Rotational thrombectomy of a subacute popliteal arterial thrombosis

Clinical History

Subacute thrombosis of proximal popliteal artery

Imaging Findings

Patient presented with a stage IV disease with non-healing ulcer of her left foot. Popliteal and all pedal pulses were absent and she reported that her left foot was cold for at least two weeks. Antegrade puncture of her left common femoral artery was performed by an 18 G needle and angiography was performed revealing a 9 cm long occlusion of the popliteal artery above the knee joint (Fig. 1). Lower leg arteries showed major atherosclerotic lesions but the interosseal artery and the anterior tibial artery were patent down to the ankle.

Discussion

A 6 F sheath was introduced over a guidewire and and a 5 F diagnostic catheter was advanced into the superficial femoral artery. Selective angiography revealed some loose thrombus material at the proximal portion of the occlusion (Fig. 2). Due to the length of clinical symptoms, diagnosis of subacute popliteal arterial thrombosis was made and a coated guidewire was carefully advanced into the occlusion that smoothly went through the occluded segment into the distal patent portion. From that, it was concluded that the guidewire was travelling through an endoluminal pathway. After advancing the catheter into the distal popliteal artery, the guidewire was exchanged for a 0.020 in wire (Schneider Gold tip, BSIC). After insertion of an 8 F sheath, a Rotarex mechanical thrombectomy catheter (Straub Medical, Switzerland) was advanced to the occlusion. The Rotarex catheter (Fig. 3) has an inner helix that is rotated by a motor-unit with 40.000 rpm while the outer catheter body has two openings with cutting blades. Due to the rotating helix a vacuum is created that sucks thrombotic material into the housing wjhich is then transported out of the body where it is collected in a bag. The activated catheter was then advanced gently through the occlusion while it was permanetly twisted to cover the whole circumference of the lumen. After three passes, a larger neolumen was created and flow was restored (Fig. 3 b, c). No additional PTA was performed. Control angiography revealed an embolic occlusion of the anterior tibial artery (Fig. 4a). A 4 F coated vertebal catheter with a large inner lumen of 0.038 in (Terumo Inc., Tokyo) was then advanced over a coated guidewire deeply into the anterior tibial artery detecting a tiny fragment blocking the very small artery. By a single aspiration the fragment was removed and the tibial artery was patent again (Fig. 4b). Besides aspiration and thrombolysis, a couple of new hydromechanic, ultrasonic and mechanical thrombectomy devices are now available that allow removal especially of fresh thrombus material. All methods have considerable deficits in removing subacute thrombus which has already undergone partial organization and show wall adherence which makes it also difficult to be removed surgically. The new rotational device used offers some advantages particularly in subacute thrombosis allowing removal of even older thrombus material. Although it is very effective with only a minimal tendency of embolization, it should be not inserted in small arteriesto avoid wall trauma. It has also a tendency to athercomize eccentric plaque material. Continuous twisting of the catheter and gentle and careful movement of the activated catheter is therefore mandatory to avoid damage to the wall. Below the knee joint it should be used with utmost care.

Differential Diagnosis List

Final Diagnosis

Successful rotational thrombectomy of a popliteal arterial thrombosis

URL:	https://www.eurorad.org/case/679
DOI:	10.1594/EURORAD/CASE.679
ISSN:	1563-4086