Percutaneous Mechanical Thromboembolectomy in Acute Lower Limb Ischemia.

PURPOSE: To analyze the immediate outcome of percutaneous mechanical thromboembolectomy in acute infrainguinal leg ischemia in a consecutive cohort of patients with acute lower limb ischemia. MATERIAL AND METHOD: We retrospectively analyzed the data of 156 acute infrainguinal ischemic events in 148 patients. Patients presented with acute limb ischemia Rutherford category I in 68 cases (44%), Rutherford category II A in 64 instances (41%) and Rutherford II B in 24 instances (15%). In 62 cases (39.7%), the occlusion site started below the knee joint level, in 94 (60.3%) cases above. As a basic technique, an intervention was started by manual aspiration but if aspiration failed, an additional device was added. Most frequently, a rotational thrombectomy device (Rotarex, Straub Medical, Wangs, Switzerland) was used. An antegrade access to the femoral artery was the preferred access to the limb (154/156). RESULTS: In 145 of 156 incidents, a technical success was achieved (93%). Aspiration was used in 153 cases (98%). Rotational thrombectomy by use of the Rotarex catheter was added in 60 cases (38%). Directional atherectomy was applied in a total of five patients. As main technical complications, a downward embolization occurred (n = 11). There were four surgical groin revisions. Five patients died during the early follow-up with four not related to the intervention. Clinically, 135 patients (86.5%) showed an improvement in their clinical situation. CONCLUSION: Acute lower limb ischemia can be successfully treated by mechanical thromboembolectomy only by combining aspiration embolectomy with rotational thrombectomy in most cases but manual aspiration alone will frequently fail especially above the knee joint level.

Percutaneous recanalization of acute internal carotid artery occlusions in patients with severe stroke.

BACKGROUND: Sudden symptomatic occlusions of the proximal internal carotid artery (ICA) resulting in severe middle cerebral artery (MCA) ischemia and stroke are usually not accessible by rt-PA thrombolysis and the prognosis is usually very poor. Mechanical recanalization of the proximal ICA combined with intravenous and intra-arterial thrombolysis was therefore used as a rescue procedure. METHODS: Ten patients (9 men, 1 woman; mean age 56.1 years) were treated with emergency recanalization of the proximal carotid artery by using stents and/or balloon angioplasty as a rescue procedure. Three patients showed dissection, and 7 had atherothrombotic occlusions. Nine of 10 presented with an initial modified Rankin Scale (mRS) of 5, the remaining patient with mRS 4 (average NIHSS 21.4). After sonographic confirmation of ICA with associated MCA/distal ICA occlusion and bridging with rt-PA (without abciximab) an emergency angiography was performed with subsequent mechanical recanalization by percutaneous transluminal angioplasty (PTA) (n = 1) or primary stenting (n = 9) using self-expanding stents. Distal protection was used in 1 of 10 patients. RESULTS: Recanalization of the proximal ICA was achieved in all. At least partial recanalization of the intracerebral arteries was achieved in all, and complete recanalization in 5. In 4 of 10 patients limited hemorrhage was detected during CT controls. Major complications included 2 patients who had to undergo hemicraniectomy. One patient died from malignant infarction. At the time of discharge from the stroke unit 9 of 10 patients had improved markedly, 5 patients having an mRS of < or =2, and 3 patients a mRS of 3. At control after a mean of 20 weeks, 7 of 8 (88%) patients had a mRS < or =2, and 1 a mRS of 3. CONCLUSIONS: Primary mechanical recanalization of ICA occlusions by stent and PTA combined with fibrinolysis and/or GPIIb/IIIa-receptor antagonists seems to be feasible to improve patient outcome significantly.