Puvvala Gowri Kiran, Loukas Karamperidis, Donas Konstantinos P, Hinkelmann Juergen, Faiz Ba-Fadhl, Gerado Luna Vidriales, Psyllas Anastasios
Department of Vascular Surgery, Marien Hospital, 46483 Wesel, Germany.
Department of Vascular Surgery, Asklepios Clinic, 63225 Langen, Germany.
J Clin Med. 2024 Jul 9;13(14):4002. doi: 10.3390/jcm13144002.
Acute limb ischemia due to limb-graft occlusion (LGO) after fenestrated endovascular aneurysm repair (FEVAR) and acute bypass graft occlusion with an ePTFE graft pose critical challenges, necessitating prompt intervention to prevent limb loss. This paper discusses two cases of acute limb ischemia treated with a hybrid approach using the AngioJet™ Ultra Thrombectomy System as an adjunct to Fogarty thrombectomy. Case I involved a 69-year-old male post-FEVAR with contralateral iliac limb graft occlusion of the fenestrated Anaconda™, while Case II featured a 70-year-old male (ASA IV) post-bypass surgery (iliopopliteal arterial bypass with ePTFE Graft) with acute bypass graft occlusion. Both cases underwent successful recanalization using the AngioJet™ Ultra Thrombectomy System (ZelanteDVT™ 8F catheter, Solent™ Proxi 6F catheter) (Boston Scientific, Marlborough, MA, USA), combined with adjunctive techniques including Fogarty thrombectomy, balloon angioplasty, stenting, and local lysis. Immediate postoperative and follow-up assessments after 6 months revealed restored limb perfusion and improved clinical outcomes, with palpable pulses and improved ulcer healing. The aim of this treatment strategy is not only to alleviate limb ischemia but also to preserve future options in the event of graft failure. The use of the AngioJet™ Thrombectomy System in cases of LGO aims not only to clear the thrombus load but also to avoid the need for graft relining. In the case of acute arterial bypass graft occlusion in a patient with ASA IV, the goal of using the thrombectomy device is to preserve the native vessels for future procedures, such as long infragenual bypass, in addition to limb salvage. These cases demonstrate the efficacy of a hybrid surgical approach in managing acute limb ischemia following graft occlusion following FEVAR and bypass surgery. Long-term follow-up will further elucidate the durability of these interventions and their impact on limb salvage and overall patient outcomes. By combining mechanical thrombectomy with adjunctive techniques, such as balloon angioplasty and stenting, this hybrid approach offers a comprehensive solution to acute limb ischemia, addressing both the underlying occlusive pathology and ensuring optimal limb perfusion. Furthermore, the utilization of the AngioJet™ Ultra Thrombectomy System provides a minimally invasive yet effective method for thrombus removal, reducing procedural time and potential complications associated with open surgical techniques. As such, this approach represents a valuable addition to the armamentarium of treatments for acute limb ischemia, particularly in cases of graft occlusion following complex endovascular and bypass procedures.
开窗式血管腔内动脉瘤修复术（FEVAR）后因肢体移植物闭塞（LGO）导致的急性肢体缺血以及使用ePTFE移植物的急性旁路移植物闭塞带来了严峻挑战，需要及时干预以防止肢体丧失。本文讨论了两例采用杂交方法治疗的急性肢体缺血病例，使用AngioJet™ 超血栓切除术系统作为Fogarty血栓切除术的辅助手段。病例一为一名69岁男性，FEVAR术后，带开窗的Anaconda™对侧髂部肢体移植物闭塞；病例二为一名70岁男性（美国麻醉医师协会IV级），旁路手术后（ePTFE移植物髂股动脉旁路移植术）出现急性旁路移植物闭塞。两例均使用AngioJet™ 超血栓切除术系统（ZelanteDVT™ 8F导管、Solent™ Proxi 6F导管）（美国马萨诸塞州马尔伯勒市波士顿科学公司）成功实现再通，并结合了包括Fogarty血栓切除术、球囊血管成形术、支架置入术和局部溶栓等辅助技术。术后即刻及6个月的随访评估显示肢体灌注恢复，临床结果改善，可触及脉搏，溃疡愈合情况改善。这种治疗策略的目的不仅是缓解肢体缺血，还在于在移植物失败时保留未来的选择。在LGO病例中使用AngioJet™ 血栓切除术系统，不仅旨在清除血栓负荷，还可避免移植物内衬的需要。对于美国麻醉医师协会IV级患者的急性动脉旁路移植物闭塞，使用血栓切除装置的目的除了挽救肢体之外，还在于保留天然血管以备未来手术，如长段膝下旁路移植术。这些病例证明了杂交手术方法在处理FEVAR和旁路手术后移植物闭塞导致的急性肢体缺血方面的有效性。长期随访将进一步阐明这些干预措施的持久性及其对肢体挽救和患者总体结局的影响。通过将机械血栓切除术与球囊血管成形术和支架置入术等辅助技术相结合，这种杂交方法为急性肢体缺血提供了全面的解决方案，既解决了潜在的闭塞性病变，又确保了最佳的肢体灌注。此外，AngioJet™ 超血栓切除术系统的使用提供了一种微创但有效的血栓清除方法，减少了手术时间以及与开放手术技术相关的潜在并发症。因此，这种方法是急性肢体缺血治疗手段中的一项有价值的补充，尤其适用于复杂血管腔内和旁路手术后的移植物闭塞病例。
