Clot in Transit and Pulmonary Artery Percutaneous Mechanical Thrombectomy.
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ABSTRACT:
SUBMITTER: Janus SE
PROVIDER: S-EPMC8641437 | biostudies-literature | 2021
REPOSITORIES: biostudies-literature
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Clot in Transit and Pulmonary Artery Percutaneous Mechanical Thrombectomy.
Janus Scott E SE Hajjari Jamal J Chami Tarek T Karnib Mohamad M Osman Mohammed Najeeb MN
Kansas journal of medicine 20211105
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Project description:BackgroundAcute pulmonary embolism (PE) is a life-threatening situation. While anticoagulation should be initiated without any delay in all patients with an intermediate or high clinical probability of PE, individual acute phase treatment in patients with intermediate or intermediate-high-risk PE still can be optimized.Case summaryAn 82-year-old female patient was referred to our emergency department after experiencing syncope and acute onset of shortness of breath. Computed tomography (CT) of the chest showed central and extensive peripheral PE. Echocardiography additionally revealed a massive and highly mobile clot-in-transit located in the right atrium (RA). Given the size and mobility of the clot-in-transit, we chose to perform an off-label mechanical thrombectomy. Due to repeated PE with progressive right ventricular (RV) failure and high peripheral thrombus burden, we decided to perform low-dose systemic lysis. After 24 h, she showed significant clinical improvement and was discharged later with recovered RV function and dimensions.DiscussionIn that case, acute PE was complicated by the presence of a large clot-in-transit in the RA. Initially, there was no indication for mechanical thrombectomy or systemic lysis for the patient's intermediate to high-risk PE. The risk of embolization of the very large clot-in-transit prompted us to remove the mobile thrombus mechanically. When the repeated PE resulted in an increase in afterload and progressive right heart failure, we decided to perform low-dose systemic lysis. The off-label use of the FlowTriever® prevented the impending embolization of the 14 cm long thrombus from the RA into the pulmonary circulation. In this case, lysis also appears to make sense, particularly given the high peripheral thrombus burden.
| S-EPMC11799944 | biostudies-literature
Project description:BackgroundTo our knowledge we report the first case of percutaneous mechanical thrombectomy used for the treatment of massive pulmonary embolism in the United Kingdom. Pulmonary embolism is a common disease process but can be difficult to diagnose. Massive pulmonary embolism presenting with profound hypotension, however, is rare. Both phenomena carry with them significant mortality. Traditionally those patients suffering haemodynamic compromise from pulmonary embolism are treated with intravenous or catheter-directed thrombolysis. When this is contraindicated surgical embolectomy or mechanical techniques via a right heart catheter are alternative options. The former is well established but the latter is less commonly utilised in clinical practice. Our aim is to highlight the effectiveness and relative safety of percutaneous mechanical thrombectomy as a therapeutic tool in massive pulmonary embolism.Case presentationA 70 year-old gentleman presented with a 4-month history of dry cough and general malaise. Clinical examination along with routine chest radiograph confirmed a left pleural effusion which was drained. Computed tomography of the chest, abdomen and pelvis revealed a left renal mass consistent with renal cell carcinoma plus multiple metastatic subpleural nodules. Following planned thoracoscopy and pleural biopsy the patient became acutely dyspnoeic and hypotensive. Relevant investigations including computed tomography pulmonary angiogram confirmed a large saddle embolus extending in to the lobar branches of both left and right pulmonary arteries. There were several relative contraindications to thrombolysis and so the patient proceeded to have percutaneous mechanical thrombectomy with excellent results. The patient made a full recovery from the acute episode and was discharged home on warfarin with a view to planned cyto-reductive nephrectomy.ConclusionWe illustrate here that percutaneous mechanical thrombectomy can be a safe and effective method of treating massive pulmonary embolism when thrombolysis is relatively contraindicated. It may also be of use as an adjuvant therapy in those patients able to receive thrombolysis. In the future further evaluation involving a larger cohort of subjects is necessary to determine whether this treatment is superior to surgical embolectomy when thrombolysis cannot be performed.
| S-EPMC2222237 | biostudies-literature
Project description:BackgroundCoronavirus disease 2019 (COVID-19) disease is a highly prothrombotic state. Deep vein thrombosis (DVT) and pulmonary embolism (PE) are observed with increased incidence in patients infected with the severe acute respiratory syndrome coronavirus 2 virus.Case summaryA 57-year-old male patient with a recent COVID-19 infection complained of leg swelling shortly after his COVID ward discharge. A few days later he was hospitalized with acute massive PE and DVT of his left leg was diagnosed. In another facility, as the first line of treatment, the PE was managed with catheter-directed therapy (CDT) using thrombus defragmentation via 5F (French) Pigtail catheter and supraselective application of 40 mg alteplase. Following the procedure, in addition, 50 mg alteplase was also applied as a 1 hour systemic infusion. Despite the haemodynamic stabilization of the patient, he remained persistently symptomatic and tachycardic. Three days later-in our institution, a second computed tomography pulmoangiography revealed massive thrombotic masses mainly in the left pulmonary artery. Successful percutaneous thrombus aspiration was conducted. The procedure was uneventful with an immediate drop of systolic pulmonary artery pressure from 68 to 47 mmHg and relief of the patient's symptoms.DiscussionIn the era of the COVID-19 pandemic, physicians have to remain vigilant of its potential thrombotic complications, the most commonly observed being DVT and PE. We demonstrated the efficacy of percutaneous thrombus aspiration in a patient with acute COVID-19-associated PE, after initial CDT with thrombus defragmentation and high-dose tissue plasminogen activator was implemented with a suboptimal result.
| S-EPMC9214152 | biostudies-literature
Project description:ObjectivesPercutaneous pulmonary artery cannulas, used as inflow for left ventricular venting or as outflow for right ventricular mechanical circulatory support, are easily and rapidly deployable with transesophageal and fluoroscopic guidance.MethodsWe chose to review our institutional and technical experience with all right atrium to pulmonary artery cannulations.ResultsBased on the review, we describe 6 right atrium to pulmonary artery cannulation strategies. They are divided into total right ventricular assist support, partial right ventricular assist support, and left ventricular venting. A single limb cannula or a dual lumen cannula can be used for right ventricular support.ConclusionsIn the right ventricular assist device configuration, percutaneous cannulation may prove beneficial in cases of isolated right ventricular failure. Conversely, pulmonary artery cannulation can be used for left ventricular venting as drainage to a cardiopulmonary bypass or extracorporeal membrane oxygenation circuit. This article can be used as a reference for the technical aspects of cannulation, decision-making in patient selection, and management of patients in these clinical scenarios.
| S-EPMC10122133 | biostudies-literature
Project description:ObjectivesThe FlowTriever All-Comer Registry for Patient Safety and Hemodynamics (FLASH) is a prospective multi-center registry evaluating the safety and effectiveness of percutaneous mechanical thrombectomy for treatment of pulmonary embolism (PE) in a real-world patient population (NCT03761173). This interim analysis reports outcomes for the first 250 patients enrolled in FLASH.BackgroundHigh- and intermediate-risk PEs are characterized by high mortality rates, frequent readmissions, and long-term sequelae. Mechanical thrombectomy is emerging as a front-line therapy for PE that enables immediate thrombus reduction while avoiding the bleeding risks inherent with thrombolytics.MethodsThe primary endpoint is a composite of major adverse events (MAE) including device-related death, major bleeding, and intraprocedural device- or procedure-related adverse events at 48 h. Secondary endpoints include on-table changes in hemodynamics and longer-term measures including dyspnea, heart rate, and cardiac function.ResultsPatients were predominantly intermediate-risk per ESC guidelines (6.8% high-risk, 93.2% intermediate-risk). There were three MAEs (1.2%), all of which were major bleeds that resolved without sequelae, with no device-related injuries, clinical deteriorations, or deaths at 48 h. All-cause mortality was 0.4% at 30 days, with a single death that was unrelated to PE. Significant on-table improvements in hemodynamics were noted, including an average reduction in mean pulmonary artery pressure of 7.1 mmHg (22.2%, p < 0.001). Patient symptoms and cardiac function improved through follow-up.ConclusionsThese interim results provide preliminary evidence of excellent safety in a real-world PE population. Reported outcomes suggest that mechanical thrombectomy can result in immediate hemodynamic improvements, symptom reduction, and cardiac function recovery.
| S-EPMC9542558 | biostudies-literature
Project description:IntroductionThis study aimed to describe and analyze the rate of clot migration of vessel thrombosis to distal segments in patients with acute ischemic stroke (AIS) who received intravenous thrombolysis (IVT) with tenecteplase (TNK) and alteplase (ALT) before mechanical thrombectomy (MT). In addition, we aimed to determine the relationship between thrombus migration and functional prognosis.MethodsThis study followed the STROBE reporting guidelines. We performed a retrospective analysis of a series of patients from November 2017 to April 2023 with an AIS with thrombosis on CT imaging, treated with IVT (TNK or ALT, split into two distinct groups) prior to mechanical thrombectomy.ResultsTwo hundred and fifty-six patients with large vessel occlusion (LVO) were included. Ninety-six had received TNK. One hundred and sixty had received ALT. Of the 96 TNK patients, 25 experienced either complete recanalization (n = 3) or thrombus migration (n = 22). Of the 160 ALT patients, 20 experienced either complete recanalization (n = 6) or thrombus migration (n = 14). The difference being statistically substantial for the thrombus migration rate (OR = 3.61, 95% confidence interval: 1.63; 7.98). Migration to an irretrievable very distal segment occurred in four (4%) patients with TNK and in three patients (2%) with ALT (p > 0.05). Thrombus migration was not significantly associated to a different functional prognosis, measured through Rankin scale after 3 months (OR = 0.44, 95% confidence interval: 0.17; 1.12).ConclusionThe use of TNK over ALT as a fibrinolytic agent is associated with a higher thrombus migration rate. The migration of thrombi to distal segments, which are theoretically less accessible for mechanical thrombectomy, did not result in worse clinical outcomes.
| S-EPMC11569452 | biostudies-literature
Project description:Renal artery embolism (RAE) is an uncommon event that is associated with a high rate of renal loss. We present a case of RAE to a solitary kidney that was treated with combined percutaneous rheolytic thrombectomy, intra-arterial thrombolysis, and supplemental renal artery stent placement.
| S-EPMC3331639 | biostudies-other
Project description:ObjectiveThrombolytic therapy has been a mainstay of treatment for massive or submassive pulmonary embolism (PE), a common and highly morbid pathology. New percutaneous mechanical thrombectomy (PMT) devices have recently become widely available and have been used increasingly for the treatment of acute PE, but evidence demonstrating its efficacy over standard catheter-directed lytic protocol remains limited.MethodsUsing TriNetX Data Network, a global federated database of >250 million patients, we conducted a retrospective cohort study of patients from January 2017 to August 2023 with a diagnosis of PE, treated with either PMT or catheter-directed thrombolysis (CDT). Eligible patients were 1:1 propensity score-matched for preoperative covariates including demographics and comorbidities. We calculated and compared the 30-day outcomes of all-cause mortality, bleeding complications (blood transfusion, gastrointestinal bleed, and intracranial hemorrhage), diagnosis of acute respiratory failure (RF), myocardial infarction (MI), and pulmonary hypertension (PH) using odds ratios (OR) with 95% confidence intervals (CIs). Also, the 5-year outcomes of all-cause mortality, a composite outcome of chronic PH (chronic PE, chronic cor pulmonale, chronic thromboembolic PH), right heart failure (RHF), RF, and emergency department visits, were compared using hazard ratios (HRs) with 95% CIs.ResultsWe identified 2978 patients treated with PMT and 1137 patients treated with CDT. After matching, we compared 1102 patients in each cohort. For 30-day outcomes, all-cause mortality, acute RF, and blood transfusion were similar between the two groups. However, compared with CDT, PMT was associated with a better safety profile, including lower bleeding risk for both ICH (OR, 0.46; 95% CI, 0.24-0.890) and gastrointestinal bleed (OR, 0.42; 95% CI, 0.28-0.63). PMT also demonstrated better immediate functional outcomes, with less PH (OR, 0.53; 95% CI, 0.41-0.68) and MI (OR, 0.54; 95% CI, 0.41-0.76). At 5 years, the all-cause mortality and RF for both procedures were similar, but PMT was associated with lower rates of chronic PH (HR, 0.70; 95% CI, 0.55-0.90), RHF (HR 0.49; 95% CI, 0.37-0.65), and emergency department visits (348 for PMT vs 426 for CDT; P < .01).ConclusionsIn patients undergoing catheter-based therapy for PE, PMT has an improved procedural safety profile vs CDT and results in significantly fewer 30-day postoperative complications, with fewer bleeding events, and is also associated with fewer periprocedural MIs and less acute PH. Perhaps, more important, PMT also demonstrated improved long-term outcomes with significantly fewer chronic PH and RHF diagnoses with fewer emergency department visits.
| S-EPMC11774124 | biostudies-literature
Project description:BackgroundAlthough tortuosity of the internal carotid artery (ICA) can pose a significant challenge when performing mechanical thrombectomy, few studies have examined the impact of ICA tortuosity on mechanical thrombectomy outcomes.MethodsIn a registry-based hospital cohort, consecutive patients with anterior circulation stroke in whom mechanical thrombectomy was attempted were divided into 2 groups: those with tortuosity in the extracranial or cavernous ICA (tortuous group) and those without (nontortuous group). The extracranial ICA tortuosity was defined as the presence of coiling or kinking. The cavernous ICA tortuosity was defined by the posterior deflection of the posterior genu or the shape resembling Simmons-type catheter. Outcomes included first pass effect (FPE; extended Thrombolysis in Cerebral Infarction score 2c/3 after first pass), favorable outcome (3-month modified Rankin Scale score of 0-2), and intracranial hemorrhage.ResultsOf 370 patients, 124 were in the tortuous group (extracranial ICA tortuosity, 35; cavernous ICA tortuosity, 70; tortuosity at both sites, 19). The tortuous group showed a higher proportion of women and atrial fibrillation than the nontortuous group. FPE was less frequently achieved in the tortuous group than the nontortuous group (21% versus 39%; adjusted odds ratio, 0.45 [95% CI, 0.26-0.77]). ICA tortuosity was independently associated with the longer time from puncture to extended Thrombolysis in Cerebral Infarction ≥2b reperfusion (β=23.19 [95% CI, 13.44-32.94]). Favorable outcome was similar between groups (46% versus 48%; P=0.87). Frequencies of any intracranial hemorrhage (54% versus 42%; adjusted odds ratio, 1.61 [95% CI, 1.02-2.53]) and parenchymal hematoma (11% versus 6%; adjusted odds ratio, 2.41 [95% CI, 1.04-5.58]) were higher in the tortuous group. In the tortuous group, the FPE rate was similar in patients who underwent combined stent retriever and contact aspiration thrombectomy and in those who underwent either procedure alone (22% versus 19%; P=0.80). However, in the nontortuous group, the FPE rate was significantly higher in patients who underwent combined stent retriever and contact aspiration (52% versus 35%; P=0.02).ConclusionsICA tortuosity was independently associated with reduced likelihood of FPE and increased risk of postmechanical thrombectomy intracranial hemorrhage.RegistrationURL: https://www.Clinicaltrialsgov; Unique identifier: NCT02251665.
| S-EPMC9311296 | biostudies-literature
Project description:BackgroundEuropean Society of Cardiology (ESC) recommends catheter-directed thrombectomy for management of high-risk pulmonary embolism (PE) with contraindications to thrombolytics or in patients that have failed thrombolytic therapy, as well as intermediate-risk PE with haemodynamic deterioration. In this case report, the role of catheter-directed mechanical thrombectomy is highlighted in the urgent peri-operative setting.Case summaryA 71-year-old female presented with 10 days of progressive lower extremity weakness and was found to have malignant cord compression along with incidental saddle, intermediate-high-risk PE that extended to all lobes on chest computed tomography. Given the intermediate to high-risk PE with acute cor pulmonale, urgent need for surgery, and risk of haemodynamic collapse upon induction of general anaesthesia, the decision was made to proceed with urgent percutaneous treatment of the PE. Percutaneous catheter-directed thrombectomy was successfully performed. The patient returned to the intensive care unit in stable condition and was able to then receive urgent cord decompression and further treatment for malignancy with no complication.DiscussionIn this case, single-session thrombectomy resulted in rapid reduction of pre-operative cardiopulmonary risk by alleviating the right ventricular strain, allowing urgent cord decompression surgery to proceed with optimized haemodynamics, no bleeding events, and no further oxygen requirements. While peri-operative risk stratification for cardiovascular outcomes is well established in current guidelines, there are no clear guidelines for peri-operative risk stratification in the setting of pulmonary embolism. The importance of the multidisciplinary PE Response Team is thus emphasized, as well as the importance of continuous evaluation of clinical decompensation in PE.
| S-EPMC7859591 | biostudies-literature