A Novel Percutaneous Technique for Aorto-Iliac Thrombectomy without the Risk of Embolization

Abstract

Classic surgical thrombectomy of the aorta and iliac arteries through an incision in the groin vessels harbors the risk of embolization to the viscero-renal as well as hypogastric arteries, while percutaneous endovascular thrombectomy techniques can lead to peripheral embolization to the lower limbs. Therefore, we describe a novel, percutaneous technique that tackles the above issues. Furthermore, we also present our initial experience using the technique. The principle of the technique is to percutaneously place large-bore sheaths in the iliac arteries that deliberately occlude the latter to protect the lower limbs from embolization. Through one of these sheaths, over wire Fogarty^® catheters can be placed and inflated in the ostia of the coeliac trunk, superior mesenteric artery, renal arteries, and hypogastric arteries as needed. A large thrombectomy balloon catheter is then used to bring any aorto-iliac thrombus into the sheaths, whereafter the thrombus is removed from the sheaths by simply deflating their valves. Additional endovascular procedures of the aorto-iliac branches can be performed as needed. We report nine procedures in 8 patients (4 males and 4 females) with a median age of 63 (53-68.5). Additional endovascular procedures were performed in 6 (66.7%) procedures. All but one procedure were technically successful, and all patients had palpable foot pulses on completion of the procedures, while no patient had clinical signs of peripheral embolization. This technique is a very valid addition to the vascular surgeon's armamentarium when treating aorto-iliac thrombotic events because it is minimally invasive while still protecting against embolization and offering the flexibility to perform a wide range of additional endovascular procedures where needed.

Keywords: endovascular; percutaneous thrombectomy; protection from embolization.

Figure 1

(a) Thrombotic occlusion of the right EVAR limb (ballerina situation) (red arrow); (b) thrombectomy of the graft limb (red arrow) under balloon protection of both renal bridging stentgrafts and the right hypogastric artery (yellow arrows). The large-bore sheaths are occlusive in the left graft limb and in the right external iliac artery (white arrows); (c) Iatrogenic dissection of the right renal artery (red arrow); (d) Right renal artery after implantation of a self-expanding stent graft (red arrow).

Figure 2

(a) Thrombus in the aorta and in the origin of the coeliac trunk (red arrow); (b) thrombectomy (red arrow) of the thoracoabdominal aorta under balloon protection of the coeliac trunk, superior mesenteric artery, and both renal arteries (yellow arrows). The large-bore sheaths are occlusive in both common iliac arteries (white arrows); (c) Postoperative CT scan with no residual thrombus in the aorta or the coeliac trunk (red arrow).

Figure 3

(a) Occlusion of the infrarenal aorta (red arrow); (b) thrombectomy of the infrarenal aorta (red arrow) under balloon protection of both hypogastric arteries (yellow arrows). The large-bore sheaths are occlusive in both external iliac arteries (white arrows); (c) iatrogenic rupture of the infrarenal aorta; (d) covered endovascular reconstruction of the aortic bifurcation (red arrows); (e) stenoses at the origins of the left renal and a right accessory renal artery (red arrows); (f) no residual stenoses after PTA of the right accessory renal and PTA/stenting of the left renal artery (red arrows).