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Rheolytic Thrombectomy in a Patient with Thrombosis of the Popliteal-Tibial Segment in Clti (Clinical Case)

Dr. Arshed A. Kuchay1., Dr. Nikita N. Gruzdev1., Prof. Dr. Alexander N. Lipin1., Dr. Yanis P. Eminov1., Dr. Kirill A. Atmadzas1., Dr. Alina I. Lubimova1., Dr. Roman S. Sobolev1., Prof. Dr. Kirill L. Kozlov2

1Saint Petersburg State Budgetary Institution, Limb Salvage Center “City Hospital No. 14”. Russian Federation.
²Saint Petersburg Institute of Bioregulation and Gerontology. Russian Federation

*Corresponding author

*Dr. Arshed A. Kuchay. MD, MS, PhD. Cardiovascular surgeon, Clinical researcher - Limb Salvage Center, City Hospital № 14. Saint-Petersburg, Russian Federation.

Abstract

Through significant advances in the treatment of peripheral arterial occlusive disease, acute ischemia of the lower extremity is still associated with significant morbidity, limb threat and mortality. Atherosclerotic lesions of lower limb arteries, manifested by critical ischemia, are the main cause of lower limb amputations and disability of patients. Patients with critical ischemia of the lower limbs are patients with multilevel lesions of the arteries of the lower limbs. The two main causes of acute ischemia in lower extremities are arterial embolism and atherosclerotic arteries. Timely recognition and treatment of acute limb ischemia in emergency situations is essential in order to minimize the duration of ischemia. We would like to present the result of treatment of a 59-year-old patient with critical ischemia of the left lower limb, thrombosis of the popliteal artery and tibial segment, extensive infected wound of the left foot, performed in the Limb Salvage Center (“St. Petersburg City Hospital No. 14”).

Key Words: Atherosclerosis, Critical Ischemia, Thrombosis, Endovascular Surgery, Thromboaspiration

Introduction

Chronic limb threatening ischemia (CLTI) is a condition that threatens not only limb preservation but also the life of the patient. All global vascular surgery communities and guidelines agree that a patient suffering from CLTI needs to be admitted to a vascular center as soon as possible and undergo surgical revascularization of the ischemic limb as quickly as possible. Often such patients require repeated interventions, which is associated with a high risk of intraoperative and postoperative complications. One of such complications is thrombosis of arteries, both native and previously undergone surgical interventions (bypass and/or endovascular reconstructions).

Acute lower extremity arterial embolism is a common clinical emergency. It has the characteristics of acute onset and rapid development; if treatment is not pursued in time, within hours, it can cause irreversible damage to limb tissue, even threatening life and reducing the quality of life. Therefore, the key to the treatment of acute lower extremity arterial embolism is to pursue treatment in a timely manner and implement an effective treatment plan, which is of great significance to reduce the amputation rate and mortality.

Rheolytic thrombectomy is a modern method of endovascular thrombectomy using a special device based on the principle of hydrodynamic destruction and aspiration of thrombotic masses (Bernouli principle). This method emerged as a result of a long search for minimally invasive, quick and safe ways to treat acute and subacute thrombosis alternative to traditional surgery.

Purpose of the Work

To investigate and demonstrate the efficacy and application effect of rheolytic thrombectomy with AngioJet Boston Scientific in the treatment of a clinical case of a patient with in-stent thrombosis of the popliteal and tibial arteries in CLTI.

Materialsand Methods

We analyzed a case of treatment of a patient with thrombosis of the popliteal-tibial segment and previously undergone balloon angioplasty of the popliteal artery with stenting and the tibial arteries (thrombosis period of 14 days).

Clinical Case Description

Based on the collected anamnesis, clinical picture and analysis of the patient's medical history, the following results were obtained.

Patient R., 59 years old, female, was admitted to the emergency department of the St. Petersburg State Budgetary Institution “City Hospital No. 14” on 16.11.2022 with complaints of pain at rest in the left foot, extensive infected wound on the medial surface of the left foot. From the anamnesis it is known that the above complaints have been bothering for about a year. In September 2022, she underwent autopsy and drainage of phlegmon of the left foot, balloon angioplasty (BAP) with stenting of the popliteal artery (PopA) and tibial arteries, and a series of staged necrectomies. She was discharged with improvement to outpatient care. In November 2022, she felt sharp pain in the left lower extremity.

Recurrence of rest pain in the left lower limb and negative dynamics from the side of the wound process.

The main clinical diagnosis: Obliterative atherosclerosis of lower extremities. Balloon angioplasty and stenting of the left PopA from 09.2022. Critical ischemia of the left lower limb. Chronic arterial insufficiency, 4th degree. Infected wound of the left foot. Lymphangitis.

Concomitant pathology: Ischemic heart disease. Atherosclerosis of coronary and cerebral vessels. Hypertension stage 3, risk of cardiovascular complications - 4, Arterial hypertension 3 degree. PICS MI 2010, stenting of CA 2018. CHI - 2. Cerebrovascular disease. DE 2 st. of mixed genesis. Diabetes mellitus type 2, insulin consuming.

Examined, the following data were obtained:

General blood analysis: leukocytes - 15,43*109/l, erythrocytes - 3,94*1012/l, hemoglobin - 114 g/l, platelets - 238*109/l. Leukocytic formula: bacilli - 10%, segmented - 74%, lymphocytes - 10%, monocytes - 6%.

In biochemical blood test, creatine phosphokinase elevation-193.24 μmol/L, due to extensive necrotic process on the foot.

CT-angiography: On the left - common iliac artery (CIA), external iliac artery (EIA), common femoral artery (CFA), deep femoral artery (DFA), superficial femoral artery (SFA) - without significant stenosis, popliteal artery (PopA) - occluded throughout, stents are visualized in the lumen, anterior tibial artery (ATA) - filled due to collaterals from the oblique section, without significant stenosis, tibioperoneal trunk (TPA), peroneal artery (PA), posterior tibial artery (PTA) - occluded. (Figure 1)

Figure 1: CT-angixogxraphy.

Taking into account the clinical and angiographic pictures, the decision was made to perform rheolytic thrombectomy from the popliteal and tibial arteries of the left lower limb.

31.11.2022 –Patient was taken to the operating room of the Endovascular surgery department. Under local anesthesia with lidocaine solution 0.5% - 20 ml antegrade femoral access of the left CFA was performed. A 6F intraducer was placed. Systemic heparinization 5000 units intravenously. Intraoperative angiography was performed - CFA, DFA, SFA were patent, without stenosis. PopA - occluded throughout (thrombosis), ATA - filled from the oblique section without stenosis. TPT, PA, PTA - occluded. (Fig.2).

Intraluminal recanalization of PopA, ATA was performed using a 0.014” wire with the support of a 4F Ver-catheter. The guidewire was inserted into the middle third of the ATA (Fig.3A). Ver-catheter was replaced by Solent Dista catheter. Thrombaspiration from the PopA, source of the ATA was performed using AngioJet device (Fig.3B). Recanalization and thrombectomy from TPT, PA and PTA. (Fig.3C).

After thrombectomy, hemodynamically significant dissection of PopA over the stent is noted. After BAP the dissection persists. Implantation of a self-expanding stent from the P1 segment of the PopA to the distal third of the SFA was performed. (Figure 4)

At control angiography - trunk blood flow, direct revascularization of the foot. The PTA is working up to the distal third. Lateral and medial plantar arteries were ligated during the operation for opening and drainage of phlegmon of the left foot (Fig.5)

In the postoperative period, pain syndrome control is noted. The wound with positive dynamics. A number of staged necrectomies were performed. To stimulate the growth of granulation tissue, negative pressure therapy was performed - 1 course.

Ultrasound of the arteries of the left lower extremity in the postoperative period was performed. (Fig.6)

Figure 2: A - direct angiography of CFA, DFA, SFA, B - occlusion of PopA, C - occlusion of tibial segment.

Figure 3: Path of surgery.

Figure 4: Balloon angioplasty and stenting of PopA, SFA A), B).

Figure 5: Control angiography A), B), C).

Figure 6: Balloon angioplasty and stenting of PopA, SFA A), B).

The patient was discharged for outpatient observation, with the recommendation of re-hospitalization for closure of the wound defect. Autodermoplasty with a free graft was performed. At the control examination in July 2024 - complete epithelization of the left foot wound.

Dynamics of the wound process (Fig.7)

Figure 7: A - SFA blood flow, B - PopA blood flow, C - ATA blood flow, D - PA blood flow.

Discussion

The risk of amputation with chronic limb threatening ischemia is between 15% and 30%, and the perioperativemortalityand morbidity are high[2, 14-42]. Chronic limb threatening ischemia mainly includes acute and subacute arterial thrombosis based on lower limb arteriosclerotic occlusive disease, lower limb artery embolism, and acute lower limb artery thrombosis of an unknown cause. It is important to differentiate these conditions because the tactics of treatment and prognosis are very different[3]. Embolic disease is characterized by the presence of a foreign body (embolus) that partially or completely occludes the vascular lumen [4]. Aneurysms may also produce emboli, so the abdomen and popliteal fossa should be palpated carefully, and atherosclerosis may also cause distal emboli upon plaque rupture[5]. Hypertension, diabetes, and hyperlipidemia can all induce the formation of cardiovascular plaques and increase the risk of thrombosis[1,6]. Coronary heart disease is either an incomplete or a complete blockage of the cardiovascular system caused by the formation of plaques in the coronary arteries. If the plaques rupture, thrombosis may occur[7]. Atrial fibrillation can lead to blood pooling in the atrium, thereby forming a thrombus, and atrial fibrillation can easily lead to thrombus shedding[8]. Currently, the majority of acute lower extremity ischemia (approximately 70%) is caused by arterial thrombosis, which usually occurs in the presence of preexisting vascular disease and is common in patients with diabetes[9].

Traditional arterial incision and Fogarty catheter thrombectomy are very effective in the treatment of acute arterial embolization of the lower extremities, especially in cases involving a single large blood vessel. However, in some cases, such as the presence of sclerotic occlusive lesions in lower extremity arterioles or peripheral artery lesions, the early clinical results are still unsatisfactory, which may be related to the existence of potential stenosis occlusive lesions. Even secondary vascular injuries by Fogarty balloon catheters may limit clinical success[10]. Diabetic patients are generally at higher risk for severe peripheral arterial disease in the lower infra-knee artery and are at higher risk for poor outcomes after thrombectomy using the Fogarty balloon catheter. The arterial walls of diabetic patients are fragile, prone to spasms, and severely calcified, so Fogarty catheters are difficult to pass through and reach the target vessel. In these cases, bypass surgery may be used as the primary option or as a second-line treatment when thromboembolic resection fails[11]. However, conventional arteriotomy and Fogarty catheter thrombectomy or bypass surgery usually have a longer anesthesia duration, higher surgical risk, more severe trauma, higher rates of thrombus retention, and higher rates of thrombus recurrence[12]. In addition, the disadvantages of open surgery include scarring of the incision, difficulty in reoperation with femoral artery dissection, increased likelihood of lymphatic leakage, incision infection, and inability of the catheter to pass through the sclerosis to occlude the diseased artery.

Rheolytic thrombectomy is an effective tactics for removing thrombi, restoring and maintaining arterial patency and alleviating symptoms and can shorten the time of special bed care for patients with severe conditions[13]. It is recommended to rehydrate patients with isotonic saline during and after surgery and alkalize urine with sodium bicarbonate.

Conclusions

In conclusion, rheolytic thrombectomy is a safe and effective technique and an alternative to open reconstructive surgery for the treatment of acute and subacute lower extremity arterial embolism and thrombosis (up to 1 month), which effectively reduces the risks of wound complications, the volume of surgical intervention, and shortening the period of rehabilitation of patients, operation time, postoperative pain and postoperative complication rate and speeds up postoperative recovery. This study is a retrospective study with only single case and a short follow-up time. The clinical application and utility of rheolytic thrombectomy is limited. Therefore, a larger sample size is needed to evaluate the relevant risk factors and more clinical experience. In addition, prospective clinical studies are needed to accumulate experience and improve techniques to better grasp indications.

Additional Information

Author contribution. Thereby, all authors made a substantial contribution to the conception of the work, acquisition, analysis, interpretation of data for the work, drafting and revising the work, final approval of the version to be published and agree to be accountable for all aspects of the work.

Competing interests: The authors declare that they have no competing interests.

Funding source. This study was not supported by any external sources of funding.

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