Successful Treatment of Acute Limb Ischemia Secondary to Iatrogenic Distal Embolization Using Catheter Directed Aspiration Thrombectomy

Abstract

Objective: Acute limb ischemia (ALI) due to thromboembolism is a limb-and life-threatening condition regularly encountered by vascular surgeons. Iatrogenic distal embolization is occasionally seen as a complication of various endovascular procedures. We present a series of four patients who developed ALI due to arterial embolization during cardiovascular procedures that were successfully treated via catheter directed aspiration embolectomy. Methods: Retrospective review of demographics, risk factors, and procedural outcomes was completed for 4 patients who presented with ALI due to distal embolization following cardiovascular procedures. All patients were successfully treated with catheter directed aspiration embolectomy using the Penumbra Indigo System (Penumbra Inc., Alameda, California). All patients had high-quality angiography demonstrating successful embolectomy and end-procedure patency. Results: Three patients presented with Rutherford 2A and one with Rutherford 2B ALI secondary to intraoperative distal embolization. Three patients presented with ALI secondary to distal embolization during peripheral vascular interventions, and one following emergent intra-aortic balloon pump (IABP) placement for myocardial infarction. All emboli were located in the infra-inguinal vasculature. Median post-operative ABIs were 0.94 (n = 4). Median length of stay was 2 days. There were no mortalities and no need for adjunctive fasciotomy, amputation, or bypass for limb salvage. All patients improved clinically after intervention, and returned to their reported pre-hospitalization functional status. Conclusion: All procedures achieved technical success with catheter-directed aspiration thrombectomy with or without adjunctive lysis. Catheter-directed aspiration embolectomy with the Penumbra Indigo System for ALI following an iatrogenic embolic event is a safe, less-invasive treatment option. The use of this technology may reduce the need for traditional open thrombectomy or thrombolytic therapy to address ALI.

Case report: Endovascular treatment of acute limb ischemia in an adolescent with newly diagnosed lupus

“…In this situation, the Penumbra aspiration system (Penumbra Inc., Alameda, California), which has a soft tip to facilitate tracking of tortuous brain vessels and perform large-bore aspiration power for stroke intervention, is most suitable in this scenario. Farhat-Sabet et al reported using Penumbra Indigo (Penumbra Inc., Alameda, California) to successfully treat iatrogenic distal embolization in four patients with acute limb ischemia ( 8 ). In the PRISM trial, the reported success rate with Penumbra Indigo aspiration catheter was 87.2% ( 9 ).…”

Extended Use of Distal Embolic Protection Devices in Treatment of Distal Embolism During Lower Extremity Arterial Endovascular Interventions

“…Commercial suction thrombectomy devices, such as the Penumbra Indigo System (Penumbra, Alameda, CA, USA), are also available and effective. 13,15 However, these devices are expensive and cumbersome to set up in a clinically emergent situation. Also, they require the use of a larger catheter than that required for the EPD technique, carrying the risk of emboli dislodgement distally.…”

“…Numerous minimally invasive treatment options have been described, but none is established as the “gold standard,” nor are they effective in all circumstances. 11–15…”

“…Numerous minimally invasive treatment options have been described, but none is established as the "gold standard," nor are they effective in all circumstances. [11][12][13][14][15] Embolic protection devices (EPDs) are essentially filter baskets, consisting of a membrane with 80 to 130 μm pores attached to a guidewire that captures embolic debris while simultaneously maintaining antegrade flow. 16 They are designed and primarily used for the prevention of distal embolization during endovascular interventions.…”

Evolving Management Trends and Outcomes in Catheter Management of Acute Pulmonary Embolism

“…The disadvantages with the Angiovac apparatus include the large cannula size, hemodynamic perturbations from blood loss, need for an extracorporeal circulation and risk of right heart perforation due to due to the device's limited maneuverability. 30,31 C. Penumbra Indigo System (Penumbra Inc., Alameda, California): 32,33 The Penumbra system is a suction aspirator device that has a proprietary "smart" catheter tubing system that can adjust the suction applied across the catheter to establish suction. Sista et al evaluated the Penumbra system in a multi-center single-arm study that enrolled 119 acute submassive PE patients in the EXTRACT-PE study.…”