Percutaneous mechanical thrombectomy in acute and subacute lower-extremity ischemia: impact of adjunctive, solely nonthrombolytic endovascular procedures

Abstract

Purpose: We aimed to evaluate the role of adjunctive, solely nonthrombolytic endovascular therapy in treatment of acute lower-extremity ischemia by rotational percutaneous mechanical thrombectomy.

Methods: A retrospective, single-center evaluation of 165 patients (167 limbs) that underwent rotational percutaneous mechanical thrombectomy between 2009 and 2016 was performed.

Results: Rotational percutaneous mechanical thrombectomy was used as a single therapy in 9.0% (15 limbs), followed by percutaneous aspiration thrombectomy in 6.0% (10 limbs), percutaneous transluminal angioplasty in 19.8% (33 limbs) and stenting in 25.7% (43 limbs). Rotational percutaneous mechanical thrombectomy was followed by any combination of these three interventions in 39.5%. Clinical and technical success was documented in 92.2%, complications in 10.3% (n=17). No significant difference in clinical and technical success was observed using rotational percutaneous mechanical thrombectomy alone or with additional endovascular therapy. On a long-term basis, the re-ischemia-free survival was nearly twice as high as in previous studies that reported more cases treated by rotational percutaneous mechanical thrombectomy alone.

Conclusion: To assure a long-lasting primary patency after percutaneous mechanical thrombectomy, concomitant treatment of underlying lesions with adjunctive, nonthrombolytic endovascular methods should be considered.

Figure 1

Flowchart diagram of the workflow and treatment of lesions above and below the knee in our institution. ALI, acute limb ischemia; ATK, above the knee; BTK, below the knee; Long lesion, >10 cm; Short lesion, ≤10 cm; PMT, percutaneous mechanical thrombectomy; PTA, percutaneous transluminal angioplasty; PAT, percutaneous aspiration thrombectomy.

Figure 2. a–e

A 60-year-old patient with known history of peripheral arterial occlusive disease who presented with symptoms of acute lower limb ischemia on the right side within <7 days (acute A). Panel (a) shows occlusion of the distal superficial femoral artery (SFA) reaching POP - II segment, measuring 5 cm, which was first treated by rotational PMT (b). Subsequent DSA revealed residual stenosis >30%. After additional stenting (c) a satisfactory result and 3 run-off vessels distal of the lesion could be achieved (d, e).

Figure 3. a–c

An 87-year-old patient who presented with symptoms of acute lower limb ischemia on the left side within 8–14 days (acute B). DSA shows 10 cm measuring embolic occlusion of the SFA, reaching POP I segment (a). Complete removal of the clot by rotational PMT alone (b) with a subsequent 3 run-off vessel (c).

Figure 4. a–c

Panel (a) shows 3-year amputation-free survival; panel (b) shows re-ischemia and secondary intervention within 3 years. Panel (c) shows 3-year overall survival.