Thrombectomy using suction filtration and veno-venous bypass: single center experience with a novel device.

OBJECTIVES: To describe the first single center experience with a novel aspiration thrombectomy device. BACKGROUND: The appearance of inferior vena cava or right-sided intracardiac thrombus may prompt consideration of percutaneous thrombectomy as a method to prevent new or worsening pulmonary embolism (PE). The AngioVac is a novel thrombectomy device composed of a cannula and extracorporeal circuit with filter for pump-assisted removal of intravascular debris which is coupled with a reinfusion catheter for return of blood to the patient. The device has been approved by the United States Food and Drug Administration since 2009. This report represents the first significant case series describing its use, feasibility and outcomes in evacuating large caval thrombi or intracardiac masses in PE. METHODS: This is a retrospective analysis of patient and case characteristics and in-hospital clinical outcomes of AngioVac thrombectomy in 14 consecutive patients treated between April 2010 and July 2013 at our institution. RESULTS: Fourteen consecutive patients (mean age 50, 64% female) underwent 15 AngioVac procedures over 40 months. Indications included intracardiac mass (73%), acute PE (33%), and caval thrombus (73%). Four patients (27%) were in shock at the start of the procedure. Peri-procedure mortality was 0% and in-hospital mortality was 13% at a mean follow-up of 23 days. There were no pulmonary hemorrhages, strokes or myocardial infarctions. Though 73% had a post procedural drop in hematocrit, only two bleeding events were related to access site and required a transfusion. CONCLUSIONS: AngioVac thrombectomy is feasible in critically ill patients with acute DVT or PE and large caval thrombi or intracardiac masses.

Popliteal venous aneurysms: characteristics, management strategies, and clinical outcomes--a modern single-center series.

BACKGROUND: Popliteal vein aneurysm (PVA) may be an incidental finding on imaging, but often presents in the context of acute venous thromboembolism (VTE). The role of anticoagulation with or without surgical excision versus expectant management is ill defined. METHODS: In this single-center, retrospective, cohort study, patient records from January 2002 to December 2013 were queried for terminology consistent with PVA. Demographic data and clinical outcomes were extracted via chart review. RESULTS: A total of 21 patients with PVA were identified (57% male). Mean follow-up was 38 ± 31 months. Mean PVA diameter was 2.5 ± 1.1 cm; 67% were saccular (with the remainder being fusiform), 19% contained thrombus, 67% were left sided, and bilateral PVA was present in 24% of cases. At the time of PVA diagnosis, 14% had pulmonary embolism. Treatment consisted of observation only (62%), anticoagulation (19%), surgery (5%), or both anticoagulation and surgery (14%). There were no recurrences of VTE once treated, although there was 1 acute deep venous thrombosis in a patient who was managed conservatively. Two patients had recurrent PVA after surgery, and there were 2 surgical complications (transient foot drop and hematoma). CONCLUSIONS: PVA is associated with VTE. Based on our series, it is unclear if incidentally discovered PVA (without VTE) warrants treatment with anticoagulation and/or surgical repair. Further multicenter studies are needed to establish the indications for safety and durability of surgery.

Increased local cytokine production at culprit superficial femoral artery plaques.

Characterization of local inflammation at culprit superficial femoral artery (SFA) stenosis has not been studied. We hypothesized that arterial cytokine concentrations would be greater at sites of stenosis. Twenty patients with ≥50 % angiographic stenosis of the SFA had blood drawn just proximal to the lesion and from a contralateral site free of disease. A microplate immunoassay was used to determine the concentrations of 42 distinct cytokines and growth factors. Exact conditional logistic analysis was used to compare measures at the two sites with interaction terms describing clinical factors used to identify difference mediators. Interaction terms identified clinical factors that could predict cytokine levels. The concentrations of soluble CD40 ligand (sCD40L; mean 212 and 177 pg/ml, p = 0.01) and tumor necrosis factor beta (TNF-B; mean 16.6 and 15.9 pg/ml, p = 0.04) were increased immediately proximal to areas of stenosis. Factors associated with greater concentrations at sites of stenosis were bilateral ankle-brachial index ≤0.90 (p = 0.04), no statin use (p = 0.02), claudication (p = 0.03), low leukocyte count (p = 0.03), absence of limb ischemia (p = 0.04) and lack of aspirin or clopidogrel therapy (p ≤ 0.06). Greater concentrations of sCD40L and TNF-B at sites of stenosis suggest that these cytokines play a role in the pathogenesis of symptomatic SFA disease. Our results also suggest that statin, aspirin and clopidogrel therapy may attenuate localized inflammation in the SFA, though due to a small sample size and the use of multiple comparisons across groups, these findings can be viewed as hypothesis generating only. In conclusion, selected cytokines are heightened at culprit SFA lesions and inflammation may be modulated by statin and antiplatelet therapy.