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Limb Salvage Using Pounce LP Mechanical Thrombectomy Device After Failed Percutaneous And Open Thromboembolectomy: A New Tool For The Armamentarium
Hassan Chamseddine, MD, Loay Kabbani, MD, Alexander Shepard, MD, Timothy Nypaver, MD, Mitchell Weaver, MD, Kevin Onofrey, MD.
Henry Ford Hospital, Detroit, MI, USA.
DEMOGRAPHICS:An 83-year-old female with chronic atrial fibrillation and chronic kidney disease.
HISTORY:This patient initially presented to an outside hospital with sudden-onset right foot pain, paresthesia, and cyanosis. CTA revealed a right external iliac artery occlusion. She underwent percutaneous thrombectomy with Penumbra Lighting Bolt, achieving flow in the posterior tibial artery. Re-occlusion and distal embolization to the tibial vessels prompted an open thromboembolectomy via femoral and popliteal artery exposure. Although flow was reportedly restored with a Doppler signal in the PT at the ankle, ischemic changes and pain progressed in the right forefoot. The patient was offered a below-knee amputation.
She presented to our institution with mild sensorimotor deficit and distal ischemic changes. CT angiography showed patent iliac and femoral vessels with tibial and peroneal vessel occlusion in the mid-calf.
PLAN:The femoral artery was exposed from the previous incision. Angiography revealed occluded AT and PT with reconstitution at the ankle via a subtotal occlusion of the posterior peroneal perforating artery. A 7F sheath was placed antegrade into the right superficial femoral artery. The reconstituted PT was traversed via the posterior peroneal perforating artery utilizing a 0.035 wire and Navicross catheter.
After traversing the occlusion, the hydrophilic catheter of the Pouce LP kit was advanced into the reconstituted PT artery. The wire was exchanged for the dual 4mm diameter nitinol self-expanding baskets for capturing thrombus. The baskets were moved into position in the PT artery extending into the mid foot. The catheter was removed and the 7mm x 6.5cm long funnel to capture the baskets was moved into the mid-peroneal artery. Two passes achieved successful thromboembolectomy of organized white material and restoration of inline flow into the PT and the proximal plantar branches. AT thrombectomy ensued with limited runoff restored to proximal dorsalis pedis branch.
Upon completion, the patient had restored pulse to the PT at the medial malleolus with a multiphasic signal extending in the distal PT artery. Over the ensuring 8 weeks the foot was allowed time to demarcate. A successful TMA resulted in limb salvage.
DISCUSSION:The POUNCE LP mechanical thrombectomy system, designed for 2.0-4.0mm vessels, was effective in revascularization of pedal vessels allowing for limb salvage after profound thromboembolism. It offers new hope for patients with severely compromised arterial flow in the pedal distribution.
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