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Fast-Track Thrombolysis Protocol for Acute Limb Ischemia

Ascher, Enrico; Kibrik, Pavel; Rizvi, Syed Ali; Alsheekh, Ahmad; Marks, Natalie; Hingorani, Anil
OBJECTIVE:Catheter-directed thrombolysis (CDT) in the treatment of acute lower-extremity arterial occlusions (ALI) often requires several interventional sessions to generate successful outcomes. CDT is typically an expensive procedure, necessitating extended hospital length of stay (LOS) that may be associated with an increase in both local and systemic hemorrhagic complications. Five years ago, we created the Fast-Track Thrombolysis Protocol for Arteries (FTTP-A) to deal with these concerns. The goal of our protocol is to re-establish patency during the first session of thrombolysis, thus decreasing costs and complications associated with prolonged periods of thrombolytic exposure. METHODS:A retrospective study of 42 patients was performed at our institution who were treated for ALI utilizing FTTP-A from January 2014 to February 2019. FTTP-A includes: peri-adventitial lidocaine injection at the arterial puncture site under ultrasound guidance, contrast arteriography of the entire targeted segment, pharmacomechanicalrheolytic thrombectomy of the occluded arterial segment, tissue plasminogen activator (tPA) infusion along the occluded segment, balloon maceration of the thrombus, and if deemed necessary, placing a stent in areas of significant (≥30%) stenosis that is refractory to balloon angioplasty and thrombolysis. After the stenosis or thrombus was cleared, patients were placed on an oral anticoagulant agent. RESULTS:Forty-two primary FTTP-As (50 total interventions) were performed in 42 patients. The median age was 67.2±12.2 years (range 41-98), of which 54.8% were male. 59.5% of the procedures were performed on the left lower extremity. Initial arterial access sites as obtained via the common femoral artery (CFA), in 39/42 cases (92.9%), with the remaining three being obtained in a left bypass access site, a right femoral-popliteal graft and a right femoral-femoral graft. The mean operative time was 148.9±62.9 minutes (range: 83-313), and the mean volume of tPA infused was 9.7±4.0 mg (range: 2-20). The median cost including medications and interventional tools was $4673.19 per procedure. The mean post-operative length of stay was 3.1±4.5 days (range: 1-25). Median post-operative length of stay was 1 day. Mean post-operative follow-up was 27±19.2 months (range: 0-62). Single-session FTTP-A was successful in 81% (n = 34/42) of patients. The remaining 8 patients (19%) required a single additional session. Thirty-four of the 42 patients (81%) required arterial stenting. Peri-procedural complications consisted of 1 patient with hematuria, which resolved, and 1 patient with thrombocytopenia, which resolved. No patients experienced re-thrombosis within 30-days of FTTP-A. Over the five-year study period, there were no significant local or systemic hemorrhage, limb loss, or mortality related to this protocol. CONCLUSION/CONCLUSIONS:FTTP-A, appears to be safe, efficacious and a cost-effective procedure in the resolution of acute lower-extremity arterial occlusions.
PMID: 32437952
ISSN: 1097-6809
CID: 4444612

Effect of Pre-Procedure Clopidogrel With Iliac Vein Stenting in Non-Thrombotic Vein Lesions

Kibrik, Pavel; Arustamyan, Michael; Alsheekh, Ahmad; Ostrozhynskyy, Yuriy; Rabinovich, Vera; Marks, Natalie; Hingorani, Anil; Ascher, Enrico
OBJECTIVES/UNASSIGNED:Iliac vein stenting is a relatively new procedure in the treatment of chronic venous insufficiency. Research has shown that it is a safe and effective form of treatment, however, one of the well-known risks is in-stent thrombosis. We hypothesize that a single 75 mg dose of Clopidogrel the night prior to the procedures along with a 3-month regimen post-op would decrease the 30-day thrombosis rate. METHODS/UNASSIGNED:A retrospective study was performed on 3,518 patients from September 2012 to August 2018 who received an iliofemoral stent. Patients were broken down into 2 main groups: those given Clopidogrel post-stent and those given Clopidogrel both pre- and post-stent. In our practice, we prescribe a 3-month course of Clopidogrel after iliac vein stenting. Patients were also checked for any anticoagulant medications pre- and/or post-stent. The 30-day thrombosis rates were recorded for each patient. RESULTS/UNASSIGNED:1,205 patients received Clopidogrel pre-procedurally and post-procedurally, 1,941 patients received Clopidogrel only post-procedurally. 372 patients were excluded from the study because they were on other anti-coagulant medications. Mean follow-up for this cohort was 17 months. 112 total patients developed some degree of 30 day in-stent thrombosis (3.6%). 74 patients developed a complete thrombosis of the stent and 38 developed a partial (≤60% occlusion) thrombosis. Of the 1,205 patients who were on clopidogrel pre-stenting, 28 had a complete thrombosis and 10 had a partial in-stent thrombosis. Of the 1,941 patients on Clopidogrel only post-stenting, 46 had a complete thrombosis and 28 had a partial in-stent thrombosis. Using the Chi-squared test, there were no statistically significant differences between the group of patients receiving Clopidogrel pre- and post-stent vs. just post-stent with respect to 30-day any degree of thrombosis rates (complete and partial thrombosis) (p = .33). Using the Chi-squared test, there were no statistically significant differences between the group of patients receiving Clopidogrel pre- and post-stent vs. just post-stent with respect to 30-day complete thrombosis rates (p = .93). CONCLUSIONS/UNASSIGNED:There appears to be no statistical difference in 30-day thrombosis rates between those receiving Clopidogrel the night prior vs. those who do not receive Clopidogrel the night prior. Therefore, we conclude that it is not necessary to give this single dose the night prior to iliac vein stenting procedures.
PMID: 33602039
ISSN: 1938-9116
CID: 4787112

Explore no more: Early experience with a novel minimally invasive approach to penetrating trauma to zone II of the neck [Case Report]

Kaslow, Sarah R; Gurney, Onaona; Ascher, Enrico
The traditional approach to penetrating injuries to zone II of the neck has included operative neck exploration, extensive enough to allow for proximal and distal vascular control of the potential vascular injury. Few studies have reported cases of entirely endovascular management of penetrating injury to this portion of the neck. In the present case report, we describe the case of a 38-year-old man who had sustained a stab wound to zone II of the neck. The injury to the internal carotid artery was managed endovascularly with placement of a covered stent. The findings from the present case illustrate the potential use of minimally invasive vascular treatment strategies as an alternative to mandated operative intervention.
PMID: 33145471
ISSN: 2468-4287
CID: 4661242

A comparison of the Society for Vascular Surgery and the European Society for Vascular Surgery guidelines to identify which asymptomatic carotid patients should be offered a carotid endarterectomy

Paraskevas, Kosmas I; Veith, Frank J; AbuRahma, Ali F; Ascher, Enrico; Ricco, Jean-Baptiste
PMID: 32839044
ISSN: 1097-6809
CID: 4575342

Resolution times of endovenous heat-induced thrombosis

Kibrik, Pavel; Chait, Jesse; Arustamyan, Michael; Alsheekh, Ahmad; Rajaee, Sareh; Marks, Natalie; Hingorani, Anil; Ascher, Enrico
OBJECTIVE:Lower extremity endovenous ablation has become the primary treatment modality for symptomatic venous reflux disease. Endovenous heat-induced thrombosis (EHIT) has been reported as one of the primary complications of these venous ablative procedures. Our aim was to determine how long EHITs take to resolve and the factors affecting this length of time. METHODS:A retrospective analysis was performed of 10,029 consecutive procedures from March 2012 to September 2018 performed on 3218 patients who underwent endovenous ablation for lower extremity venous reflux. There were 6091 procedures performed with radiofrequency ablation (RFA) and 3938 with endovenous laser ablation (EVLA). Postprocedural venous duplex ultrasound was performed to evaluate for EHIT and recanalization at 3 to 7 days, every 3 months for the first year, and every 6 to 12 months thereafter. JMP version 14 (SAS Institute, Cary, NC) was used for all statistical analysis. RESULTS:EHIT was found to have developed in 186 patients; 109 patients had been treated with RFA and 77 with EVLA. The average age of the patients receiving EVLA in whom EHIT developed was 59.97 ± 11.61 years. The patients who received RFA and in whom EHIT developed had an average age of 73.4 ± 9.64 years. The average time of resolution for the EVLA group was 75 ± 71.97 days. The average resolution time for the RFA group was 139.8 ± 232.52 days. There were no statistical differences between EHIT resolution times and age, sex, body mass index, clinical class, laterality, type of vein treated, or whether the patient was taking clopidogrel preoperatively or postoperatively. A statistical difference was found between EHIT resolution time and whether the patient was treated with EVLA or RFA (P = .0332). CONCLUSIONS:Our study seems to suggest that EHIT resolution times may be related to the difference in treatment modality between EVLA and RFA. The data suggest that EHIT resolves more quickly with the use of EVLA than with RFA.
PMID: 32321690
ISSN: 2213-3348
CID: 4397242

Dyeless iliac vein stenting

Ahmed, Taqwa; Chait, Jesse; Kibrik, Pavel; Alsheekh, Ahmad; Ostrozshynskyy, Yuriy; Hingorani, Anil; Ascher, Enrico
OBJECTIVE:Iliac vein stenting is increasingly being explored for the treatment of chronic venous insufficiency. While venography is considered the gold standard for assessing iliac veins, some have proposed that intravascular ultrasound should be utilized instead due to its greater sensitivity at detecting stenotic lesions. Routinely, our service uses both intravascular ultrasound and venography, but we have noted that some patients cannot tolerate dye due to allergy, renal insufficiency, or deemed high-risk by the interventionalist due to uncontrolled medical co-morbidities. This study aimed to investigate whether forgoing dye had an impact on iliac vein stent thrombosis. METHODS:From 2012 to 2016, 1482 iliac vein procedures (91 intravascular ultrasound-only and 1391 intravascular ultrasound plus venography) were performed on 992 patients who failed conservative treatment for chronic venous insufficiency. Our mean patient age was 65.8 years (range 21-99; SD ± 14.3) with 347 male and 645 female patients. The clinical presenting symptoms per clinical-etiology-anatomy-pathophysiology classification for the intravascular ultrasound-only cohort were C1:0, C2:3, C3:31, C433, C5:5, C6:20 and for the intravascular ultrasound plus venography cohort were C1:0, C2:24, C3:566, C4:583, C5:30, C6:188. Stent thrombi that developed within or at 30 days of stenting were categorized as early and greater than 30 days as late. Transcutaneous duplex ultrasound classified stent thrombi as either partial or occlusive. Our average follow-up time was 19.4 months (0-42, SD ± 12.5). RESULTS:0.55. CONCLUSION/CONCLUSIONS:Results of our study show no significant difference in stent thrombosis between the intravascular ultrasound-only and intravascular ultrasound plus venogram cohorts. This concludes that using intravascular ultrasound alone is safe for iliac vein stenting.
PMID: 32990527
ISSN: 1708-539x
CID: 4616702

NICE Guidelines for AAA Repair: An Enigma [Editorial]

Sultan, Sherif; Veith, Frank J; Ascher, Enrico; Ouriel, Kenneth; Hynes, Niamh
PMID: 32659137
ISSN: 1545-1550
CID: 4527912

Compartment Syndrome of the Leg After Intraosseous (IO) Needle Insertion

Kibrik, Pavel; Alsheekh, Ahmad; Rajaee, Sareh; Marks, Natalie; Hingorani, Anil; Ascher, Enrico
Intraosseous (IO) needles are used in patients who are critically ill when it is not possible to obtain venous access. While IO allows for immediate access, IO infusions are associated with complications including fractures, infections and compartment syndrome. We present a case of an 87 year old man who developed lower extremity compartment syndrome after receiving an IO needle insertion and had to be treated surgically with fasciotomy to correct the problem.
PMID: 31676383
ISSN: 1615-5947
CID: 4184362

Reply [Letter]

Ascher, Enrico; Chait, Jesse; Marks, Natalie; Hingorani, Anil; Kibrik, Pavel
PMID: 32305121
ISSN: 2213-3348
CID: 4395432

Reply [Letter]

Chait, Jesse; Marks, Natalie; Hingorani, Anil; Ascher, Enrico
PMID: 32305118
ISSN: 2213-3348
CID: 4396662