Rheolytic thrombectomy in the management of acute and subacute limb-threatening ischemia

PURPOSE: To 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. MATERIALS AND METHODS: A 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. RESULTS: Angiographic 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. CONCLUSION: PMT 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.