Percutaneous Thrombectomy in Patients with Occlusions of the Aortoiliac Segment: A Case Series

Study Population

An overview of the demographics and characteristics of the study population is presented in Table 1.

Table 1 Demographic characteristics of the patient collective with pre-existing conditions and the degree of vessel calcifications

Of the 18 patients identified, ten patients presented with thrombosis related to stent-grafts, and eight with thrombosis in native vessels. A total of N = 21 vascular occlusions were treated with percutaneous thrombectomy. All patients underwent CTA of the abdomen and lower limbs to establish a diagnosis before the intervention. There was no significant difference in lesion length or vessel calcification between the groups or in complications.

Occlusion in Stent-Grafts

A detailed overview of each patient, including the age of the lesion, is presented in Table 2.

Table 2 Overview of all patients in the stent-graft group

Of the ten patients with stent-graft thrombosis, seven (70%) were previously treated with aorto-biiliac stent-grafts for infrarenal aortic aneurysm repair, and three patients (30%) with an iliac stent-graft for common iliac artery aneurysm. Vessel occlusions were localised in the aortoiliac segment in eight patients (80%) and iliac segment in two patients (20%). All lesions were classified as TASC (Inter-Society Consensus for the Management of Peripheral Arterial Disease) type D. The mean occlusion length was 147 ± 4 mm. Two patients with acute onset of symptoms presented with acute limb ischaemia (ALI) category IIa according to the Rutherford classification for ALI. Of the patients with subacute and chronic occlusions, six had severe intermittent claudication (Rutherford category 3 for chronic limb ischaemia [CLI]) and two had rest pain (category 4). The mean ankle-brachial index was 0.61 before treatment.

Occlusion in Native Vessels

A detailed overview of each patient is presented in Table 3.

Table 3 Overview of all patients in the “native vessel” group

Among the eight patients with native vessel occlusions, one aortic (13%), two aortoiliac (25%), and five iliac (62%) occlusions were found. All lesions were classified as TASC type D. The average occlusion length was 99  ±  49 mm (P = 0.06, compared to the stent-graft group).The two patients with acute onset of symptoms presented with ALI category IIa, according to the Rutherford classification for ALI. Of the patients with subacute and chronic occlusions, four had severe intermittent claudication (Rutherford category 3 for CLI) and two patients had rest pain (category 4). The mean ankle-brachial index before treatment was 0.55 (P = 0.76, compared to the stent-graft group).

Technical Success and Complications

The overall technical success rate was 100%, with primary technical success in 38% (7/18) of the cases (stent-graft group, 40% (4/10); native vessel group, 38% (3/8); P = 0.91). In all patients in the stent graft group, stent or stent-graft placement was performed after thrombectomy, while patients in the native vessel group received a stent-graft/EVAR in four cases (50%; 4/8; P = 0.01). Reasons for stent (-graft) placement were residual stenosis of > 30% (28%; 5/18), residual thrombus (34%; 6/18), and dissection (17%; 3/18). No amputations or deaths occurred due to this procedure. Further procedural details for each patient are presented in Tables 2 and 3.

Table 4 provides an overview of the complications. The most common complication was peripheral embolism, with 44% (8/18; stent-graft group, 5/10; native vessel group, 3/8). In both groups, embolism was treated successfully via aspiration thrombectomy in the same procedure, although it was supported by local lysis therapy in two cases in the native vessel group (5 mg Actilyse; Boehringer, Ingelheim, Germany). If there was a mismatch of > 1 mm between the diameters of the sheath and target vessel (6/8), peripheral embolism always occurred (P < 0.001). There was no significant difference between the lesion length and the occurrence of peripheral embolism (P = 0.74).

Table 4 Overview of complications of all patients treated with the percutaneous thrombectomy

The median length of hospital stay was 3 [2,3,4,5,6, 9] days, with no significant difference between the two groups (P = 0.27).

Follow Up

Two early re-occlusions occurred in the stent-graft group, which were subsequently treated with bypass surgery.

All patients in the stent-graft group underwent follow-up CTA imaging (219 ± 125 days). In the native vessel group, follow-up CTA was performed in three cases (after 511, 458, and 301 days, P  = 0.05). No re-occlusions were detected during these follow-up examinations.

All patients were contacted by phone (follow-up period for all patients, 653 ± 264 days). The follow-up period for patients in the stent-graft group was 538 [443; 589] days; for patients in the native vessel group 796 [598; 960] days (P = 0.04). One patient in the stent-graft group reported re-occlusion after 298 days, and two patients in the native vessel group reported re-occlusion after 177 and 372 days. Accordingly, the primary patency after the follow-up period was 72% overall (stent-graft group, 70%; native vessel group, 75%; P = 0.94). No deaths or limb loss did occur. Data is illustrated in Fig. 3.

Fig. 3figure 3

Presentation of the arterial patency following percutaneous thrombectomy of the entire study population (dark grey), the “stent-graft” (red) and the “native vessel” (blue) groups. There was no significant difference between groups. The standard error (Greenwood formula) exceeded 10% for the entire study population (dark grey) after 12 months, for the “stent-graft” (red) group after six months and for the “native vessel” (blue) group after one month

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