Thrombus Removal Research Articles

736 Hazy spots: through the eye of optical coherence tomography

Abstract Aims Acute stent thrombosis after coronary artery stent placement is a rare but serious complication in percutaneous coronary intervention (PCI). Stenting culprit lesions in acute coronary syndrome (ACS) has higher risk of acute stent thrombosis than stable coronary artery disease, and many local and systemic factors may contribute to increase this risk. Tissue protrusion (TP), and in particular, plaque prolapse after PCI can play a role in acute stent thrombosis, and intra-vessel imaging is the principal instrument to identify such underlying lumen alteration after stent implantation, and guide intervention. Methods and results We report the case of a 54-year-old man with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, obesity and no other relevant comorbidities in remote history, who underwent a coronary angiography for an unstable angina. A long, calcific sub-occlusion of the left anterior descending artery (LAD), which involved LAD-first diagonal branch (D1) bifurcation (Medina 1.1.1) and LAD-D2 bifurcation (Medina 1.1.0) was found. After deployment of two overlapping drug-eluting stents (DES), (ULTIMASTER TANSEI 3.0 × 38 mm and 3.0 × 21 mm) and struts apposition optimization with sequence of proximal optimization technique (POT) on D1 and D2, and a kissing balloon technique (KS) on LAD-D2 bifurcation, a ‘hazy’ in-stent image was detected right after the LAD-D2 bifurcation, suggesting an acute in-stent thrombosis, in absence of flow alteration (TIMI 3), symptoms or ECG modifications. Multiple thrombus-aspiration were made and resulted in abundant thrombus removal and improvement in the angiographic image, with persistent valid flow on every three vessels (TIMI 3). After 5 days of triple anticoagulant therapy with ticagrelor, cardioaspirin and UFH infusion, he underwent a new coronary angiography control. A similar ‘hazy’ image was detected right after LAD-D2 bifurcation within the LAD. An optical coherence tomography (OCT) pullback was made to assess the nature of the angiographic finding. OCT showed good struts apposition in almost every cross-sectional images, but an evident TP was detected right on the angiographic hazy spot. OCT allowed to evaluate the lipid-richness of the stented plaque and the nature of the TP, which was mixed with evident both white and red thrombus apposition (minimum luminal area measured 4.5 mm2). OCT guided a new PCI, with a stent-in-stent implantation on LAD. TP was absent on the post-PCI OCT run. Conclusions In this report, we showed the usefulness of OCT in revealing a potential high risk thrombogenic source. OCT not only characterized something that angiography alone couldn’t, but suggested the etiology of the amount of thrombus removed by the vessel during the first PCI. Indeed, despite an optimized cycle of anticoagulant therapy, OCT still revealed several mixed thrombus apposition on the TP, and this suggested its role in the acute stent thrombosis. OCT guided the choice to appose a new stent-in-stent to solve a potential thrombogenic source.

3D Turbo Spin-echo MRI-based Mechanical Thrombectomy at Middle Cerebral Artery Bifurcations.

We describe three cases with acute middle cerebral artery (MCA) occlusion. From the pre-operative MRI, including three-dimensional turbo spin-echo sequences using T1WI and T2WI, we assessed both thrombus configuration and arterial anatomy at the MCA bifurcations. For efficient endovascular thrombectomy, we identified the applied MCA segment 2 (M2) branch, in which the main thrombus was buried. Sufficient recanalization after a single pass was achieved and the patients made a marked recovery. Although mechanical thrombectomy for M2 occlusion has not been of proven benefit, the endovascular procedure based on three-dimensional turbo spin-echo imaging is useful for more complete thrombus removal at MCA bifurcations.

Aortic Thrombus Embolization in A Patient with Tuberous Sclerosis

AbstractTuberous sclerosis complex (TSC) is an autosomal dominant genetic disorder affecting many organ systems. Patients commonly develop a variety of benign tumors as well as neurological disease, including seizures, autism, and cognitive delay. We report here the case of an adolescent patient with TSC and a history of mild COVID-19 who presented with a 1-day history of altered mental status. The patient was found to have ischemic cerebral infarction of the right MCA and ACA territories. Initial angiography showed an occlusion of the right internal carotid artery without a demonstrable etiology, with follow-up echocardiography and angiography revealing a large aortic thrombus. The patient was not a candidate for thrombus removal due to her cerebral infarct and received medical anticoagulation. Thrombosis progressed to involve the left ICA, with left cerebral infarction and subsequent death. Aortic thrombus embolization as a cause of cerebrovascular accident (CVA) is a novel finding in the setting of TSC and should be considered for pediatric patients with CVA of unknown etiology. It is unclear whether this was related to the prior COVID-19 infection.

Functional evaluation of anterolateral thigh flap and forearm flap for repairing defects after oropharyngeal cancer

Objective:To investigate the oropharyngeal function recovery of oropharyngeal squamous cell carcinoma repaired by anterolateral thigh flap and forearm flap. Methods:Retrospective study between September 2016 and September 2020 complete line 37 cases of oropharyngeal cancer postoperative soft tissue defect of femoral anterolateral flap or forearm flap to repair the patient data, in which 22 cases, using the forearm skin flap to repair 15 cases with femoral anterolateral flap, flap survival rate of preparation, compare the two groups, the incidence of vascular crisis, The functions of swallowing, speech, and velopharyngeal closure were evaluated. Results:21 cases of forearm flaps survived, and 1 case had vascular crisis. After surgical exploration, the contralateral forearm flaps survived transplantation. Fourteen anterolateral femoral flaps survived, 2 flaps had vascular crisis, and 1 flap survived after thrombus removal. The other one was repaired with pectoralis major myocutaneous flap for necrosis. Swallowing, speech, palatopharyngeal closure and other functions of the patients after the two kinds of flap repair had higher satisfaction. Conclusion:Forearm flap and anterolateral thigh flap are good choices for soft tissue defect after oropharyngeal cancer, Must act according to the special details choice appropriate therapeutic schedule.

Technical success and short-term results from mechanical thrombectomy for lower extremity iliofemoral deep vein thrombosis using a computer aided mechanical aspiration thrombectomy device

BackgroundThe symptoms of deep vein thrombosis (DVT) include severe pain and swelling, and the complications can include post-thrombotic syndrome and recurrent venous thromboembolism. Aspiration thrombectomy (AT) treats arterial and venous disease by removing acute thrombus without reliance on thrombolytic agents but also has the potential to remove fresh blood. Intelligent aspiration is designed to minimize blood loss during AT by aspirating continuously in the thrombus but only intermittently when in a patent vascular segment with active flow. The Indigo System with Lightning 12 intelligent aspiration (Penumbra, Inc, Alameda, Calif) uses an automatic valve controlled by a proprietary computer algorithm to optimize thrombus removal and minimize blood loss. This computer-aided mechanical AT (CMAT) system was used for 16 consecutive patients. MethodsThe present retrospective review included 16 patients who had undergone CMAT for iliofemoral acute DVT from July 2020 to June 2021. The primary outcome was >70% thrombus removal as determined by multiplanar venography. The secondary outcomes included single-session therapy, blood loss during aspiration, the need for postprocedure blood transfusion, thrombolytic use, symptom resolution before discharge, and periprocedural complications. ResultsSixteen patients (mean age, 58.6 years; range, 31-80 years; 75.0% women) had undergone CMAT with the Lightning 12 system. All the patients had presented with pain and swelling of 2 to 16 days in duration. No patient had presented with phlegmasia. Access was obtained via the popliteal (n = 11), posterior tibial (n = 3), small saphenous (n = 1), or soleal (n = 1) vein. Thrombus reduction of ≥70% was achieved for all 16 patients (100%). Single-session therapy was successful for 15 patients (93.8%). Eight patients (50%) had received stents. All patients had experienced symptom resolution before discharge. The median blood loss was 155.0 mL (interquartile range, 95.0-187.5), and no patient had required a postprocedure transfusion. One patient had undergone angioplasty after thrombectomy, and one patient (6.2%) had received adjunctive tissue plasminogen activator therapy. No patient had developed postoperative acute kidney failure. No periprocedural complications occurred. At 1 to 8 months of follow-up, 15 of the 16 patients (93.8%) had patency of the treated iliofemoral area, and 14 (87.5%) had no recurrent symptoms. ConclusionsThese results suggest that CMAT using the Lightning 12 system is safe for clot removal for patients with acute iliofemoral DVT with a high rate of single-session technical success and symptom resolution. In the present case series, the Lightning 12 system was also associated with low blood loss, and no patient had required a blood transfusion.

Abstract 17133: Complete Inferior Vena Cava Thrombosis In A Sickle Cell Patient With Suspected May Thurner Syndrome

Case Presentation: 19 year old woman with sickle cell anemia and nephrotic syndrome presented with leg and back pain. While treated for vaso-occlusive crisis, patient developed dyspnea and chest pain. She underwent CT chest which revealed a right lower lobe pulmonary embolism. The patient was started on anticoagulation. Her transthoracic echocardiography revealed normal right heart function but nearly occlusive inferior vena cava (IVC) thrombus just distal to the right atrium. Subsequently a CT venogram demonstrated extensive thrombus from the left external iliac vein to the right atrium as well as compression of the left common iliac vein. Multidisciplinary discussion was performed to discuss options including medical therapy, surgical removal, or catheter-based removal. Given concern for further pulmonary embolization, patient underwent catheter based thrombus removal. A 26 french access was obtained in the right internal jugular vein and a 17 french access was obtained in the right femoral vein. Using the Angiovac system, mechanical thrombectomy was performed in the IVC. The angiovac system is a 24 french suction catheter with filtration and reperfusion through the right femoral vein. Limited thrombus removal was achieved. Next,14 french left femoral vein access was obtained and the Inari Clottriever device was used to mechanically score and remove a significant amount of thrombus (Figure 1). Post removal angiography revealed a patent IVC with minimal residual thrombus. Discussion: IVC thrombosis is a rare presentation of venous thromboembolism (VTE). This patient had multiple reasons for VTE including nephrotic syndrome and likely May Thurner Syndrome (MTS). MTS is an underdiagnosed entity resulting in mechanical compression of the left iliac vein in upto 50% of patients presenting with left lower extremity VTE. While proximal extension of thrombus is rare as seen in this case, high clinical suspicion is warranted for accurate diagnosis and treatment.

Impact of positive vascular margins status after surgical resection of non-metastatic renal cell carcinoma with caval tumour thrombus: a propensity score multicentre study.

Data evaluating the impact of positive vascular margins (PVMs) following surgical resection of non-metastatic renal cell carcinoma (RCC) with inferior vena cava (IVC) tumor thrombus are lacking. To analyze the oncological impact of positive vascular margins following surgical resection of RCC with IVC tumor thrombus. Patients who underwent radical nephrectomy with the removal of IVC tumour thrombus for RCC between 2000 and 2019 were included. PVMs were identified from pathology reports defined as microscopically identified tumour present in the IVC wall at the site of resection or in case of thrombus was not completely removed. To achieve balance in baseline characteristics between patients with PVMs versus negative vascular margins, we used inverse probability of treatment weighting (IPTW) based on the propensity score. Local recurrence, distant metastasis and overall mortality were evaluated between groups using Cox proportional hazards regression models. 209 patients were analyzed. Among them, 49 (23%) patients with PVMs were identified. Median follow-up was 55months. After adjustment, excellent balance was achieved for most propensity score variables. In IPTW analysis, PVMs was associated with a higher risk of local recurrence (HR = 3.66; p < 0.001) without any impact on systemic recurrence (HR = 1.15; p = 0.47) or overall mortality (HR = 1.23; p = 0.48). Limitations include the sample size and unmeasured confounding. Our results suggest that a PVMs in patients with RCC after nephrectomy with thrombectomy is associated with a higher risk of local recurrence, however, it did not appear to influence the risk of distant metastasis or death.

Flexible fibre optic bronchoscopy as angioscope to ascertain completeness of pulmonary embolectomy: surgery for pulmonary embolism-how I do it.

Rarely pulmonary embolectomy has also been used as a salvage procedure for acute right ventricle (RV) dysfunction following acute pulmonary embolism (APE). Complete surgical removal of thromboembolus in acute pulmonary thromboembolism is an essential pre-requisite for good outcome. Complete clearance of thromboembolic load from pulmonary arterial tree is difficult to assess intraoperatively. We hereby describe the use of flexible fibre optic bronchoscope (FFB) as angioscope to visualise the pulmonary arterial tree intraoperatively. Angioscopy ascertains the complete clearance up to subsegmental level after thromboembolectomy and aids in the removal of residual thrombus or embolus. Herein, we describe a case series of two patients, where FFB was used as angioscope during surgery for APE.

Mechanical Thrombectomy of Pulmonary Emboli With Use of the Indigo System and Lightning 12 Intelligent Aspiration

Mechanical Thrombectomy of Pulmonary Emboli With Use of the Indigo System and Lightning 12 Intelligent Aspiration

Case Reports: Endovascular Treatment of Cerebral Venous Sinus Thrombosis

Background: The causes of cerebral venous sinus thrombosis (CVST) are diverse, and headache is the only symptom in mild cases. However, in severe cases, perfusion disorders may concomitantly cause intracerebral hemorrhage, resulting in serious complications. Herein, we report two severe CVST cases in which good outcomes were obtained following endovascular treatment. Patients and Methods: Case 1. A 42-year-old man consulted an ophthalmologist with a chief complaint of decreased vision. The patient had a considerably high intraocular pressure and papilledema. However, due to unknown etiology, he was only prescribed eye drops. He subsequently developed headaches and experienced an alteration in his. An urgent surgery was performed with using the pull-back technique using a suction catheter, following which, the patient’s neurological symptoms improved. Case 2. A 50-year-old man was transferred to our hospital with a chief complaint of generalized clonic convulsions. The patient was diagnosed with venous sinus thrombosis. Attempts were made to crush the thrombus with a percutaneous transluminal angioplasty balloon and aspirate the thrombus with an aspiration catheter. However, thrombus removal and recanalization could not be achieved. Subsequently, a thrombectomy was performed using the FilterWire technique with a distal embolic protection device. Anterograde blood flow was restored, and the convulsive seizures disappeared. Conclusion: Venous perfusion injury should be avoided in severe cases of CVST, and endovascular treatment using various devices is a therapeutic option in such cases.

Thrombus Removal With ClotTriever in the ClotTriever Outcomes Registry: The Effect of Thrombus Chronicity

In deep vein thrombosis (DVT), the composition of the thrombus transforms over time, becoming more resistant to anticoagulation and thrombolytic treatment. A patient's clinical symptoms are often used to estimate the thrombus composition to help determine effective treatment. However, DVT can be asymptomatic for days to weeks. Using data from the CLOUT (ClotTriever Outcomes) Registry, a study evaluating real-world patient outcomes after treatment of lower extremity (LE) DVT with the ClotTriever System (Inari Medical, Irvine, Calif), we compared the indicators of thrombus chronicity and examined their effects on thrombus removal. The CLOUT Registry is actively enrolling ≤500 proximal LE DVT patients. Thrombus chronicity was assessed before the procedure according to symptom duration, during the procedure from the pretreatment imaging findings (venography, intravascular ultrasound, duplex ultrasound) and clinical history, and after thrombectomy by visual inspection of the thrombus morphology. Thrombus chronicity was classified as acute (<2 weeks), subacute (2-6 weeks), or chronic (>6 weeks). Complete or near-complete thrombus removal was defined as ≥75%, calculated via core laboratory-adjudicated Marder scores. A total of 225 patients (age, 58.7 ± 15.3 years; 52.9% male) with 240 treated limbs were included in our interim analysis. Overall, 93 patients (41.5%) had contraindications for thrombolytic agents and 53 (23.6%) had had a prior DVT. The median ClotTriever thrombectomy time was 28.0 minutes (range, 20.0-45.0 minutes). Classified by symptom duration, 69.1% of the limbs had acute thrombus, 22.2% had subacute thrombus, and 8.7% had chronic thrombus. After pretreatment imaging, the limbs were reclassified as 38.1% acute, 37.7% subacute, and 24.2% chronic. After thrombectomy, the limbs were reclassified further as 30.5% acute, 36.1% subacute, and 33.5% chronic. Comparing the initial and final post-thrombectomy assessment, 55.6% of the limbs had been misclassified, with most having thrombus more chronic than expected (Fig). With the addition of pretreatment imaging, the classification of chronicity has improved. However, still 16.5% of the limbs had thrombus more chronic than expected. Complete or near-complete thrombus removal was similar across the chronicity classifications: 86.2% in acute, 78.1% in subacute, 81.7% in chronic thrombus. In an all-comer DVT patient population, thrombus that had been first assessed using symptom duration was found to be more chronic than expected in nearly one half of the treated limbs. The use of the ClotTriever device was effective in removing thrombus in each chronicity category. This finding has implications in the treatment choice for patients presenting with DVT.

Video assisted, transaortic removal of left ventricular thrombus during concurrent cardiac surgery: a case report

IntroductionLeft ventricular (LV) thrombus is a complication of acute myocardial infarction and is associated with systemic thromboembolism. We describe a trans-aortic endoscopic approach to the removal of an LV thrombus in a patient undergoing concurrent coronary artery bypass grafting and aortic valve replacement.Case presentationA 47 year old male presented following an embolic middle cerebral artery stroke and underwent transthoracic echocardiography demonstrating a mobile LV thrombus. Additional investigation revealed a moderately stenosed bicispid aortic valve, two vessel coronary artery disease and ischemic cardiomyopathy. The patient underwent early surgery to reduce the risk of further embolic episodes. A trans-aortic approach was utilized with videoscopy and single shafted instrumentation to aide in removal of the thrombus. The patient then underwent aortic valve replacement and coronary artery bypass grafting.ConclusionWe report an alternative technique for the removal of a left ventricular thrombus in a patient undergoing concurrent coronary and aortic valve surgery. The transaortic video-assisted approach provided excellent visualisation of the apex and near complete removal of the thrombus without damaging the surrounding trabeculae. The main benefit of this technique is sparing of LV tissue, thereby preserving left ventricular function.

AngioVac Aspiration Thrombectomy of Right Atrial Thrombus is Safe and Effective in Cancer Patients

The aim of this study was to test the hypothesis that endovascular aspiration thrombectomy of right atrial thrombus (RAT) using the AngioVac device is as safe and effective in patients with cancer as those without cancer. RAT is a uniquely challenging clinical presentation of venous thromboembolism due to its low incidence and historically high-risk of mortality due to thrombus propagation into the pulmonary arteries. There is a lack of consensus regarding management, particularly in high-risk cancer patients. Endovascular aspiration thrombectomy utilizing the AngioVac device is effective in removal of right atrial thrombus and may be a safer option for patients with cancer in whom avoidance of higher-risk intervention is preferred. This was an institutional review board-approved retrospective single-center case control study of patients with RAT who underwent AngioVac aspiration thrombectomy between August 2013 and July 2020. Analysis of patient demographics and clinical characteristics, thrombus-related factors, and operative details was performed. Primary endpoints included survival, safety, and technical success. A total of 44 patients met inclusion criteria, 20 of whom with active malignancy. The oncology group had a significantly higher Charlson comorbidity index (P=0.01). Comparative outcomes between the oncology and non-oncology group showed no difference in survival (P=0.8) or technical success (OR 3, 95% CI 0.83-10.9). There were 9 complications, including 6 minor, 1 moderate, 1 severe, and 1 death. AngioVac aspiration thrombectomy of RAT is as safe and effective in patients with cancer as those without cancer.

Application of manual aspiration thrombectomy in the treatment of deep vein thrombosis in cancer patients: Descriptive retrospective cohort study.

ObjectivesTo determine the outcomes and feasibility of endovascular treatment, mainly based on manual aspiration thrombectomy (MAT) with adjunctive percutaneous balloon angioplasty with or without stent deployment, for treatment of symptomatic ilio-femoral deep vein thrombosis (IFDVT) in cancer patients.Materials and methodsIn this retrospective cohort study, 135 consecutive patients (56 men; mean age, 63 years; 149 limbs) with acute (n = 113; 83.7%) and subacute to chronic (n = 22; 16.3%) symptomatic IFDVT underwent MAT-based endovascular treatment. Among them, adjunctive balloon angioplasty and stent placement was performed in 94 patients. Technical and clinical success regarding stage and cause of DVT was assessed.ResultsTechnical success (complete thrombus removal without residual thrombus or stenosis) was achieved in 89.6%, and subjective symptom improvement was stated by 71.5% of treated patients. The primary patency rates were 88.1%, 81.6%, 76.0%, 74.1% and 69.1% at 1, 3, 6, 12, and 30 months, respectively. Recurrent IFDVT occurred in 19.3% (26/135) of patients, 0.79 cases per patients-years of follow up. According to the analysis by causes of IFDVT, recurrence rate was 19.3% (11/57), 21.2% (12/57), and 14.3% (3/21) in unknown, compression/invasion of the vein by cancerous mass, and May-Thurner syndrome groups, respectively (p = 0.798). No procedure-related complication developed.ConclusionsEndovascular treatment based on MAT is a feasible treatment option with favorable outcomes and minimal risk of complication in cancer patients with symptomatic IFDVT.

Computational research of mTORC1 inhibitor on cerebral ischemia-reperfusion injury.

Ischemic stroke contributes to more than 80% of all strokes and has the four characteristics of high prevalence, high disability, high mortality, and high recurrence. Stroke is a preventable and controllable disease. In addition to controlling the primary disease, effective prevention and control measures need to be given to the occurrence and development of stroke. With the development and progress of modern treatment methods for ischemic stroke, the mortality and disability rate have decreased significantly. At present, the main treatment methods for ischemic stroke include thrombolysis, thrombus removal at the ultra-early stage, and treatment of improving collateral circulation in the acute phase. However, the ultra-early and early blood reperfusion involves reperfusion injury, which will cause secondary nerve damage, which is called cerebral ischemia/reperfusion injury (CIRI). Studies have found that autophagy is involved in the entire process of CIRI and can reduce the damage of CIRI. The mammalian target of Rapamycin (mTORC1) is the primary signal pathway regulating autophagy. And the mTORC1 inhibitor, Rapamycin, has been proved to exert neuroprotective effects in the ultra-early and early cerebral ischemia-reperfusion. Therefore, screening and designing mTORC1 inhibitors is very important to control reperfusion injury and reduce neuronal death and apoptosis. In this research, plenty of computer-assisted was applied to virtually screen and select potential mTORC1’s inhibitors. We used Libdock to screen the structure and performed toxicity predictions, ADME (absorption, distribution, metabolism, excretion) to predict small molecules’ pharmacological and toxicological properties. To assess the binding mechanism and affinity between the mTORC1 dimer and the ligand, molecular docking was performed. Then, the pharmacophore of small molecules in the docking conformation with the protein was supplemented by Schrodinger. Additionally, molecular dynamics simulations were conducted to assess if the ligand-receptor complex was stable in a natural environment. Furthermore, an experiment was performed to verify the inhibitory effect of compound 1 and compound 2 on mTOR protein. All in all, the study provides a hand of candidate drugs as well as pharmacological properties, which can play an essential role in mTORC1 inhibitors.

Elastic compression stockings to prevent post-thrombotic syndrome in proximal deep venous thrombosis patients without thrombus removal

ObjectiveTo evaluate the effectiveness of elastic compression stockings (ECS) in prevention of post-thrombotic syndrome (PTS) in patients suffering from proximal deep venous thrombosis (DVT) who did not undergo thrombus removal procedures. MethodsIn this randomized trial, patients with Iliofemoral venous thrombosis (IFDVT) and femoral-popliteal venous thrombosis who had not undergone thrombus removal procedures were screened at a single medical institution between December 2016 and June 2018. These patients were randomly assigned as an ECS group (wear ECS) and control group (not wear ECS). The primary end point was the incidence of PTS based on the Villalta scale at 24 months. The secondary end points included patient quality of life and symptom severity based on the VEINES-QoL/Sym questionnaire. Recurrent DVT in the same limb, compliance with ECS use, and other adverse events were also recorded. A logistic regression analysis was also performed to determine risk factors of PTS. ResultsTwo hundred thirty-two patients were included in this study. One hundred thirteen patients were in the ECS group and 119 in the control group. The incidence of PTS was 42.0% in the ECS group and 57.8% in the control group at 24 months (risk ratio [RR], 0.726; 95% confidence interval [CI] 0.547-0.964; P = .024). The VEINES-QoL score was 63.7 ± 4.6 in the ECS group, which was higher than in the control group (60.6 ± 6.9; P < .001). Moreover, the VEINES-Sym scores revealed that patients in the ECS group reported better symptom relief than those in the control group (45.8 ± 5.1 vs 43.8 ± 6.1; P = .014). According to Logistic regression analysis of the entire cohort, IFDVT was a risk factor for PTS (RR, 2.253; 95% CI, 1.136-4.468) and high compliance with the use of ECS was protect factor (RR, 0.516; 95% CI, 0.277-0.961). ConclusionsThese results suggest that ECS can prevent PTS in patients with IFDVT and femoral popliteal venous thrombosis who do not undergo thrombus removal procedures.

Single-Session Mechanical Thrombectomy of Lower Extremity Deep Venous Thrombosis Using the ClotTriever System: A Single-Institution Experience

Abstract Purpose The aim of this study was to provide a single-center experience in utilization of the ClotTriever mechanical thrombectomy system in acute and subacute deep vein thrombosis (DVT). Methods Retrospective review was performed for all patients who underwent DVT thrombectomy using the ClotTriever system at a single academic medical center. Data recorded included age, gender, etiology, laterality of DVT, fluoroscopy time, perioperative parameters, type of anesthesia, concomitant usage of thrombolytics and/or stents. Follow-up Doppler ultrasounds or diagnostic venograms were reviewed, and time of reintervention (if performed) and Villalta scores were recorded. Results Ten patients were included in the study, with 6/10 female (60%), mean age 54.6 years (range: 24–80). Eight patients presented with acute iliofemoral DVT, one patient with subacute iliofemoral DVT, and one patient with subacute inferior vena cava thrombosis. Only one patient required concomitant intraprocedural thrombolytic administration, and four patients underwent same-session venous stent placement. Technical success was achieved in 90% patients and no procedure-related adverse events were observed. Reintervention within 30 days was required in two (20%) patients at 12 and 13 days. No patient required intensive care unit (ICU) stay, and mean postprocedure hospital length of stay was 2.3 days. On follow-up (mean: 214 days), five patients had no evidence of DVT and four patients showed chronic postthrombotic changes in femoropopliteal veins not requiring intervention. Conclusion The ClotTriever mechanical venous thrombectomy system demonstrates high efficacy in removal of thrombus from lower extremities in a single session, often obviating the need for thrombolytic therapy with low reintervention rates and short postprocedure hospital stay.

Clinical Outcomes of a Pharmacomechanical Catheter-Directed Venous Thrombolysis Strategy that Included Rheolytic Thrombectomy in a Multicenter Randomized Trial

PurposeTo describe the clinical outcomes of a pharmacomechanical catheter-directed venous thrombolysis (PCDT) strategy that included AngioJet rheolytic thrombectomy. MethodsIn the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis multicenter randomized trial, physicians at 33 sites designated AngioJet as their preferred device for PCDT. In these sites, 364 patients with acute proximal lower-extremity deep vein thrombosis (DVT) were randomized to a strategy of PCDT that incorporated either AngioJet along with anticoagulation or anticoagulation alone. Relief from presenting DVT symptoms was evaluated over 30 days of follow-up. Postthrombotic syndrome (PTS), quality of life (QOL), recurrent venous thromboembolism (VTE), and safety were evaluated over 24 months of follow-up. ResultsWithin 30 days, AngioJet-PCDT led to a greater improvement in leg swelling (mean difference calf circumference 0.55 cm, P = .009), venous QOL (mean difference 6.5 Venous Insufficiency Epidemiologic and Economic Study [VEINES]-QOL points, P = .0073), and venous symptoms (mean difference 5.6 VEINES-symptoms points, P = .0134) than control, with differences most apparent in iliofemoral DVT. AngioJet-PCDT reduced PTS at 6 months (24% with AngioJet-PCDT vs 40% with control, P = .003) but did not influence PTS or QOL between 12 and 24 months. Major bleeding, pulmonary embolism, renal failure, and bradycardia were infrequent with AngioJet-PCDT (<2% each), but 24-month VTE recurrence may have been more frequent (13.9% with AngioJet-PCDT vs 6.8% with control, P = .03) ConclusionsIn patients with acute proximal DVT, a treatment strategy that included first-line AngioJet-PCDT was reasonably safe and led to an improved symptom status and venous QOL at 1 month and reduced PTS at 6 months compared with anticoagulation alone. However, AngioJet-PCDT did not influence PTS or the QOL beyond 6 months and may have increased recurrent VTE.

Free-floating thrombus of the aorta: 3 case reports

BackgroundIdiopathic free-floating thrombus (FFT) of the aorta is a rare occurrence, but it can lead to catastrophic consequences. The initial symptoms are typically cerebral or peripheral embolisms. Surgical thrombectomy and thrombolysis are two primary treatments for FFT. Here, we report three cases of patients with idiopathic FFT in the absence of coagulopathy who were treated successfully by surgery with no recurrent thrombi or relapse of symptoms.Case presentationCase 1 involved a 72-year-old male patient with a pedunculated thrombus in the distal aortic arch. Case 2 involved a 62-year-old female patient with a cylinder thrombus in the aortic arch and left common carotid artery. Case 3 involved a 65-year-old male patient with three pedunculated thrombi in the ascending aorta, aortic arch, and left subclavian artery. None of the patients had clinical signs of coagulopathy. Pedunculated or cylinder thrombi have a greater risk of breaking off, which can produce severe peripheral embolism in contrast with intramural thrombi (73% vs. 12%). Due to the high embolism risk for each patient, conservative medical treatment by heparinization was deemed inappropriate, so each patient underwent emergency surgical thrombus removal. After surgery, each of the three patients was treated with warfarin for secondary prevention of thromboembolism. At 7-month follow-up in outpatient practice, a computed tomography (CT) scan indicated that Patient 1 had no recurrent thrombus, and the patient has been symptom-free for 11 months. At 1-month follow-up in outpatient practice, a CT scan indicated that Patient 2 had no recurrent thrombus, and the patient has been symptom-free for 8 years. At 3-week follow-up in hospital, a CT scan indicated that Patient 3 had no recurrent thrombus, but he failed to follow-up after discharge, so his follow-up status is unknown.ConclusionsFor a large pedunculated or cylinder thrombus located in the thoracic aorta, surgical thrombectomy should be performed. And, in surgical thrombectomy, the location of the cannulas and cross-clamp should be selected carefully according to the location of the thrombus. After surgery, anticoagulant is important to prevent recurrent idiopathic thrombi.

Manual Aspiration Thrombectomy for Embolic Acute Mesenteric Ischemia.

A 65-year-old woman was admitted with diffuse abdominal pain, diarrhea, and hematochezia of one day's duration. Her medical history included surgical repair of an anterior mitral valve cleft and an associated ostium primum atrial septal defect, implant of a single-chamber pacemaker programmed in VVIR mode for complete atrioventricular block, and stroke despite appropriate anticoagulant therapy for paroxysmal atrial fibrillation (AF). At admission, the patient had been on chronic anticoagulant therapy with acenocoumarol (target international normalized ratio, 3.0). Mesenteric arterial embolization was highly suspected.Abdominal computed tomographic angiograms revealed a large thrombus in the first 5 cm of the superior mesenteric artery (SMA) distal to its ostium (Fig. 1). Within 6 hours, this finding was confirmed on a mesenteric angiogram (Fig. 2A). Access was obtained by introducing a 6F angiographic catheter into the right brachial artery and advancing it to the SMA. Next, the 6F angiographic catheter was exchanged for a 6F multipurpose guiding catheter. Under fluoroscopic guidance, the multipurpose catheter was passed through the thrombotic segment several times. A large amount of thrombotic material was manually aspirated from the SMA and its branches by means of suction from a large-bore 50-mL syringe connected externally to the guiding catheter (Fig. 2B). A final postprocedural mesenteric angiogram confirmed thrombus removal (Fig. 2C), which was accompanied by prompt relief of symptoms and normalization of laboratory values.The thrombotic event was considered embolic, given the patient's history of stroke despite anticoagulant therapy, incomplete occlusion of the SMA just distal to its ostium, and the absence of ostial calcified atherosclerosis. The patient's anticoagulation regimen was switched from acenocoumarol to apixaban 5 mg 2×/d and clopidogrel 75 mg/d. Four days after the thrombectomy and an uncomplicated course of recovery, she was discharged from the hospital. At one-year follow-up, she had experienced no recurrent cardioembolic events.Acute mesenteric ischemia is typically caused by SMA emboli and, despite advances in endovascular therapy, is associated with high morbidity and mortality rates.1 Early diagnosis and revascularization are essential to prevent intestinal complications. However, because acute mesenteric ischemia is rare and often associated with nonspecific abdominal pain, diagnosis is difficult. This is particularly relevant in patients with AF, in whom early evaluation by computed tomographic angiography is crucial.2 The development of thrombosis despite appropriate anticoagulation for comorbid AF puts patients at high risk for bleeding during surgery and thus poses additional therapeutic challenges. For patients who are promptly diagnosed and show no signs of advanced bowel ischemia, percutaneous revascularization is a viable option.3 If an aspiration catheter is not available, manual aspiration thrombectomy is feasible.Section editor: Raymond F. Stainback, MD