1. Acute Arterial Clot Management
John Fritz Angle, MD

2. Disclosures Speaker: Abbott, Cook, and Medtronic
Grant support: Siemen’s
Consultant: Proteon Therapeutics, Terumo

3. Evaluation Points That Help Define Surgery, Mechanical First or Lysis Only
Duration and severity most important part of history
If profound motor/sensory, my observation is mechanical can often re-establish flow and avoid open embolectomy
If mild symptoms and proximal clot take precautions to avoid distal embolization
CTA very helpful in triage (if GFR>50)
Left atrium to toes
Inflow=surgery or lysis
Outflow=mechanical or lysis
Runoff=suction embolectomy (unless known disease) or lysis

4. Aspiration of Distal Emboli after PTA Works
23 PTA patients had aspiration of emboli (6Fr guide)
TS = 95.7% (22/23)
Outcomes similar to 237 patients without an embolus
>90% stenosis = 12.9 HR for embolus
Intraluminal PTA (rather than sub-intimal PTA) = 18.4 HR for embolus
5–6-F guiding catheters (ENVOY MPD; Cordis, Miami Lakes, Florida) 
Wei L, et al. Infrainguinal Endovascular Recanalization: Risk Factors for Arterial Thromboembolic Occlusions and Efficacy of Percutaneous Aspiration Thrombectomy. JVIR 2016; in press

5. 69 y/o Woman With Cold Right Leg

6. Acute Lower Extremity Ischemia Has Two Main Causes
Embolic
Very sudden onset of symptoms
Afib, LAA clot, LV aneurysm/infarct, Aorto-iliac plaque
Branch point and multiple
Little disease on other side at that level
Thrombotic
Occlusion of a vessel due to in-situ thrombosis in (atherosclerotic disease, bypass anastomosis, etc)
Calcifications at site of obstruction
Bilateral disease

7. When Source Control Is A Problem
LAA (A fib), MV, LV (old MI) or AV
Aortic disease
Closure device
Popliteal aneurysm
Thrombolysis may be relatively contraindicated

14. Thrombectomy Device in Profunda and SFA

23. Mechanical Only Is Often Not Enough
Debulk to speed lysis
Re-establish flow to shorten ischemic time
Short segment of small vessel responds best to mechanical-only
Distal protection nearly essential
Use covered stent for residual thrombus

25. Summary
Contraindications to thrombolysis are relative thanks to mechanical devices
Thrombectomy devices slowly challenging the motor-sensory loss paradigm
History and CTA provide treatment plan
Very close monitoring for complications on table and post-procedure (high risk population)