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Mechanical recanalization of subacute arterial vessel
occlusions using the SilverHawk atherectomy catheter
Poster No.:
C-2112
Congress:
ECR 2010
Type:
Scientific Exhibit
Topic:
Interventional Radiology
Authors:
A. Massmann, M. Katoh, P. Minko, S. Jaeger, G. K. Schneider, A.
Bücker; Homburg/DE
Keywords:
peripheral artery disease, atherectomy, silverhawk
DOI:
10.1594/ecr2010/C-2112
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Purpose
To demonstrate the technical feasibility and safety of mechanical recanalization of
subacute peripheral arterial vessel occlusions using the SilverHawk atherectomy device
(ev3 endovascular, MN, USA) (figure 1-3).
The SilverHawk atherectomy device is typically used in patients with peripheral arterial
disease (PAD) and its related clinical complaints. It is used as an endovascular procedure
to remove occluding atheromatous plaque material (figure 4-5). As yet, only patients with
chronic arterial stenosis or occlussion were treated with the SilverHawk device in large
register studies. A hallmark of the intervention was the very high initial success rate.
Until now, reports concerning the treatment of subacute arterial vessel occlusion with the
SilverHawk device are not available.
Images for this section:
Fig. 1: Silverhawk atherectomy device (ev3 endovascular, MN, USA)
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Fig. 2: close-up view of the cutting blade of the Silverhawk atherectomy device (ev3
endovascular, MN, USA)
Fig. 3: visualization of the mechanism of the atherectomy with the Silverhawk device
(ev3 endovascular, MN, USA)
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Fig. 4: macroscopic view of the excised and extracted typical red thrombus material after
removal of a subacute vessel occlusion
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Fig. 5: macroscopic view of the excised and extracted typical white material after
atherectomy of intimal hyperplasia
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Methods and Materials
Overall, five patients (female 1, male 4, age 51-81 years, average 64 ± 12.6 years) with
subacute arterial vessel occlusion were treated with the SilverHawk atherectomy device.
Patients suffered from a sudden worsening of their known PAD related complaints within
2 - 6 weeks. The arterial occlusion was located in four patients within the popliteal artery.
One patient suffered from an in-stent occlusion located in the distal superficial femoral
artery.
In every patient, excised occluding material consisted of macroscopic red thrombus
material (figure 1). In contrast, removal of intimal hyperplasia typically consists of white
tissue cylinders (figure 2). A histological proof of subacute occluding thrombus material
was verified in only one patient. The diameter of treated arterial vessels was 5.1 ± 1.0
mm. The length of the arterial vessel occlusion was 2- 14 cm.
Images for this section:
Page 7 of 18
Fig. 1: macroscopic view of the excised and extracted typical red thrombus material after
removal of a subacute vessel occlusion
Page 8 of 18
Fig. 2: macroscopic view of the excised and extracted typical white material after
atherectomy of intimal hyperplasia
Page 9 of 18
Results
Diagnostic angiography depicted 4 subacute peripheral vessel occlusions in four patients
within the PA and in one patient an in-stent occlusion within the distal superficial femoral
artery (SFA) (figure 1). The length of the occlusion ranged from 2 - 14 cm. The mean
diameter of the treated vessel was 5.1 mm ± 1mm.
Every patient underwent a mechanical recanalization of a subacute arterial vessel
occlusion of a femoropopliteal segment. A successful treatment needed 2 - 3 atherectomy
maneuvers, consisting of 3 - 4 cutting procedures, which immediately yielded to a
substantial initial reduction of the occlusion (figure 2-3). The primary technical success
rate was 100%.
Histological analysis of excised material proved the presence of typical subacute, partially
organized red thrombus (figure 4) in all cases.
A residual stenosis <20% was seen in four of five patients of an initially occluded PA and
a 30% stenosis in one patient with an initial in-stent occlusion of the SFA.
A mechanic recanalization of an in-stent occlusion showed a very good hemodynamic
result at a residual stenosis of 40%. In this case, atherectomy was terminated at this
point, to prevent a stent injury or entanglement within the stent braces.
There were no procedure related complications such as peripheral emboli, dissection
or vessel perforation. One female patient underwent a surgical intervention during
the hospitalization due to a previously unknown HIT-syndrome with a consecutive reocclusion after an initial technical success.
After the atherectomy, one patient showed again a 3-vessel supply, three patients a 2vessel and two patients a 1-vessel supply of the lower leg. Within the re-evaluation period
after 6 months till now, there was no need for (surgical) re-intervention.
Images for this section:
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Fig. 1: The digital substraction angiography shows a new occlusion of the distal
superficial femoral artery and popliteal artery. The patient reported a substantial increase
of his PAD related claudicatio since 3 weeks.
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Fig. 2: After initial successful mechanic recanalization with the SilverHawk atherectomy
device only discrete irregularities within the P2-segment of the popliteal artery could be
delineated.
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Fig. 3: Another atherectomy manoeuvre in the same session yields to a nearly complete
removal of the subacute arterial vessel occlusion.
Fig. 4: macroscopic view of the excised and extracted typical red thrombus material after
removal of a subacute vessel occlusion
Page 16 of 18
Conclusion
Until now, usage of the SilverHawk atherectomy device was only described for the
treatment of chronic arterial vessel stenosis or occlusion. To treat subacute arterial
vessel occlusion the same mechanic recanalization technique is applied. Based on
symptomatic clinical complaints related to PAD in our patients, subacute occlusions could
definitely be assumed. This implements a substantial inferior response to a thrombolysis
therapy. As a possible therapeutic option primary stent-PTA after vessel recanalization
was avoided due to occlusion of the popliteal artery. So, technical successful mechanic
recanalization of the popliteal artery could be performed in four patients without the need
for stentimplantation within the region of the popliteal artery. As well as another stent
implantation in a patient with a previous stent-PTA within a superficial femoral artery
could be avoided.
The evaluation of the treated subacute arterial vessel occlusions reveals an initial
technical success in 100% combined with a very good morphologic and hemodynamic
result. In one patient re-intervention was necessary due to an previously unknown HITsyndrome. Apart from that, mechanic recanalization of subacute arterial vessel occlusion
with the SilverHawk atherectomy device showed no procedure-associated complications
in any patient. Notably, there was no angiographic visible or clinically symptomatic
peripheral embolization.
In summary, according to our initial results, mechanic recanalization of subacute arterial
vessel occlusion with the SilverHawk atherectomy device is feasible with a very high
technical success rate and without clinically symptomatic complications. It may be
considered as an alternative to conventional thrombolytic or thrombectomy procedures.
As a limitation of our study, there is still a lack for long-term success rates for this particular
indication.
References
1. Ramaiah V, Gammon R, Kiesz S, et al. Midterm outcomes from the TALON Registry:
treating peripherals with SilverHawk: outcomes collection. J Endovasc Ther. 2006
Oct;13(5):592-602.
2. McKinsey JF, Goldstein L, Khan HU, et al. Novel treatment of patients with lower
extremity ischemia: use of percutaneous atherectomy in 579 lesions. Ann Surg. 2008
Oct;248(4):519-28.
3. Zeller T, Krankenberg H, Reimers B, et al. Erste klinische Erfahrungen mit einem
neuen Atherektomiekatheter zur Behandlung femoro-poplitealer Stenosen. Röfo. 2004
Jan;176(1):70-5.
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4. Zeller T, Rastan A, Schwarzwälder U et al. Percutaneous Peripheral Atherectomy of
Femoropopliteal Stenoses Using a New-Generation Device: Six-Month Results From a
Single-Center Experience. J Endovasc Ther 2004; 11: 676-685.
5. Zeller T, Sixt S, Schwarzwälder U, et al. Two-year results after directional
atherectomy of infrapopliteal arteries with the SilverHawk device. J Endovasc Ther. 2007
Apr;14(2):232-40.
6. Garcia LA, Lyden SP. Atherectomy for infrainguinal peripheral artery disease. J
Endovasc Ther. 2009 Apr;16(2 Suppl 2):II105-15.
7. Lam RC, Shah S, Faries PL, et al. Incidence and clinical significance of distal
embolization during percutaneous interventions involving the superficial femoral artery.
J Vasc Surg. 2007 Dec;46(6):1155-9.
Personal Information
Saarland University Hospital
Clinic for Diagnostic and Interventional Radiology
66421 Homburg/Saar
Germany
Dr. med. Alexander Maßmann
PD Dr. med. Marcus Katoh
Dr. med. Peter Minko
Dr. med. Sabine Jäger
PD. Dr. med. Dr. rer. nat. Günther Karl Schneider
Prof. Dr. med. Arno Bücker
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