Thrombosuction for Acute Limb Ischemia Equipment, Technical Tips and Results A. Katsargyris, W. Ritter, B. Moehner, M. Bruck, and E. Verhoeven Paracelsus Medical University, Klinikum Nuernberg, Germany Disclosures • William Cook Europe/Cook Inc. – Consultant & Research grants • W.L. Gore & Associates – Consultant & Research grants • Atrium – Consultant • Siemens – Consultant • Medtronic – Advisory board Background (1) Conventional Treatment of Acute Limb Ischemia (ALI) • Heparinisation+delayed surgery (Grade I) • Prompt Embolectomy/Bypass (Grade II) ↓ Up to 40% amputation rates Ann Vasc Surg, 1995;9:32-38 Background (2) Alternative Treatment of Acute Limb Ischemia (ALI) • Thrombolysis (Passive clot lysis → 48h duration) → Only for Grade I • Thrombosuction (Immediate clot removal) → For Grade I & II Eur J Vasc Endovasc Surg, 2000;20:138-45 Equipment • 8F Sheath – Removable Valve • 8F Aspiration catheter – 1 end-hole • 6F Aspiration catheter – Smooth tip (crural) • 50cc Syringe Technique (1) • Aspiration catheter just above the proximal end of the thrombus • Do not cross the thrombus – Avoid distal embolisation Technique (2) • Continuous aspiration – 50cc Syringe • Catheter withdrawal • Clot removal Technique (3) • Valve disconnection for large thrombus removal Technique (4) • Repeat sequence until no more thrombi can be aspirated • Adjunct PTA/Stenting if residual stenosis or remaining clots Technique (5) • 8F Closure device • Immediate heparinisation Indication Pt with Acute Limb Ischemia – Relative recent onset of symptoms – Fresh thrombus on DSA – Relatively short occlusion – Femoral, popliteal, crural level Patient Demographics • 2009-2013 • N = 262 – Mean age, 74.5 ± 11 yrs – 49.6 % male – 41.6% ASA II, 53.4% ASA III Severity of ALI Rutherford Classification • Grade I (Viable) 199 (76%) • Grade II (Threatened) 63 (24%) Early Outcome • Technical success – Additional PTA – Additional PTA & Stenting • 30-d Mortality • Additional open surgery – Embolectomy – Bypass • 30-d Major amputation 237 (91%) 78 (29.8%) 72 (27.5%) 12 (4.6%) 11 (4.2%) 5 (1.9%) 6 (2.3%) 2 (0.8%) Follow-up Mean 26.2 ± 16 months • New onset of symptoms • Reintervention • Major amputation – AKA – BKA • Related death 61 (23.3%) 35 (13.4%) 10 (3.8%) 5 5 2 (0.8%) Freedom from Reintervention 90.4 ± 2% at 1 year 80 ± 3.7% at 3 years Freedom from Amputation 94.1 ± 1.7% @ 1 year 93.5 ± 1.8% @ 3 years Case (1) • 88 YO Female Pt • ALI (left) 20 h ago – Grade I • Atrial Fibrilation MRA → Case (1) Initial DSA After Thrombosuction Case (2) • 69 YO Male Pt • Claudication (50m) left – 1 week onset, Grade I • Heart Failure MRA→ Case (2) Initial DSA After Thrombosuction After Stenting Case (3) • 76 YO Female Pt • PAD st IIb • Elective SFA Stenting Case (3) Iatrogenic TF Trunk embolisation After Thrombosuction Case (4) • 63 YO Male Pt • Elective AFS Stenting (left) – (2 years before) • ALI (Left) – Grade II MRA→ • Acute AFS stent thrombosis (?) Case (4) Initial DSA After Thrombosuction After PTA + Stent Conclusions Thombosuction – Simple equipment and idea – Minimal invasive – Quick treatment (vs Trombolysis) – ↑ Technical success in acute and subacute cases – Durable in the mid-term – Does not preclude surgery if it fails Thrombosuction for Acute Limb Ischemia Equipment, Technical Tips and Results A. Katsargyris, W. Ritter, B. Moehner, M. Bruck, and E. Verhoeven Paracelsus Medical University, Klinikum Nuernberg, Germany
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