1 Vascular Health and Risk Management 2012 Vol: 8():. DOI: 10.2147/VHRM.S30819

Percutaneous mechanical thrombectomy for treatment of acute femoropopliteal bypass occlusion

Acute and subacute ischemia of the legs in acute and subacute femoropopliteal bypass occlusion is a dramatic situation that endangers the survival of the limbs, depending on the severity of the ischemia. Different therapy options like percutaneous mechanical thrombectomy procedures, which include rotational thrombectomy, have become available in recent years, in addition to local lysis and surgical thrombectomy. Surgical thrombectomy using the Fogarty catheter technique, in particular, shows an increased incidence of perioperative complications but only small technical success rates in randomized trials. On the other hand, local lysis is associated with increased costs due to resource-consuming measures, such as intensive monitoring and repeat angiographies, in addition to bleeding complications. In the past, further development of the Straub Rotarex® system as an endovascular therapy option has demonstrated good success leading to amputation-free survival in multiple studies. At the same time, a low rate of complications with use has been documented. Most examinations have been conducted in the thigh. To date, there are little investigational data on its use in acutely and subacutely occluded femoropopliteal bypasses. In this paper, the current study-based significance of the Rotarex system for this indication is analyzed based on the existing literature and the authors’ own experiences with 22 patients.

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Figures
Figure 1: The Rotarex® system. Figure 2: Contraindications for Rotarex® use. Figure 3: Acute proximal occlusion of a femoro-popliteal bypass on right. Figure 4: Reperfusion after two rotation thrombectomy passes. Figure 5: Detection of a high-grade insertion stenosis of the bypass as the presumed cause of the occlusion. Figure 6: Normal flow in the bypass following stent percutaneous transluminal angioplasty. Figure 7: Degeneratively altered femoropopliteal venous bypass on right following acute reopening with rotation thrombectomy (Rotarex® 8 F).Notes: Large bypass aneurysm upstream of the distal anastomosis. Elimination of the aneurysm in two steps using a Viabahn® endoprosthesis.
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References
  1. A comparison of thrombolytic therapy with operative revascularization in the initial treatment of acute peripheral arterial ischemia J Vasc Surg 19, 1021-1030 (1994) .
    • . . . Therapeutic recommendations based on large randomized studies on local lysis can be found on this in the current TASC Working Group Guidelines.1–4 Percutaneous mechanical thrombectomy (PMT) has also been proven as an additional therapy option in recent years . . .
  2. The STILE Trial: results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity Ann Surg 220, 251-266 (1994) .
    • . . . A great advantage of the PMT system compared with local lysis is the minimization of systemic bleeding complications, which were documented in particular in the large lysis studies.2,3 . . .
  3. A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs N Engl J Med 338, 1105-1111 (1998) .
  4. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) Eur J Vasc Endovasc Surg 33, S1-75 (2007) .
    • . . . Therapeutic recommendations based on large randomized studies on local lysis can be found on this in the current TASC Working Group Guidelines.1–4 Percutaneous mechanical thrombectomy (PMT) has also been proven as an additional therapy option in recent years . . .
  5. Percutaneous mechanical thrombectomy by means of rotational thrombectomy. Current Study situation Med Klin (Munich) 105, 705-710 (2010) .
    • . . . Because of good study data from the interventional therapy of acute and subacute arterial occlusion, more and more attention has been paid to rotational thrombectomy.5 In the meantime, the Rotarex® system (Straub Medical, Wangs, Switzerland), with technical enhancements, has become a relevant thrombectomy treatment for arterial vessel occlusions . . .
    • . . . Through this form of hybrid therapy, good long-term courses were able to be documented, even in larger native vessel areas (aorta, pelvic circulation).5 In several cases, a high-grade, hemodynamically relevant insertion stenosis was able to documented as the cause of the femoropopliteal bypass occlusion, which was then treated in the same session . . .
    • . . . Because of this, acute aortoiliac angles no longer pose a significant problem in comparison with the earlier Rotarex generation.5 The incidence of device-associated vessel perforations or dissections is low when care is taken with the intravascular course of the guide wire and it is monitored . . .
  6. Mechanical rotational thrombectomy for treatment thrombolysis in acute and subacute occlusion of femoropopliteal arteries: retrospective analysis of the results from 1999 to 2005 Rofo 180, 325-331 (2008) .
    • . . . Zeller and Wissgott et al in particular have described favorable courses with the Rotarex in systematic study analyses following acute recanalization.6–8 . . .
    • . . . The data correspond to the empirical values of Wissgott et al,6,10 who followed their patient collective over 12 months and describe a primary patency rate of 66% and a secondary patency rate of 86% . . .
  7. Early experience with a rotationel thrombectomy device for treatment of acute and subacute infra-aortic arterial occlusions J Endovasc Ther 10, 322-331 (2003) .
    • . . . The Zeller Working Group likewise reports a high rate of technical success following rotation thrombectomy. 7 By performing a stent-optimized angioplasty following the thrombectomy, a high percentage (78%) of very good early functional results were achieved (see Table 4) . . .
    • . . . A possible reason is surely the fact that, in the collective of Zeller et al, only patients with an artificial bypass were examined.7,8 In the collective we describe and in that of Wissgott et al, the percentage of artificial bypass thrombectomies was significantly smaller . . .
    • . . . In our opinion, the technical problems of the Rotarex system reported in earlier papers,7 particularly the danger of helix breakage in acute aortoiliac bifurcations, no longer exist in the current generation of the system . . .
  8. Long-term results after recanalization of acute and subacute thrombotic occlusions of the infra-aortic arteries and bypass-grafts using a rotational thrombectomy device Rofo 174, 1559-1565 (2002) .
  9. Recanalisation of acute and subacute femoropopliteal artery occlusions with the rotarex catheter: one year follow-up, single center experience Cardiovasc Intervent Radiol 28, 603-610 (2005) .
  10. Treatment of acute femoropopliteal bypass graft occlusion: comparison of mechanical rotational thrombectomy with ultrasound-enhanced lysis Rofo 180, 547-552 (2008) .
    • . . . A paper by Wissgott et al10 demonstrated, in a direct comparison between the Rotarex system and the EKOS Lysus® peripheral catheter system, a technical success rate of 100% for the Rotarex system in this indication, and also documented a significantly shortened procedural time with the Rotarex system . . .
    • . . . The data correspond to the empirical values of Wissgott et al,6,10 who followed their patient collective over 12 months and describe a primary patency rate of 66% and a secondary patency rate of 86% . . .
  11. Therapeutic options on femoral artery occlusion: indications, techniques and result – a vascular surgeon’s view Z Gefäßmed 2, 4-11 (2005) .
    • . . . The cause of the elevated reintervention rate for PTFE bypasses lies in the “foreign body reaction” of the vessels, which has been scientifically proven and recognized. 11 Since the restenosis rate in the collective of Zeller et al suddenly jumped after 6 months, one of the causes may lie in a proliferative restenosis of the anastomosis area, making repeat interventions or operations necessary. . . .
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