Safety, Efficacy and Outcome of Rotational Thrombectomy assisted Endovascular Revascularisation of the Superior Mesenteric Artery in Acute Thromboembolic Mesenteric Ischaemia

Abstract

Purpose To evaluate the efficacy and safety of percutaneous rotational thrombectomy-assisted endovascular revascularization of acute thromboembolic superior mesenteric artery occlusions in acute mesenteric ischemia.

Materials and Methods Fifteen cases of percutaneous rotational thrombectomy- assisted (Rotarex S, BD, USA) revascularization were retrospectively analyzed. The etiology was embolic in 40 % of cases and thrombotic in 60 %. A “Thrombectomy in Visceral Ischemia” (TIVI) 5-point score determined vessel patency at presentation, after percutaneous rotational thrombectomy, and after adjunctive technologies. TIVI 3 indicated nearly complete revascularization (minimal residual side branch thrombus). TIVI 4 indicated complete revascularization. Technical success was defined as successful device application and a final TIVI score of 3/4 after adjunctive technologies. Safety and outcome were also analyzed.

Results Device application via femoral access was feasible in 100 % of cases and improved flow in 86.7 % of cases (1 × TIVI 0→1, 11 × TIVI 0→2, 1 × TIVI 1→2). There was no change in 13.3 % of cases (2 × TIVI 2→2). Additional devices resulted in further flow improvement in 93.3 % of cases (8 × TIVI 3, 6 × TIVI 4). One recanalization failed (TIVI 2→2→2). After adjunctive technologies (10 × manual aspiration, 11 × angioplasty, 9 × stenting), the technical success rate was 93.3 %. The mean procedure time was 40.5(± 14) minutes for embolism and 72.1(± 20) minutes for thrombosis. There was one device-related major complication (catheter tip fracture) resulting in a device-related safety rate of 93.3 %. The overall major complication rate was 20 %. Surgical exploration (13 ×), bowel resection (9 ×) and Fogarty embolectomy/bypass (3 ×) were also performed. The 30-day mortality rate was 40 %.

Conclusion Percutaneous rotational thrombectomy is an effective adjunct for rapid endovascular recanalization of acute thromboembolic superior mesenteric artery occlusions with an acceptable rate of major procedural complications.

Key Points 

• Percutaneous rotational thrombectomy-assisted superior mesenteric artery revascularization in acute occlusive mesenteric ischemia is feasible and effective.

• Percutaneous rotational thrombectomy facilitates rapid flow restoration in native and stented superior mesenteric artery segments.

• Brachial access should be considered in the case of steep take-off angles of the superior mesenteric artery.

Zusammenfassung

Ziel Evaluation von Wirksamkeit und Sicherheit additiver perkutaner Rotationsthrombektomie bei der endovaskulären Therapie akuter thrombembolischer Verschlüsse der Arteria mesenterica superior.

Material und Methoden Retrospektive Auswertung von 15 Fällen akut okklusiver Mesenterialischämie, bei denen eine perkutane Rotationsthrombektomie (Rotarex S, BD, USA) als additives endovaskuläres Verfahren eingesetzt wurde. Ursachen waren Emboli in 40 % und Thrombosen in 60 %. Ein „Thrombektomie In Viszeraler Ischämie“ (TIVI)-5-Punkte-Score wurde als angiographischer Parameter zu Beginn der Intervention, nach perkutaner Rotationsthrombektomie und nach dem Einsatz additiver Verfahren erhoben. TIVI 3 stand für nahezu komplette Gefäßeröffnung mit winzigen Thrombusresten in Seitästen. TIVI 4 bedeutete vollständige Rekanalisation. Technischer Erfolg, definiert als erfolgreiche Rotarex-Applikation in Kombination mit einem TIVI-score 3/4 am Interventionsende, Sicherheit und Outcome wurden zusätzlich analysiert.

Ergebnisse Von femoral gelang der Einsatz von Rotarex zu 100 % und konnte den Fluss in 86,7 % der Fälle verbessern (1 × TIVI 0→1, 11 × TIVI 0→2 und 1 × TIVI 1→2). Bei 13,3 % gab es keine Verbesserung (2 × TIVI 2→2). Nach additiven Verfahren weitere Flussverbesserung in 93,3 % (8 × TIVI 3, 6 × TIVI 4). Eine Rekanalisation war frustran (TIVI 2→2→2). Die technische Erfolgsrate nach additiven Verfahren (10x manuelle Aspiration, 11 × Angioplastie, 9 × Stenting) war 93,3 %. Die mittlere Interventionsdauer betrug 40,5(± 14) min bei akuter Embolie und 72,1(± 20) min bei akuter Thrombose. Wegen einer schweren Komplikation (Katheterspitzenbruch) lag die gerätebezogene Sicherheitsrate bei 93,3 %. Die Gesamtrate an Major-Komplikationen betrug 20 %. Es erfolgten zudem 13 chirurgische Explorationen, 9 Darmresektionen und 3 chirurgische Revaskularisationen. Die 30-Tage-Mortalitätsrate war 40 %.

Schlussfolgerung: Perkutane Rotationsthrombektomie unterstützt eine schnelle, effektive endovaskuläre Revaskularisation bei akut okklusiver Mesenterialischämie mit einer akzeptablen Rate an prozedurbedingten Major-Komplikationen.

Kernaussagen 

• Ergänzende perkutane Rotationsthrombektomie bei der Rekanalisation akuter Verschlüsse der Arteria mesenterica superior ist praktikabel und wirksam.

• Die perkutane Rotationsthrombektomie unterstützt eine schnelle Revaskularisation von nativen und gestenteten Abschnitten der Arteria mesenterica superior.

• Bei steilen Abgangswinkeln der Arteria mesenterica superior ist ein brachialer Zugang ratsam.

Zitierweise

• Thurner A, Peter D, Dalla Torre G et al. Safety, Efficacy and Outcome of Rotational Thrombectomy assisted Endovascular Revascularisation of the Superior Mesenteric Artery in Acute Thromboembolic Mesenteric Ischaemia. Fortschr Röntgenstr 2024; 196: 1055 – 1062

Keywords

acute mesenteric arterial embolus - acute mesenteric arterial thrombosis - rotational atherectomy - mesenteric ischemia - percutaneous revascularization

Publication History

Received: 04 October 2023

Accepted after revision: 15 December 2023

Article published online:
13 March 2024

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