Acute arterial graft thrombosis resulting in acute limb ischemia is a limb threatening condition with a need for emergent treatment. Apart from open surgery, endovascular treatment options are available – catheter directed thrombolysis (CDT), percutaneous mechanical thrombectomy (PMT) and acoustic pulse thrombolysis. Since only 5% of limb ischemia affect the upper limb, literature upon the treatment is scarce, although CDT for upper limb ischemia can be effective in over 60% of patients, the most feared of complication is bleeding, with major hemorrhage incidence of up to 14% (Schrijver et al. 2016). The potential benefits of PMT are shorter procedure duration, cost-reduction, less volume of contrast media, possibility of delivering bolus of thrombolytic, decline in bleeding and overall complications.
AngioJet PMT system uses the Venturi-Bernoulli effect to macerate and aspirate thrombus. Although postprocedural hemolysis and hemoglobinuria are common, developing severe AKI requiring renal replacement therapy is an infrequent complication. Four of these cases occurred after PMT for venous thrombosis (Arslan et al. 2007; Bedi, and Daniel, and Reichman, Aaron, and Chou, Shyan-Yih, and Reiser, Ira 2018; Mathews et al. 2011; Sebastian et al. 2018) and one following PMT for pulmonary embolism (Dukkipati et al. 2009). We found no published cases reporting AKI after AngioJet PMT for peripheral arterial thrombosis.
The registry of AngioJet Use in the Peripheral Vascular System (PEARL II) (Registry of AngioJet Use in the Peripheral Vascular System 2018) reports renal failure rate of 0,47% in patients treated for limb ischemia. The use of AngioJet was found to be an independent risk factor for developing AKI, increasing the odds by a factor of eight (Escobar et al. 2017). Retrospective study on 145 patients with thrombosis, also reported higher incidence of AKI in PMT group, proposing more vigilant renal protective measures in post-PMT patients (Morrow et al. 2017).
We believe that, in our patient, previously unrecognized chronic kidney disease, might have played a role in developing AKI. Although intravenous iodinated contrast is associated with contrast induced nephropathy, it is not shown to be an independent risk factor for developing AKI. Our patient had received approximately the same volume of ionated contrast during first endovascular procedure, 3 months before PMT, without deterioration in kidney function tests. However, during the second procedure, hemolysis was an additional factor for developing AKI. Due to acute graft thrombosis, MDT decided that the risk of potential complications associated with PMT was acceptable.
Although there is no consensus upon which eGFR would be a cut-off value for administration of intravenous contrast, studies suggest that there is no significant risk for AKI in patients with eGFR> 30 ml/min/1.73m2 (McDonald et al. 2014). It is believed that optimizing intravenous hydration is a protective measure against developing contrast-induced AKI (Gupta et al. 2016), however, there are no recommendations for preventing AKI during PMT.