Recanalisation of occluded popliteal stent by fibrinolysis, PTA and clot aspiration

Clinical History

80-year-old lady with multiple risks factors (atrial fibrillation, hypertension, ischaemic and valvular cardiopathy, previous smoker) underwent endovascular recanalisation of popliteal occlusion of right lower limb for critical ischaemia by PTA, fibrinolytic therapy (FT) and stent deployment (Supera-IDEV) with an acceptable result. One month later she was readmitted with the same symptoms due to stent occlusion (Fig.1).

Imaging Findings

A guidewire was easily advanced in the occluded stent and a 4F-diagnostic-catheter was advanced inside the stent and local FT with urokinase was started (240000 IU/hour for 2 hours followed by 60000 IU/hour for 22 hrs). 24hs-angiogram showed good stent recanalisation and partial reopening of below-the-knee arteries (Fig.2). After further 24 hs of FT check-angiogram showed complete recanalisation of popliteal stent (Fig.3a, b) but persisting occlusion of anterior tibial artery (ATA) and short stenosis of peroneal artery (PA). An attempt to achieve further improvement by conventional PTA was done, however, no improvement was seen in PA (Fig.3c). For this reason we tried "clot aspiration" in both arteries using a 4F diagnostic catheter which was advanced to the level of occlusion and pulled-back during continuous aspiration with a 20 ml syringe. Small clots were detected (Fig.3f) and final angiography showed excellent recanalisation of both BTK arteries (Fig.3e). Clinical symptoms completely recovered and Color-Doppler US 3 months later showed regular patency of distal arteries.

Discussion

The endovascular treatment of acute occlusion of femoro-popliteal district after PTA or stent deployment or bypass-surgery can be done in different ways as local fibrinolytic therapy or using complex mechanical devices based on rotational systems which aspirate or fragment clots and thrombotic materials. However, these last systems are quite complicated to use and expensive. Another option is to try to aspirate thrombotic material with simple catheters with a big lumen as guiding catheters of 6 or 7 French. This technique has been proposed since 1985 by Starck et al and was named Percutaneous Aspiration Thromboembolectomy (PAT) [1]. However, this technique did not reach great popularity although some papers report convincing results [2, 3, 4]. During the last decade different devices based on the same principles have been developed (Hydrolyser, Pronto, Angiojet etc) [5], but none reached large diffusion and they have limitations because of complexity of use and results. In the case shown here after fibrinolysis and PTA we tried to solve the problem simply using a conventional 4F diagnostic catheter with a .038" lumen. Under road mapping showing exactly the site of the filling defect we advanced the tip of the catheter and after removal of the guidewire we applied a strong suction power by means of a 20 cc syringe while slowly pulling back the catheter. A good sign that you're capturing "something" is when you don't have blood filling in your syringe during aspiration anymore. Aim of this presentation is to underline that in selected cases "clot" or "thrombus" aspiration is a valid option which can solve a complex situation in an "easy" way.

Differential Diagnosis List

Final Diagnosis

Recanalisation of occluded stent by fibrinolysis, PTA and clot aspiration

URL:	https://www.eurorad.org/case/10063
DOI:	10.1594/EURORAD/CASE.10063
ISSN:	1563-4086