Endovascular clot removal in small and tortuous arteries: a case series

Abstract

Acute limb ischemia (ALI) due to arterial thromboembolic occlusion is a critical emergency in vascular medicine, requiring attention for rapid diagnosis and intervention, to prevent limb loss and major amputation, which is associated with patient disability in the long term. Traditionally, surgical embolectomy has been used for the treatment of ALI. Endovascular treatment of ALI traditionally involved catheter-directed thrombolysis. This option, however, poses some limitations, including an increased risk for access site and systemic bleeding complications, especially in patients with high bleeding risk. Therefore, in the last decades, several devices have been developed and tested for the mechanical endovascular treatment of ALI. Such devices involve either rotational thrombectomy or continuous thrombus aspiration. While rotational thrombectomy is limited in rather large arteries due to the risk of dissection and perforation in arteries <3 mm, continuous thrombus aspiration can be applied in smaller vessels and tortuous anatomies. In our case series we present a minimal-invasive endovascular approach for the treatment of two patients with ALI due to thrombotic occlusion of tortious and small diameter arteries. Minimal-invasive mechanical thrombectomy using the Penumbra Aspiration System emerged as a successful alternative to surgical embolectomy, enabling prompt treatment and with a short hospital stay for both patients. Our article therefore highlights the use of continuous thrombus aspiration in small diameter vessels and tortuous anatomies, which may represent a contraindication for the use of rotational thrombectomy. In addition, this technique may be applied even in patients with higher bleeding risk since additional lysis is not necessary in patients, where complete thrombus removal can be achieved by this device.

Introduction

In contemporary medical practice, mechanical thrombectomy has emerged as a promising alternative to conventional surgical thrombectomy and catheter-directed thrombolysis (CDT).^1–3 This technique offers a modern and effective approach to address acute arterial occlusions, without the need for lysis, thus circumventing potential access site and bleeding complications, especially in patients at high bleeding risk. Therefore, in the last decades, several devices have been developed and tested for the mechanical or pharmaco-mechanical endovascular treatment of acute limb ischemia (ALI). In this regard, the Rotarex is a mechanical rotational thrombectomy device, based on a spiral, which is connected to the tip of the catheter, rotating at high speed. The high rotational speed generates a vacuum force, which enables active aspiration of fragmented thrombotic material, thus reducing the risk for distal embolization. ⁴ Due to its strong suction force, the Rotarex device can also be used for the removal of organized thrombus in patients with subacute or chronic thrombotic occlusions. However, its use is not recommended in smaller diameter vessels of <3 mm by information for use. The AngioJet device, on the other hand, is based on the concept of hydro-dynamic aspiration, where high-speed saline jets are injected through the catheter tip to create a “venturi effect.” This also results to a vacuum effect, which can effectively lyse and aspirate fresh thrombus. ⁵ The minimum diameter of treated vessels is 1.5 mm, which allows effective treatment down to the level of the crural arteries.

In this article, we present two cases where successful recanalization of peripheral vessels, such as the radial artery, ulnar artery, and internal iliac artery, was achieved using the Penumbra Thrombectomy System (Penumbra, CA, USA), a purely mechanical thrombectomy device.

Methods

The study was conducted and reported in accordance with the CARE statement (Supplemental Materials). ⁶

Case 1

A 65-year-old female presented with acute arterial occlusion of her radial and ulnar arteries. The occlusion was attributed to cardiac embolism, possibly due to newly diagnosed atrial fibrillation. The patient was not on anticoagulation treatment and presented with acute intense pain of the left upper limb in the last 4 days. In addition, paresthesia was present in the last 4 h prior to her presentation without motoric deficits (Rutherford category (RC) IIA). ⁷ The arm of the patient was pale and pulseless by clinical assessment. The patient had history of arterial hypertension but no history of coronary heart disease, heart failure, or atrial fibrillation. Medical treatment involved only antihypertensive medication and no oral anticoagulation or antithrombotic drugs. Duplex sonography revealed thrombotic occlusion of the brachial artery with non-detectable flow in the radial and ulnar arteries. ECG exhibited new onset atrial fibrillation with a resting heart rate of 115 bpm. Due to the acute and severe symptoms of the patient, including intense pain and paresthesia, reperfusion was promptly scheduled and performed.

After obtaining femoral access, a long 110 cm 6F sheath was inserted up to the left axillar artery of the patient. Angiography confirmed thrombotic occlusion of the proximal ulnar and radial arteries (Figure 1(a)). An interventional aspiration thrombectomy was performed using a 6F Eliminate Catheter (Terumo, Tokyo, Japan). However, despite some clot removal, flow restorage was not possible despite multiple aspiration attempts (Figure 1(b) and (c)). Due to ongoing ischemic pain in the patient, the operators decided to proceed with the use of the mechanical Penumbra thrombectomy device. Hereby, a 3F Penumbra catheter was inserted through the sheath and was advanced to the distality of both the radial and the ulnar arteries (Figure 1(d)). After two passages in the radial artery and a single passage in the ulnar artery, successful restoration of blood flow was achieved in both vessels, with reconstruction of the palmar arch (Figure 1(e)). Subsequent follow-up assessments conducted at 2 and 6 months revealed palpable pulses of the arm, whereas Duplex sonography demonstrated triphasic blood flow in both the arteries. The patient was set on oral anticoagulation with rivaroxaban 20 mg/day, accompanied by clopidogrel 75 mg daily for 4 weeks.

Figure 1.

Angiography demonstrated occlusion of the proximal ulnar and radial arteries (blue arrows in a). Aspirations thrombectomy by a 6F Eliminate Catheter (Terumo) failed to restore flow (b). Thus, the radial and ulnar arteries remained occluded and only small collaterals were detectable to the arm provided by an interosseous artery (blue arrow in c). A 3F Penumbra catheter was inserted through the sheath and was advanced to the distality of both the radial and the ulnar arteries (d). Hereby, successful restoration of blood flow was achieved in both vessels, with reconstruction of the palmar arch (e).

Case 2

Another 40-year-old male patient, who initially underwent an open aortic endarterectomy and surgical thrombectomy of the common iliac arteries with the implantation of covered stents (Viabahn BX, GORE) due to Leriche syndrome with resting ischemic pain 2 years ago, now presented to our department with lifestyle-limiting claudication and sexual dysfunction. Magnetic resonance angiography (MRA) was performed. Bilateral stent re-occlusion was detected. Due to limiting symptoms, Fogarty embolectomy was performed, ⁸ which resulted in re-opening of both common iliac arteries but led to occlusion of the internal illiac arteries during the procedure. CDT was subsequently performed over 24 h, but occlusion of the internal iliac arteries remained, as verified by a second-look angiography, which was conducted at the following day (Figure 2(a)). After surgical cut-down in the distal axillar artery and insertion of a 7F sheath, which was advance to the distal abdominal aorta, mechanical thrombectomy was performed bilaterally using a Penumbra Lightning 7 catheter (Figure 2(b) and (c)), followed by drug-coated balloon angioplasty of both internal iliac arteries. By this combined approach, complete patency was achieved in both internal iliac arteries (Figure 2(d)). Further clinical course of the patient was uneventful, and no claudication or sexual dysfunction symptoms were reported during follow-up after 12 months. In addition, the patient was set on dual platelet inhibition with aspirin and clopidogrel for 3 months, followed by aspirin 100 mg daily and rivaroxaban 2.5 mg twice per day. Follow-up MRA after 6 months exhibited patency of both internal iliac arteries (Figure 2(e)).

Figure 2.

Catheter-directed thrombolysis failed to restore flow in both internal iliac arteries (a). Therefore, mechanical thrombectomy was performed using a Penumbra Lightning 7 catheter (b, c), which restored blood flow in both arteries (d). Follow-up magnetic resonance angiography after 6 months showed sustained patency of both internal iliac arteries (e). The asterisks point to the off-resonance artifacts causing signal void at the area of the stent prostheses in the iliac arteries.

Discussion

In this case series, we report on the use of minimal-invasive mechanical thrombectomy in small and tortious arteries, which is of major importance for the restoration of blood flow and tissue salvage in patients presenting with ALI due to thrombotic arterial occlusions.^1,3 Despite advances in surgical, endovascular, and medical treatment, ALI is still a resource-intensive condition associated with significant morbidity, mortality, and amputation rates.^1,3 In addition, treatment of ALI is resource intensive and is associated with extended in-hospital stay, especially when treated by open repair.^9,10

Limited data are currently available on specific treatment algorithms, targeting the restoration of blood flow in occluded internal iliac arteries. ¹ As internal iliac arteries are small and tortious, rotational thrombectomy may pose limitations due to significant risks of vessel wall injury and embolization. In addition, the stiff angle using either a retrograde or a cross-over approach may limit maneuverability of the catheters within the target lesions. In our patient with iliac artery occlusion, mechanical aspiration thrombectomy with a 7F aspiration catheter was performed using a trans-axillar approach, which allowed quick bilateral clot removal with concomitantly reduced blood loss and minimized risk for vessel wall injury due to the atraumatic laser-cut design of the Penumbra catheter.

Like internal iliac arteries, the radial and ulnar arteries are small and tortious vessels, where limited data are available on the value of minimal-invasive approaches such as mechanical thrombectomy in case of thrombotic occlusions.^11,12 Again, due to the even smaller size of the distal vessels in the arm, compared to iliac arteries, the 3F Penumbra aspiration catheter presented an elegant option for clot removal in this case. Due to the small profile of this catheter, advancement was possible until the very distal arteries of the arm (Figure 1(d)), allowing effective clot removal without vessel injury.

In the first case, CDT had been used prior to mechanical thrombectomy without success, while in the second case mechanical thrombectomy was used as the treatment of first choice. Both CDT and mechanical thrombectomy bear advantages and limitations, being effective but associated with specific bleeding and access site or potential procedural complications, respectively. A recent study, comparing the two techniques in patients with ALI, showed that mechanical thrombectomy is associated with higher technical success rates and concomitantly significant shorter length of hospital stay. ² Indeed, in both cases presented herein, the use of mechanical thrombectomy resulted to effective clot removal with immediate restoration of blood flow, thus salvaging tissue at risk and aiding restoration of ischemic clinical symptoms. Finally, the importance of adjunct pharmacologic antithrombotic treatment after endovascular or surgical therapy needs to be considered. In patients with thromboembolic occlusion, oral anticoagulation is necessary in patients with atrial fibrillation, to prevent recurrent thromboembolic events, while dual pathway inhibition needs to be considered in patients with concomitant chronic peripheral artery disease. ¹³

Conclusion

Mechanical thrombectomy using advanced devices, such as the Penumbra system, highlights its potential as an effective alternative to conventional surgical thrombectomy and CDT. The cases presented herein highlight the successful recanalization of peripheral vessels in scenarios involving acute occlusions and smaller and tortious arteries. This innovative approach holds promise for the enhancement of vascular care and improvement of patient outcomes.

Supplemental Material

sj-pdf-1-tak-10.1177_17539447241271989 – Supplemental material for Endovascular clot removal in small and tortuous arteries: a case series

Supplemental material, sj-pdf-1-tak-10.1177_17539447241271989 for Endovascular clot removal in small and tortuous arteries: a case series by Gowri Kiran Puvvala, Anastasios Psyllas, Jürgen Hinkelmann, Daniel Herzenstiel and Grigorios Korosoglou in Therapeutic Advances in Cardiovascular Disease