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Mechanical Thrombectomy with Rotarex System in Buerger's Disease.

Kilickesmez O, Oguzkurt L - J Clin Imaging Sci (2015)

Bottom Line: We report the case of a patient with 2-month history of chronic thromboembolism of the distal superficial femoral and popliteal arteries with diagnostic features of thromboangiitis obliterans disease.The occlusion could not be crossed by antegrade approach and was achieved retrogradely via dorsalis pedis artery puncture followed by mechanical removal of the thrombus with Rotarex system (Straub Medical AG, Wangs, Switzerland).Subsequent ballooon angioplasties achieved exclusion of the thrombus, and straight-line flow established to the foot through the anterior tibial Artery.

View Article: PubMed Central - PubMed

Affiliation: Department of Diagnostic and Interventional Radiology, Istanbul Education and Research Hospital, Samatya, Turkey.

ABSTRACT
We report the case of a patient with 2-month history of chronic thromboembolism of the distal superficial femoral and popliteal arteries with diagnostic features of thromboangiitis obliterans disease. The occlusion could not be crossed by antegrade approach and was achieved retrogradely via dorsalis pedis artery puncture followed by mechanical removal of the thrombus with Rotarex system (Straub Medical AG, Wangs, Switzerland). Subsequent ballooon angioplasties achieved exclusion of the thrombus, and straight-line flow established to the foot through the anterior tibial Artery. The present case report demonstrates the success of mechanical thrombectomy in a patient with Buerger's vasculitis.

No MeSH data available.


Related in: MedlinePlus

44-year-old male patient with sudden onset of pain in left leg and ulcer on the toe, diagnosed with Buerger's disease. Digital substraction angiography of (a–d) the popliteal region and (e and f) leg during mechanical thrombectomy of the distal popliteal artery with Rotarex and reconstruction of flow to the foot. (a) Complete occlusion of the popliteal artery above the knee joint involving the trifurcation and all three lower limb artery origins (white arrows). (b) 6F Rotarex catheter (large white arrow) over the 0.018-inch wire (small white arrow). (c) Partial removal of the thrombus (open black arrows) and recanalization of the popliteal artery (black arrow) after retrograde re-entry to the true lumen following dorsalis pedis access (not shown). (d) Using the rotarex catheter, the clot was destroyed and removed totally. Patent anterior tibial artery is visible (white arrows). (e and f) Flow was reconstructed to the foot via anterior tibial artery (white arrows).
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Figure 2: 44-year-old male patient with sudden onset of pain in left leg and ulcer on the toe, diagnosed with Buerger's disease. Digital substraction angiography of (a–d) the popliteal region and (e and f) leg during mechanical thrombectomy of the distal popliteal artery with Rotarex and reconstruction of flow to the foot. (a) Complete occlusion of the popliteal artery above the knee joint involving the trifurcation and all three lower limb artery origins (white arrows). (b) 6F Rotarex catheter (large white arrow) over the 0.018-inch wire (small white arrow). (c) Partial removal of the thrombus (open black arrows) and recanalization of the popliteal artery (black arrow) after retrograde re-entry to the true lumen following dorsalis pedis access (not shown). (d) Using the rotarex catheter, the clot was destroyed and removed totally. Patent anterior tibial artery is visible (white arrows). (e and f) Flow was reconstructed to the foot via anterior tibial artery (white arrows).

Mentions: A 44-year-old man experienced sudden onset of pain in the left leg that decreased gradually. He was admitted to the hospital 1 week after an ulceration occurred on the left toe. Examination of the left lower extremity revealed a cold foot that was pale and without palpable pulse. Clinically, he was believed to have a threatened limb, but not irreversible ischemia (class III in the Rutherford classification of acute ischemia). Detailed medical history of the patient also revealed intermittent claudication for the last 2 years. He was a 1.5-pack-a-year smoker for 25 years. Color Doppler ultrasonography revealed occlusion of the distal segment of the left superficial femoral artery and the popliteal artery. There was monophasic dampened flow in both distal leg vessels. Then, revascularization of the presumably chronic thromboembolic occlusion of the the left superficial feromaral artery (SFA) and popliteal artery was planned to be performed in antegrade route via the ipsilateral common femoral artery (CFA). The patient agreed to undergo the procedure. The procedure was explained to the patient, and written informed consent was obtained. The procedure was performed in the angiography suite. The patient was placed under conscious sedoanalgesia with dormicum and fentanyl, and was monitored. After placing a 6F vascular sheath into the femoral artery, heparin was administered at a dose of 5000 IU. An angiogram obtained via the sheath revealed an abrubt thromboembolic occlusion of the distal SFA and the popliteal arteries. The trifucation arteries were occluded and, unexpectedly, the typical “corkscrew collateral” arteries could be seen in the images diagnostic for TAO [Figure 1]. Though we could get through the thrombus, attempts aiming to get access to leg arteries were unsuccessful despite the application of various guidewires and support catheters. Then, a retrograde approach via dorsalis pedis artery was planned and was achieved with ultrasound-guided micropuncture. The occluded part of the vessel was successfully recanalized by navigating a 0.018-inch, V-18 Control (Boston Scientific/Medi-tech, Natick, MA, USA) guidewire through dorsalis pedis artery upward with support from a glide Vertebral (Cordis, Warren, New Jersey, USA) catheter.[6] Subsequent to the catheterization of the true lumen of the SFA, angioplasty of the anterior tibial artery with 2 mm × 10 cm balloons distally and 3 mm × 10 cm balloons proximally (Cook Incorporated, Bloomington, IN, USA) was performed. The popliteal artery occlusion was crossed with balloon angioplasty of the occlusion. The occluded popliteal artery and anterior tibial artery (ATA) opened up well with balloon angioplasty. Following distal recanalization, an SFA roadmap with an antegrade vertebral catheter was obtained. Afterward, a 6 F Rotarex system (Straub Medical AG, Wangs, Switzerland) was navigated over a 0.018-inch guidewire for removal of the thrombi. The Rotarex system was advanced over this guidewire up to a few centimeters above the thrombotic occlusion and then activated. The occlusion was passed slowly. Small forward and backward movements were performed three times and we obtained an angiogram that revealed restoration of the flow except slight irregular residual chronic thrombi attached to the vessel wall. Angioplasty of the SFA was performed with a 0.018-inch wire using a 5 × 40 mm angioplasty balloon (Cook Incorporated). Completion angiogram showed complete exclusion of the thrombus, and straight-line flow established to the foot through the native popliteal artery and ATA [Figure 2]. The total procedure time was 2 h and 10 min. The patient responded very well to the treatment and was fully mobile the following morning. He was discharged in the same week. The ulcer healing began within a few days and took 3 weeks for recovery. A lifelong daily dose of 300 mg Aspirin (acetylsalicylic acid) was recommended for the patient. The patient was seen at the first and third months after treatment. Doppler ultrasound examination performed at the third month showed patency. However, although planned, the patient did not return for the sixth month follow-up investigation.


Mechanical Thrombectomy with Rotarex System in Buerger's Disease.

Kilickesmez O, Oguzkurt L - J Clin Imaging Sci (2015)

44-year-old male patient with sudden onset of pain in left leg and ulcer on the toe, diagnosed with Buerger's disease. Digital substraction angiography of (a–d) the popliteal region and (e and f) leg during mechanical thrombectomy of the distal popliteal artery with Rotarex and reconstruction of flow to the foot. (a) Complete occlusion of the popliteal artery above the knee joint involving the trifurcation and all three lower limb artery origins (white arrows). (b) 6F Rotarex catheter (large white arrow) over the 0.018-inch wire (small white arrow). (c) Partial removal of the thrombus (open black arrows) and recanalization of the popliteal artery (black arrow) after retrograde re-entry to the true lumen following dorsalis pedis access (not shown). (d) Using the rotarex catheter, the clot was destroyed and removed totally. Patent anterior tibial artery is visible (white arrows). (e and f) Flow was reconstructed to the foot via anterior tibial artery (white arrows).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4374197&req=5

Figure 2: 44-year-old male patient with sudden onset of pain in left leg and ulcer on the toe, diagnosed with Buerger's disease. Digital substraction angiography of (a–d) the popliteal region and (e and f) leg during mechanical thrombectomy of the distal popliteal artery with Rotarex and reconstruction of flow to the foot. (a) Complete occlusion of the popliteal artery above the knee joint involving the trifurcation and all three lower limb artery origins (white arrows). (b) 6F Rotarex catheter (large white arrow) over the 0.018-inch wire (small white arrow). (c) Partial removal of the thrombus (open black arrows) and recanalization of the popliteal artery (black arrow) after retrograde re-entry to the true lumen following dorsalis pedis access (not shown). (d) Using the rotarex catheter, the clot was destroyed and removed totally. Patent anterior tibial artery is visible (white arrows). (e and f) Flow was reconstructed to the foot via anterior tibial artery (white arrows).
Mentions: A 44-year-old man experienced sudden onset of pain in the left leg that decreased gradually. He was admitted to the hospital 1 week after an ulceration occurred on the left toe. Examination of the left lower extremity revealed a cold foot that was pale and without palpable pulse. Clinically, he was believed to have a threatened limb, but not irreversible ischemia (class III in the Rutherford classification of acute ischemia). Detailed medical history of the patient also revealed intermittent claudication for the last 2 years. He was a 1.5-pack-a-year smoker for 25 years. Color Doppler ultrasonography revealed occlusion of the distal segment of the left superficial femoral artery and the popliteal artery. There was monophasic dampened flow in both distal leg vessels. Then, revascularization of the presumably chronic thromboembolic occlusion of the the left superficial feromaral artery (SFA) and popliteal artery was planned to be performed in antegrade route via the ipsilateral common femoral artery (CFA). The patient agreed to undergo the procedure. The procedure was explained to the patient, and written informed consent was obtained. The procedure was performed in the angiography suite. The patient was placed under conscious sedoanalgesia with dormicum and fentanyl, and was monitored. After placing a 6F vascular sheath into the femoral artery, heparin was administered at a dose of 5000 IU. An angiogram obtained via the sheath revealed an abrubt thromboembolic occlusion of the distal SFA and the popliteal arteries. The trifucation arteries were occluded and, unexpectedly, the typical “corkscrew collateral” arteries could be seen in the images diagnostic for TAO [Figure 1]. Though we could get through the thrombus, attempts aiming to get access to leg arteries were unsuccessful despite the application of various guidewires and support catheters. Then, a retrograde approach via dorsalis pedis artery was planned and was achieved with ultrasound-guided micropuncture. The occluded part of the vessel was successfully recanalized by navigating a 0.018-inch, V-18 Control (Boston Scientific/Medi-tech, Natick, MA, USA) guidewire through dorsalis pedis artery upward with support from a glide Vertebral (Cordis, Warren, New Jersey, USA) catheter.[6] Subsequent to the catheterization of the true lumen of the SFA, angioplasty of the anterior tibial artery with 2 mm × 10 cm balloons distally and 3 mm × 10 cm balloons proximally (Cook Incorporated, Bloomington, IN, USA) was performed. The popliteal artery occlusion was crossed with balloon angioplasty of the occlusion. The occluded popliteal artery and anterior tibial artery (ATA) opened up well with balloon angioplasty. Following distal recanalization, an SFA roadmap with an antegrade vertebral catheter was obtained. Afterward, a 6 F Rotarex system (Straub Medical AG, Wangs, Switzerland) was navigated over a 0.018-inch guidewire for removal of the thrombi. The Rotarex system was advanced over this guidewire up to a few centimeters above the thrombotic occlusion and then activated. The occlusion was passed slowly. Small forward and backward movements were performed three times and we obtained an angiogram that revealed restoration of the flow except slight irregular residual chronic thrombi attached to the vessel wall. Angioplasty of the SFA was performed with a 0.018-inch wire using a 5 × 40 mm angioplasty balloon (Cook Incorporated). Completion angiogram showed complete exclusion of the thrombus, and straight-line flow established to the foot through the native popliteal artery and ATA [Figure 2]. The total procedure time was 2 h and 10 min. The patient responded very well to the treatment and was fully mobile the following morning. He was discharged in the same week. The ulcer healing began within a few days and took 3 weeks for recovery. A lifelong daily dose of 300 mg Aspirin (acetylsalicylic acid) was recommended for the patient. The patient was seen at the first and third months after treatment. Doppler ultrasound examination performed at the third month showed patency. However, although planned, the patient did not return for the sixth month follow-up investigation.

Bottom Line: We report the case of a patient with 2-month history of chronic thromboembolism of the distal superficial femoral and popliteal arteries with diagnostic features of thromboangiitis obliterans disease.The occlusion could not be crossed by antegrade approach and was achieved retrogradely via dorsalis pedis artery puncture followed by mechanical removal of the thrombus with Rotarex system (Straub Medical AG, Wangs, Switzerland).Subsequent ballooon angioplasties achieved exclusion of the thrombus, and straight-line flow established to the foot through the anterior tibial Artery.

View Article: PubMed Central - PubMed

Affiliation: Department of Diagnostic and Interventional Radiology, Istanbul Education and Research Hospital, Samatya, Turkey.

ABSTRACT
We report the case of a patient with 2-month history of chronic thromboembolism of the distal superficial femoral and popliteal arteries with diagnostic features of thromboangiitis obliterans disease. The occlusion could not be crossed by antegrade approach and was achieved retrogradely via dorsalis pedis artery puncture followed by mechanical removal of the thrombus with Rotarex system (Straub Medical AG, Wangs, Switzerland). Subsequent ballooon angioplasties achieved exclusion of the thrombus, and straight-line flow established to the foot through the anterior tibial Artery. The present case report demonstrates the success of mechanical thrombectomy in a patient with Buerger's vasculitis.

No MeSH data available.


Related in: MedlinePlus