total of 4086 endovascular procedures and 3075 surgeries were performed from January 2019 to July 2021 in the three national vascular access centres of Nephrocare.Blood flow decrease measured by the blood temperature sensor BTM_ (Blood Temperature Monitor), Fresenius Medical Care, Bad Homburg, Germany was the most frequent motive of referral to an endovascular procedure before and after the pandemic (P .221).During both waves, physical examination and clinical signs were the most affected motives of referral, followed by a rebound significantly increase (P .058).Thrombosis remained stable during the lockdown followed by a non-significant trend to increase.New vascular access creation was the most frequent motive to send a patient to surgery before and after the pandemic (P .480).Fistula and prosthesis thrombosis also didn't significantly increase as a motive of referral to a VAC (P .221 and 1.0 respectively).Angioplasty without stent followed by thrombolysis was the most frequent types of endovascular procedures before and during the pandemic without significant differences (P .430).Surgical thrombectomy followed by fistula creation were the most frequent types of surgical procedures before and during the pandemic without significant differences (P .683).During the first wave, there was a decrease in procedures without possibility to intervention (P .037) with posterior significant rebound increase.Although there was a trend to a decrease in intervention, the number and types of procedures didn't significantly change before and during the pandemic even after separating different centres.Additionally, the number of hospital admissions related to vascular access also didn't significantly change (P .368).CONCLUSIONWith the implementation of proactive infection control measures, it was possible to maintain proper monitoring, surveillance and VA care without significantly increasing the rate of thrombosis and minimizing related hospital admissions of haemodialysis patients.

Which is the best reperfusion therapy in patients with acute pulmonary embolism?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Pulmonary embolism (PE) represents the third most common cause of cardiovascular death. Reperfusion therapy is recommended in patients with high-risk PE, while in intermediate-risk PE is controversial but could be indicated in those patients with a higher risk of hemodynamic instability and death due to right ventricular failure. Currently, the recommended reperfusion strategy in this group of patients is systemic thrombolysis. Catheter directed therapy can also be considered with less clinical evidence. Purpose Determine the safety and efficacy of catheter directed therapy compared with systemic thrombolysis in patients with acute PE who required reperfusion therapy. Methods A single-center retrospective observational cohort study was carried out in patients who were admitted for PE in a University Hospital from 2008 to 2021. Patients with intermediate-high and high risk PE, according to ESC guidelines, who underwent reperfusion therapies based on an institutional clinical practice guideline were included. Reperfusion was recommended in high-risk patients and those with intermediate-high risk who presented right ventricular dilatation associated with at least two of the following: heart rate ≥ 100bpm, systolic blood pressure ≤100mmHg or lactic acid ≥2mmol / L. Patients with surgical thrombectomy were excluded. In-hospital outcomes and 30-day follow-up between both strategies were analyzed. Results Catheter directed therapy was performed in 66% and systemic thrombolysis in 34% of the population. The prevalence of hemodynamic instability was 28.1% and in-hospital mortality was 25%. Baseline characteristics of both populations were similar and there were no differences in the location of the thrombi between both groups. In-hospital mortality and major bleeding rates between catheter directed therapy and systemic thrombolysis were similar between both strategies (27.2% vs. 23.8%) and (9.0% vs. 4.7%) respectively. Both treatment groups presented a significant reduction in right ventricular diameters after reperfusion. Only catheter directed therapy showed an improvement in right ventricular function and a reduction in pulmonary pressures. Conclusion In this population no differences were observed in terms of safety and efficacy between both reperfusion therapies. Both strategies significantly reduced right ventricular diameters after reperfusion but only catheter directed therapy improved right ventricular function and reduced pulmonary pressures after 30 days which could have implications in a lower incidence of chronic thromboembolic pulmonary hypertension.

False lumen thrombus following aortic dissection diagnosed as the source of repeat lower extremity emboli with angioscopy: a case report

BackgroundAcute arterial embolization caused by a free-floating thrombus of the false lumen after surgery for acute aortic dissection is a rare complication; hence, determining its cause may be difficult. We report a case in which angioscopy was valuable in diagnosing and treating the unstable thrombus within the false lumen.Case presentationThe patient was a 71-year-old woman who underwent hemiarch replacement for Stanford type A acute aortic dissection. Two months after the operation, left renal infarction occurred. Eighteen months after the operation, the patient visited the hospital for treatment of intermittent claudication of her left leg. Computed tomography (CT) showed occlusion below the left common femoral artery. Surgical thrombectomy was performed for acute lower extremity arterial occlusion. One month later, thrombectomy was performed again for the same phenomenon and again after 2 months. She had no history of cardiac arrhythmia. No obvious source for the repeat embolization could be found on echocardiography or enhanced CT. Angiography was performed to further identify the cause, revealing a new entry site at the distal anastomosis, which exhibited antegrade flow into the false lumen. Furthermore, selective false lumen angiography via the re-entry revealed a thrombus in the false lumen corresponding to the descending aorta. A non-obstructive angioscopy system in the false lumen revealed a free-floating thrombus. As the patient had undergone multiple surgeries over a short period and desired minimally invasive treatment, coil embolization of the new entry site as well as false lumen was performed. As a result, blood flow from the true to the false lumen resolved. More than 1 year has passed following coil embolization with no signs of embolism.ConclusionsWe experienced a case of repeat embolism caused by unstable thrombus formation in the false lumen resulting from antegrade blood flow in the false lumen secondary to development of a new entry site. Angioscopy revealed that this antegrade flow caused formation of an unstable thrombus which caused recurrent acute lower extremity arterial occlusion. Therefore, angioscopy may be a useful option for the diagnosis of false lumen thrombosis.