Bruce Gray

Percutaneous AngioJet Thrombectomy in the Management of Extensive Deep Venous Thrombosis

PURPOSEnThis study was undertaken to evaluate the efficacy of a percutaneous mechanical thrombectomy (PMT) device for rapid thrombus removal following deep venous thrombosis (DVT).nnnMATERIALS AND METHODSnOver a 37-month period, 17 patients (14 women; mean age, 41 y +/- 20) with extensive DVT were treated with initial attempts at PMT with use of the AngioJet rheolytic thrombectomy device. Sites of venous thrombosis included lower extremities in 14 patients and upper extremity and brachiocephalic veins in three. The etiology for venous thrombosis was malignancy in seven, idiopathic etiology in three, May-Thurner syndrome and immobilization in three each, and oral contraceptive use and hypercoagulable disorder in one each. The primary endpoint was venographic evidence of thrombus extraction. Perioperative complications, mortality, and recurrence-free survival were also evaluated.nnnRESULTSnAfter PMT, four of 17 patients (24%) had venographic evidence of >90% thrombus removal, six of 17 (35%) had 50%-90% thrombus removal, and seven of 17 (41%) had <50% thrombus extraction. Adjunctive thrombolytic therapy was used in nine of 13 patients with <90% thrombus extraction by PMT; six patients (35%) had contraindications to pharmacologic thrombolytic therapy. An underlying lesion responsible for the occlusion was uncovered in 10 patients (59%). Significant improvement in clinical symptoms was seen in 14 of 17 patients (82%). No complications were noted directly relating to the use of the AngioJet thrombectomy catheter. None of the patients were lost to follow-up during a mean of 8.9 months +/- 5.3 (range, 2-21 months). At 4 and 11 months, recurrence-free survival rates were 81.6% and 51.8%, respectively.nnnCONCLUSIONnPMT with adjunctive thrombolytic therapy is a minimally invasive, low-risk therapeutic option in patients with extensive DVT, associated with clinical benefits including thrombus removal, patency, and relief of symptoms.

Complications Associated with the Use of Urokinase and Recombinant Tissue Plasminogen Activator for Catheter-directed Peripheral Arterial and Venous Thrombolysis

PURPOSEnCatheter-directed thrombolytic dissolution of peripheral arterial and venous thrombus is in widespread use, yet the frequency and nature of associated complications remain ill defined. In an effort to better characterize the complications associated with urokinase (UK) and recombinant tissue plasminogen activator (rt-PA), the clinical course of patients treated for lower extremity vascular occlusions at a single institution was reviewed.nnnMATERIALS AND METHODSnOver a 9-year period, 653 consecutive patients were treated for lower extremity arterial (527 patients) or venous (126 patients) occlusions with catheter-directed UK (483 patients), rt-PA (144 patients), or both (26 patients). Decisions regarding the choice of thrombolytic agent were made by the clinician. In-hospital complications were subcategorized into hemorrhagic and nonhemorrhagic events and the rate of intracranial hemorrhage was specifically tabulated.nnnRESULTSnThere were no significant differences in the demographics or clinical presentation of patients treated with either UK or rt-PA. Bleeding complications occurred less often in the patients treated with UK (insertion site hematoma 21.9% vs. 43.8%, P<.0001, any bleeding necessitating transfusion 12.4% vs. 22.2%, P = .004, and intracranial hemorrhage 0.6% vs. 2.8%, P = .031). Cardiopulmonary complications necessitating transfer to the intensive care unit occurred more frequently in the patients treated with rt-PA (4.9% vs. 1.5%, P = .015). The risk of mortality was not statistically different between the UK and rt-PA treated patients (2.7% vs. 6.2%, P = .221).nnnCONCLUSIONSnThrombolysis appears safer with UK than with rt-PA, with a lower incidence of hemorrhagic complications. It is possible that this finding is related to differential dosing regimens or intrinsic pharmacologic differences between the agents. The observations of this retrospective analysis require confirmation with a prospective, randomized evaluation.

Rheolytic Thrombectomy in the Management of Acute and Subacute Limb-threatening Ischemia

PURPOSEnTo evaluate the use of a percutaneous mechanical thrombectomy (PMT) catheter (AngioJet) as an initial treatment for acute (<2 weeks) and subacute (2 weeks to 4 months) arterial occlusion of the limbs.nnnMATERIALS AND METHODSnA total of 86 (acute, n = 65; subacute, n = 21) patients were available for retrospective analysis, averaging 65 +/- 14 years of age. Outcomes assessed include initial angiographic success (failure = less than 50% luminal restoration [LR]; partial success = 50%-95% LR; success = more than 95% LR), pre- and postprocedural ankle-brachial index (ABI), device-related and systemic complications, 1-month amputation, mortality, and short-term patency.nnnRESULTSnAngiographic success was evaluated in 83 of 86 patients (guide wire unable to traverse lesion in three patients). The procedure failed in 13 of 83 (15.6%) patients, partial success was seen in 19 of 83 patients (22.9%), and successful recanalization was noted in 51 of 83 patients (61.4%). Adjunctive thrombolysis was used in 50 of 86 patients (58%). However, thrombolysis resulted in angiographic improvement at the site of PMT in only seven of 50 of these patients (14%). Adjunctive thrombolysis was uniformly unsuccessful in patients in whom initial PMT failed. The median increase in ABI was 0.64 (95% CI: 0.43-0.81). Success was more likely in the setting of in situ thrombosis, with 61 of 68 (90%) procedures successful, compared to embolic occlusions, with nine of 15 (60%) procedures successful (P =.011). Angiographic outcome was not dependent on the duration of occlusion (acute, 51 of 62; subacute, 19 of 21; P =.35) or the conduit type (graft, 28 of 31; native vessel, 42 of 52; P =.35). An underlying stenosis was identified in 53 of the 70 patients (75.7%) with a successful PMT, and 51 of these 53 unmasked lesions were successfully treated. Follow-up data were available in 56 patients for patency assessment at a median of 3.9 months (range, 0.1-28.5 months). Patency at 6 months was 79% (95% CI: 65-92). Systemic complications occurred in 16.3% of patients, local complications were noted in 18.6%, and 1-month amputation and mortality rates were 11.6% and 9.3%, respectively.nnnCONCLUSIONnPMT offers the potential to rapidly reestablish flow to an ischemic extremity and may be the only available treatment option in patients at high risk for open surgery or with contraindications to pharmacologic thrombolysis.

Complex endovascular treatment for critical limb ischemia in poor surgical candidates: a pilot study.

PURPOSEnTo evaluate the effectiveness of complex endovascular treatment for limb salvage in patients with critical limb ischemia.nnnMETHODSnIn a prospective study, 23 patients (13 men; mean age 70 +/- 11 years, range 44-87) with ischemic ulceration or gangrene of 25 lower limbs were enrolled at 4 sites to evaluate treatment with excimer laser recanalization followed by balloon angioplasty with optional stenting in the superficial femoral, popliteal, and/or tibial arteries.nnnRESULTSnMultiple lesions (mean 3.1, range 1-8) were treated in most cases. Reduction of stenosis/occlusion to <50% was achieved in 22 (88%) limbs. Individual cases of vessel perforation, inability to cross the lesion, and excessive residual stenosis accounted for the 3 failures. Over a 6-month period, 4 patients died of cardiac comorbidity and 1 was lost to follow-up. Adverse events included 4 minor and 2 below-knee amputations, 4 secondary angioplasties, and 4 femorodistal bypasses. The mean wound area reduction was 70% at 3 months, increasing to 89% at 6 months. According to life table analysis, the limb salvage rate was 90% with bypass and 69% without in the successfully treated patients (corresponding intention-to-treat rates were 79% and 61%).nnnCONCLUSIONSnComplex endovascular treatment combining laser debulking and angioplasty/stenting offers an alternative for patients with critical limb ischemia who lack good surgical options.

Endovascular Management of Unusual Aneurysms of the Axillary and Subclavian Arteries

Purpose: Aneurysms of the upper extremity arteries are uncommon and may be difficult to manage with standard surgical techniques. We report the exclusion of three axillary-subclavian aneurysms with covered stents. Methods and Results: Palmaz stents were covered with either polytetrafluoroethylene (2 cases) or brachial vein and deployed to exclude pseudoaneurysms in 1 axillary (ruptured) and 2 left subclavian arteries. Two of the patients had advanced cancer and died within 52 days and 3 months of treatment, but their aneurysms were occluded at the time of their death. The repair in the third patient is patent at 9 months. Conclusions: Endovascular exclusion of axillary and subclavian aneurysms with covered stents may offer a useful alternative to operative repair, particularly in patients with significant comorbidities.

The Treatment of Iliac Artery Atherosclerosis with Angioplasty and Intravascular Stents

Case description A 66-year-old man presented with bilateral calf and thigh claudication brought on by walking less than half a block. With rest, the pain resolved within minutes. This disxad comfort was first noticed in the right leg 7 years ago and has become progressive and more disabling despite his folxad lowing a standard walking program. He was unable to purxad sue his passion for golf because of this pain. He had no ischemic ulcerations or rest pain. His atherosclerotic risk factors included hypertension, cigarette smoking since the age of 15, and elevated total cholesterol level of 285 mg/dl. The hypertension (7 years duration) was well controlled on enalapril and doxazosin. He also took levothyroxine for hypothyroidism induced after irradiation treatment of Graxad ves disease. Despite counseling he continued to smoke. Other associated medical conditions included polycythemia (controled with phlebotomy) and benign prostatic hypertroxad phy. There was no history of myocardial infarction, angina, congestive heart failure, TIAs or stroke. On physical examination he was five feet, eight inches (1.54 m) tall, weighed 190 pounds (86 kg), and had truncal obesity and male pattern baldness. The blood pressure was 160/70 mmHg in both arms, with a regular heart rate of 90/min and respiratory rate of 20/min. The neck was supple without thyromegaly, adenopathy or bruit. The lungs were hyper-resonant without rales or wheezing. The heart sounds were regular without murmur, gallop or rub. The abdominal aorta was not enlarged and there were no epigastric bruits. The right femoral pulse was absent, and the left femoral pulse was severely diminished. The popliteal, posterior tibxad ial and dorsalis pedis pulses were absent bilaterally. Resting noninvasive plethysmographic arterial studies of the lower extremities demonstrated aortoiliac disease with anklelbrachial indices of 0.53 on the right and 0.60 on the left, which dropped to 0.18 after treadmill exercise. The exercise was stopped at 90 s owing to bilateral calf and thigh pain. Arteriography confirmed the presence of severe

UNRAVELING PULSATILE TINNITUS IN FMD: A REPORT OF THE UNITED STATES REGISTRY FOR FIBROMUSCULAR DYSPLASIA

Fibromuscular Dysplasia (FMD) is an arteriopathy which may lead to stenosis, aneurysm, and dissection. Pulsatile tinnitus (PT) is a common, debilitating symptom of FMD.nnData were queried from the United States Registry for FMD from 11 clinical centers.nnOf the 873 patients (pts) enrolled, data

PHYSICAL EXAMINATION FINDINGS IN FIBROMUSCULAR DYSPLASIA: A REPORT OF THE UNITED STATES REGISTRY FOR FIBROMUSCULAR DYSPLASIA

Results: Mean age at the time of enrollment was 55.7 +13.1 years (range 18-86 years) and 91% of pts were female. Mean BMI was 25.5 + 5.2 kg/ m2 and 48.8% of patients had a BMI > 25 kg/m2. Mean blood pressure on enrollment was 130/75 + 20/12.4 mmHg and 77.9% of pts were taking at least one blood pressure medication. 60% of pts reported significant headaches and 27.5% had pulsatile tinnitus. A cervical or epigastric bruit was a presenting sign that led to FMD diagnosis in 22.2% and 9.4% of pts, respectively. A neurological and vascular PE was recorded at the time of enrollment in 92.6% (414/447). Findings suggestive of Horner’s syndrome (pupil abnormality or ptosis) were reported in 12.4% of pts. Cranial nerve abnormalities were reported in 9.4% and other focal neurological deficits were reported in 13.6%. Bruits were reported over the carotid arteries (30.5%; 18.1% bilateral), epigastrium (17.5%), and flanks (6.1%; 3.2% bilateral). Among pts with reported imaging of the extracranial circulation (carotid and vertebral) and a documented PE, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of carotid bruit in predicting extracranial carotid FMD were 45.4%, 93.7%, 95.4%, and 37.4%, respectively. The sensitivity, specificity, PPV and NPV of epigastric and/or flank bruit in predicting renal and/or mesenteric FMD were 24.0%, 93.3%, 92.6%, and 26.0%, respectively.

LARGE ARTERY OCCLUSIVE DISEASE

Large artery occlusive disease is a common problem in the United States. It affects both the upper and lower extremities and is associated with significant morbidity and mortality. This article deals with the clinical recognition of this entity in hopes that the general internist and rheumatologist will more easily recognize it. In addition, the latest technology available to diagnose and treat large artery occlusive disease is discussed.