BackTable / VI / Podcast / Transcript #315

Podcast Transcript: Arterial Thrombectomy

with Dr. Alexander Ushinsky

In this episode, host Dr. Chris Beck interviews Dr. Alexander Ushinsky about his standard workup and treatment when performing arterial thrombectomy in acute limb ischemia (ALI). You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Peripheral Artery Disease (PAD) Practice Management

(2) Acute Limb Ischemia Referral Guidelines

(3) Acute Limb Ischemia Lab Work & Imaging Recommendations

(4) Acute Limb Ischemia: Limb Salvageability Discussions

(5) Arterial Thrombectomy Preoperative Patient Preparation

(6) Arterial Thrombectomy Surgical Protocol

(7) Decision Making in Acute Limb Ischemia Treatment Modalities

(8) Arterial Thrombectomy Expert Insights

(9) Arterial Thrombectomy Postoperative Care

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[Dr. Chris Beck]
Ladies and gentlemen welcome to the BackTable podcast. If you are a new listener, welcome. For all of our regular listeners, welcome back, and thank you for listening. You can find all previous episodes of the podcast on iTunes, on Spotify, on our website, backtable.com. Subscribe to the podcast, leave us a review, or reach out to us on social media. Let us know how we can make this podcast better, and we're going to do our best to make that happen. Now, a quick word from our sponsor.

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Now back to the show. Today, we're going to discuss arterial thrombectomy with Dr. Alexander Ushinsky. Alexander, you're going by Sasha, right?

[Dr. Alexander Ushinsky]
I go by Sasha, yes.

[Dr. Chris Beck]
All right. Sasha, glad to have you on this show. Start out, will you just introduce yourself, tell us about your training, your background, and what your practice looks like nowadays?

[Dr. Alexander Ushinsky]
Sure. First of all, thank you for letting me join you. It's a pleasure. My background, I did my training at UC Irvine in Southern California for my residency. Then my fellowship in interventional radiology was done at Mallinckrodt Institute of Radiology at Washington University here in St. Louis. That was about three, three and a half years ago now. I've stayed on as faculty at WashU. Over the last three years, my partners and I have built up a lot of the peripheral vascular facets of our practice.

Here, in addition to the academic hospital, we're also starting to work at some of the community hospitals in the area and some satellite hospitals that the university is built at. We have a relatively diverse practice mix because of those different sites.

(1) Peripheral Artery Disease (PAD) Practice Management

[Dr. Chris Beck]
If you don't mind me asking, I just want to know a little bit about the WashU program. How many IR docs is it? How many facilities, just ballparking?

[Dr. Alexander Ushinsky]
We have a pretty large practice. In the academic core, we have 15 faculty, so 15 IR docs. Then in addition to that, there's two or three IRs who work in the community practice who staff a couple of the outlying hospitals, which the academic practice occasionally goes out to and have been expanding our services. For example, my colleagues in neuro IR now cover stroke at those satellite hospitals. It's a little bit of a dynamic process that I'm sure my colleagues who are in academics also have now experienced with the university's extending their presence in some of the community hospitals.

[Dr. Chris Beck]
With 15 IR docs, a lot of good work to be done, no doubt. Whenever you came on to WashU as faculty, did you know that this was an area that you wanted to dig into?

[Dr. Alexander Ushinsky]
I'd had a little bit of limited experience in residency, especially at a VA doing peripheral vascular, which I really enjoyed. When I did my fellowship early on at WashU, we had almost no volume of peripheral vascular. We were doing what was being done at the university where I did my residency at, which was mostly salvage on-call cases, acute limb ischemia, lysis catheter replacements, and not many or any elective peripheral vascular cases at all. Since that time, my partner, Carlos Guevara, myself, and a third partner, Steven Sauk, have really worked hard to practice, build, and build up a pretty extensive peripheral vascular program at WashU across all those sites that I mentioned before.

[Dr. Chris Beck]
All right. In a given week, just to give our audience an idea of what the practice is looking like now, how many cases of PAD? What do the cases look like? Are you getting all the dogs? Are you getting some of the good cases longitudinal? Is it one-off? What is it?

[Dr. Alexander Ushinsky]
Between the three faculty who are doing peripheral vascular, there's a little bit of different practice mixes. For example, I do maybe about 30% of my practice is peripheral vascular, same with my partner, Dr. Sauk. Carlos Guevara is probably 80% to 90% doing peripheral vascular.

[Dr. Chris Beck]
Wow. All right.

[Dr. Alexander Ushinsky]
He's really dedicated all of his, let's say, elective clinical work. He doesn't really support many other service lines other than placing the routine IR practice G tubes and drainages and things that we all do on call. Between the three of us, I think in the last academic year, we've done between 300 and 350 peripheral vascular cases, with I think Carlos probably doing in the 60% to 70% range of those given his practice mix.

We are doing these at both the university hospital and the community hospitals. The community hospital is more in an OBL-style practice mix, meaning it's mostly outpatient, prescheduled, relatively rapid turnaround. These are smaller hospitals. Then the university and one of the community satellites where we've been increasing our footprint, we are doing quite a bit of both inpatient and outpatient peripheral vascular work.

[Dr. Chris Beck]
Man, that's really impressive. When you think about the number of cases and you said like three years ago?

[Dr. Alexander Ushinsky]
Zero.

[Dr. Chris Beck]
Golly. That's incredible. Well, I know this isn't a practice-building podcast, it's not the topic. I want to get you back on, you and Carlos, to talk about how you built this machine. That's great.

[Dr. Alexander Ushinsky]
To be honest, Carlos started building it up while I was in my fellowship. I think the most useful thing I learned in my fellowship was that practice-building aspect of it and how to make these relationships with the referrers, maintain the relationships with the referrer. I'm sure you've had other guests speak about that in the past, but that's something that we don't learn very well as interventional radiologists is really how to run those aspects of a practice and maintain that culture.

(2) Acute Limb Ischemia Referral Guidelines

[Dr. Chris Beck]
All right. Getting into the topic, we're going to be talking about acute limb ischemia, if that wasn't clear. This disease can rear its head in a couple of different ways, but the first broad category is to talk about workup. It's a little bit artificial. We might just select a clinical scenario that best fits it. How do you start your workup maybe for an inpatient on acute limb ischemia? What's the typical presentation for you guys? I know that we're ignoring a lot of the nuance.

[Dr. Alexander Ushinsky]
Sure. I think when we get called, we get a consultation about acute limb ischemia. The patient usually arrives either through the ER or on the inpatient side. Occasionally, we'll actually get called from outpatient. We have a couple of OBLs in the community that are former alumni or former faculty at WashU. We've had a couple of calls from them. I have a patient who just called me up, has acute limb ischemia. They're at home. Can we send them over to you?

I think you and I, maybe we'll touch on this in the future, but more recently, we've been able to treat a few of those patients in a more of an outpatient or less than 24-hour inpatient type admission given some of the changes that are going on in the acute limb ischemia world. To go back to your initial question of how are these patients presenting, we're being called about patients presenting with these classic symptoms, acute pain, sensory loss, sometimes motor weakness, and cold limb. A lot of these patients carry some history of peripheral vascular disease in a more chronic setting, but not all.

[Dr. Chris Beck]
Sure. After you guys get called, so the consults in. Can you tell me a little bit what the focused history looks like and what your physical exam is if you're walking a fellow through like, "Hey, this is what we're looking for and trying to ascertain?"

(3) Acute Limb Ischemia Lab Work & Imaging Recommendations

[Dr. Alexander Ushinsky]
I think that when we are assessing the history of the patient, some important things to consider are whether they do have underlying peripheral vascular disease and trying to assess the etiology of why this patient may have developed acute limb ischemia. Making sure they don't have atheroembolic disease or something else that would require cardiology consultation, maybe considering whether they may have some coagulopathic process going on or are prone to clotting that may need to then follow up with a hematology referral.

The first thing is to take the patient's history and assess those risk factors. The other thing is the temporality of the limb ischemia. There are not infrequent cases where we are called for acute limb ischemia. When you actually speak to the patient yourself or the fellow speaks to the patient, you can ascertain that this is more on the worsening chronic limb ischemia, which you would treat sometimes less urgent fashion but it's certainly different.

Getting the medical history of the patient, like we discussed, getting the temporality of the symptoms. Always want to assess the progression of symptoms to see if the acute limb ischemia is getting worse. I tend to have my fellows try to grade the patient's face on the Rutherford acute limb ischemia grading, meaning assess their degree of sensory loss and their degree of motor weakness.

Then the other thing on the physical exam is obviously a pulse exam and an exam of the limb. The patient have immobile, paralyzed woody limb, or does the patient just have some subjective sensory loss but otherwise can wiggle their toes? That is a massive inflection point in how I determine to manage the patient.

[Dr. Chris Beck]
Going back to the physical exam, I don't know if you considered an extension of the physical exam, but do you guys Doppler the leg?

[Dr. Alexander Ushinsky]
Yes, we'll certainly get bedside Doppler.

[Dr. Chris Beck]
Oh, I didn't know. Sometimes you can just carry them around. Some places you just grab one off the IR wall and pop over. Cool.

[Dr. Alexander Ushinsky]
We usually do it, and they'll usually be at the bedside if the patient's in the emergency department. We have little carry totes with the Doppler and a little bit of gel for the fellows, definitely. The expectation is the fellow or myself if I'm going out there to the community hospital, we'll Doppler the leg. I will say that for the chronic limb ischemia patients, it can be difficult at baseline. It depends on what the patient's baseline vessels like. For those that have very calcified vessels, it can be very difficult to find those signals.

[Dr. Chris Beck]
Before we get into imaging, any lab work that's important to know ahead of time?

[Dr. Alexander Ushinsky]
Certainly all of the coagulation parameters, a normal CVC, and a chemistry panel to look at their kidney function. If you're really concerned about a pretty severely affected limb, you could start looking at lactate or other markers of tissue loss really, but if it's getting to that degree, there may not be much intervention that you can offer but certainly need to assess that.

[Dr. Chris Beck]
Moving from labs to imaging, I wanted to get your idea of how does ultrasound fall into the role of, like, how important is that for your practice and for your pre-procedure workup?

[Dr. Alexander Ushinsky]
Separate from the question of being able to Doppler, just pedal pulses or popliteal pulse. I would say that historically, I've relied a lot on CTA. I will say that, and we actually had a recent case of this where the patient just had so much severe calcific, small vessel disease and tibial disease that it was very hard to make out much of anything on the CTA below the knee.

In those patients, I think there's a really important role for a good duplex ultrasound from a vascular lab that can do a good exam to see the vessels and evaluate the weight forms if they're present.

[Dr. Chris Beck]
You touched on it, CTA versus MRA, prefer CTA.

[Dr. Alexander Ushinsky]
I think CTA is more readily available, especially in the on-call setting. I think getting a high complexity like a twist MRA is pretty difficult to do in an ER at 3:00 in the morning to get a good exam. The images that can be generated on a Monday at 8:00 AM are really nice, but it's very difficult in an emergency setting. The time commitment for that type of exam if someone who may have an emergent condition, a limb-threatening condition can be sometimes limiting.

[Dr. Chris Beck]
Absolutely. All right. Anything else I missed as far as workup goes? We did HMP, we did labs, imaging, anything else?

[Dr. Alexander Ushinsky]
The only thing I'll say is a lot of the patients are already on medication reconciliation, both for inpatient ordered meds and for outpatient medications, whether the patient's already on anticoagulation if they have not been put on anticoagulation and there's a high index of suspicion. Those are all important things to assess because actually, mobilizing your forces, and if the patient needs an intervention, bringing them for intervention may take some time and making sure that the patient's appropriately, medically treated, if nothing else is paramount.

[Dr. Chris Beck]
Will you guys go ahead and fill that gap as far as the medical treatment? You guys will haptenize them more?

[Dr. Alexander Ushinsky]
Definitely, especially in the community hospitals with the consultant being asked the question or order the exam, order the CTA, order the heparin drip or the Lovenox if the patient's not a good candidate for a heparin drip for whatever reason. In the university hospital where there are resident teams, we'll make the recommendation for whichever anticoagulation is appropriate for the patient if they haven't already received it from the referring provider.

[Dr. Chris Beck]
That's good. You guys are getting your fellows well-trained, right?

[Dr. Alexander Ushinsky]
In our practice here, we've had a very clinically-oriented practice for many years. We were the primary site for the attract trial for venous lysis and we've had an emitting service for a long time as well. Our fellows are generally very comfortable in terms of all aspects of inpatient management and interacting with the inpatient side of the hospital and the referring providers from hospital medicine or cardiology or whomever.

[Dr. Chris Beck]
That's just a way of things from here on out. I graduated eight years ago, and the IRS that are coming up now, they're just a new breed of super docs. Thank you for training these guys up and getting everyone, but you're kind of the ilk-like. Four years ago you were in fellowship, right?

[Dr. Alexander Ushinsky]
Yes, exactly right.

[Dr. Chris Beck]
That's awesome.

[Dr. Alexander Ushinsky]
It's definitely been the culture here for a long time. In retrospect, I hope that the fellows appreciate it. It's definitely burdensome to have to drive in at 3:00 in the morning to see a patient on call. It sounds luxurious to our colleagues who spend the night in the hospital three nights a week, but it becomes important, especially if you want to treat patients of any complexity or be involved in the medical decision-making for a patient.

[Dr. Chris Beck]
That's right. Patient prep, you've seen the patient, you've gone through the workup and you think this is a patient who needs to move on to intervention. The category is patient prep and we can start off in a couple areas, but one of the easy things to knock out is antibiotics, sedation level. Where do you stand on these things with these patients?

[Dr. Alexander Ushinsky]
If you'll allow me before we get into patient prep, one thought.

[Dr. Chris Beck]
Of course, Sasha. You're the guest. Of course, you can do whatever you want.

(4) Acute Limb Ischemia: Limb Salvageability Discussions

[Dr. Alexander Ushinsky]
The one thing I wanted to add is when you assess the patient, I feel like in acute limb ischemia, there is some dichotomization of the patients to those that would benefit from an intervention, meaning a revascularization of some kind, whether that is embolectomy, bypass, thrombectomy, endovascularly, and those that have really lost any salvageability of that limb.

That's something that I stress for my fellows when they evaluate the patient. There's a spectrum, and sometimes we may choose to take on a patient for thrombectomy who is a borderline candidate, the chance of success is somewhat low, but I think that's important for folks who are going to be consulted to evaluate these acute limb ischemia patients, is to also recognize those patients that are not salvageable because, for example, putting a lysis catheter in an elderly patient to try to save an unsavable limb and risk having a catastrophic hemorrhage probably is not worth it.

To have a good sense for those patients that are not a good candidate, the high Rutherford grade patients is important. We're still, I think, learning which techniques lend themselves to the middle Rutherford 2B patients. The patients who have a pretty threatened but maybe somewhat salvageable limb, and which techniques are suited for those patients and which aren't in my experience. I'm sure we'll talk about it coming up, but the jury's still out on what the best treatment for some of those patients are. We're not clear.

[Dr. Chris Beck]
Can you talk about maybe some of the risk-benefit things that you're rolling around in your mind as far as like, how do you tease apart the patients who are unsalvageable from salvageable? We won't ping you to it, but what are some of the things that you consider that push you into one category or the other?

[Dr. Alexander Ushinsky]
A pretty high demarcation of paralysis is the most clear designation. A patient who's Rutherford 3 has complete paralysis of their foot or a portion of their foot, I would not take for embolectomy or thrombectomy procedure in my lab. On the other hand, a patient who's Rutherford 1 or Rutherford 2A, I certainly would consider offering some endovascular therapy for.

I don't personally perform surgical embolectomy, but maybe a candidate for those practitioners who do. The area where I have struggled with sometimes is that Rutherford 2B group, the patients who are starting to have a little bit of extensive sensory loss and now some mild motor deficit. If you had asked me this question three or four years ago when all I had to offer was lysis catheter placement, those patients I would say probably will not benefit.

To be honest with you, I really distinctly remember a patient who I lysed in that context, had a little bit of toe paralysis, pretty extensive sensory loss, did an excellent lysis, great angiographic outcome, three-vessel runoff, patient lost her foot later that afternoon by amputation because we took too long with that approach.

After that, I told myself I'm not going to offer lysis for those patients anymore, but now with some of the newer technologies that you and I we'll talk about in the thrombectomy space, I would consider offering something about percutaneous thrombectomy-type procedures for those patients, at least consider it.

[Dr. Chris Beck]
One of the exciting things about this topic is how just your practices can change with new technology, and it's really driving what we can do and what patients we can treat. Actually, you did touch on something that I did want to talk about is, how do you work with other specialties. You mentioned embolectomy, how do you guys coordinate care between patients who have reasonable practitioners may differ on whether it's an interventional case versus a surgical case?

[Dr. Alexander Ushinsky]
It can be difficult sometimes because not only is it a question of surgical versus interventional, but it's what each particular provider is comfortable offering.

[Dr. Chris Beck]
Right. Yes, Exactly.

[Dr. Alexander Ushinsky]
I think especially when the referral comes to us from the vascular surgeon who's asking us if we'll consider an endovascular approach or a lysis catheter placement, becomes a slightly more straightforward discussion because it's two professionals who know what the other does. In that case, it's just a discussion of what am I comfortable offering versus some of my partners in our group may not routinely use some of the thrombectomy devices that are on our shelf and are more comfortable with lysis catheter placement.

What is the vascular surgeon who's making the referral comfortable offering? For example, some may not consider embolectomy in disease tibial arteries, or the patient may not have a distal target for bypass or a suitable conduit. It becomes a more nuanced discussion with those types of folks. When the referral comes from the emergency department or internal medicine hospitalist, then I'm able to lay out what I think is offerable for my endovascular approaches.

If I feel like the patient's not a good candidate for those, then I would ask them to engage our surgeons for consideration of some of the options they may have. After a discussion comes down to the fact they don't have anything different to offer, then the patients usually return to me if I feel comfortable or if I feel that they're a candidate for some of these endovascular approaches that I can offer.

[Dr. Chris Beck]
Is it a good collaborative relationship with vascular surgery or cardiology or whoever it might be that is in this space?

[Dr. Alexander Ushinsky]
I think in general, we have a fair relationship with them. We have good discussion about these types of patients when the referrals come through. Sometimes there can be some disagreement, especially when there's overlap. I think that now we have a pretty good relationship with the current surgeons in our hospital, and those folks are pretty collegial and we can have a discussion about what we think is the most appropriate treatment.

Sometimes there's a little overlap in terms of who saw the patient initially, because we do have some complimentary treatments, and who would offer the same treatment one versus the other. Some of the vascular surgeons in our hospital do offer lysis catheter replacement. When the consult comes through and it's someone who has done lysis catheter in the past, and then there's a discussion of, do you do this procedure? Do you need me to do it, and things like this? That can happen with a lot of these procedures.

(5) Arterial Thrombectomy Preoperative Patient Preparation

[Dr. Chris Beck]
Absolutely. All right. Going back to patient prep, do you want to talk about antibiotic regimens, sedation level, all the above?

[Dr. Alexander Ushinsky]
So in the realm of endovascular approaches, we are generally not offering just prophylactic antibiotics for all angiographic procedures. In our practice, we don't do that. I know some practices give Ancef pretty routinely. Certainly, if the patient has any evidence of gangrene or soft tissue infection, that needs to be covered definitely, and I would be very concerned if that weren't the case and I was expecting to leave some sort of implant like a stent or a stent graft. Routinely, I don't give Ancef or anything for skin floor coverage per my angiograms.

[Dr. Chris Beck]
Then how about sedation?

[Dr. Alexander Ushinsky]
I do almost all of these procedures under, we call it minimal sedation, but where I trained before, we called it moderate sedation. It's Fentanyl and Versed sedation with nurse and physician monitoring as is common in a lot of catheterization labs, IR labs. I would say that for most of the procedures I've done for acute limb ischemia, whether it's lysis catheter placement or placement of mechanical thrombectomy, the patients do very well with that type of sedation. Angiography is generally not a particularly painful procedure, and these thrombectomy systems are not much larger than what we routinely use for leg angiogram.

[Dr. Chris Beck]
Any patients that could benefit from GA or deeper sedation?

[Dr. Alexander Ushinsky]
Good question. If you're expecting a longer procedure, I would definitely consider GA, depending on the extent of the thrombus. If you're thinking this may be a three, four-hour procedure to remove all the thrombus and you're going to do a single-session procedure, you may consider GA. The other times where it can be helpful are patients who are in such severe pain from their acute limb ischemia that they just won't tolerate laying on the table even or any sheet touching their foot and things like this. You may benefit from it.

Then the other time where it's helpful is we get a fair amount of patients who have restless leg type syndrome or just difficulty keeping their feet steady. Sometimes this almost falls in the realm of claudication and rest pain, from maybe some underlying chronic limb ischemia or acute and chronic limb ischemia. For those patients, just to be able to have them be still to do the procedure, consider GA. The vast majority do pretty well with physician-directed monitored sedation.

[Dr. Chris Beck]
Just routine Fentanyl Versed, right?

[Dr. Alexander Ushinsky]
Yes, exactly. We use Fentanyl Versed. I know some places will use Precedex and things like this, but we don't routinely do that in our practice.

[Dr. Chris Beck]
Set the stage for us because you can have any patient. This can be the ideal patient, can be a nightmare patient, or whatever, but let's lay the table stakes as far as what kind of patient that you're going to be dealing with and then we can dig into the details.

[Dr. Alexander Ushinsky]
Which one would you like me to start? I do them all the same.

[Dr. Chris Beck]
Oh, really, okay. All right.

[Dr. Alexander Ushinsky]
Every procedure starts the same.

[Dr. Chris Beck]
Good. All right. The dream patient, the patient who you're like, "Yes, this is perfect." This is like 8:00 AM. I already had a patient canceled. They're filling a slot, so this is the perfect patient.

[Dr. Alexander Ushinsky]
Beautiful.
[Dr. Chris Beck]
Yes, exactly.

(6) Arterial Thrombectomy Surgical Protocol

[Dr. Alexander Ushinsky]
I love it. Usually, I'll have some cross-sectional imaging. The patient has a CTA, and I know what I'm getting into from the CTA, to some extent at least. All my patients who have acute limb ischemia, I will start with contralateral groin access. They're in the IR lab, we've sedated them, ultrasound-guided contralateral groin access. I begin every case by going up and over. If needed I'll do an aortogram if there's some iliac disease that I'm concerned about from the CTA, but in general, all patients begin with a diagnostic angiogram.

A nice diagnostic angiogram with the power injector with the flush catheter parked in a patent segment, usually in the distal external iliac or the common fem, depending on the site of the acute thrombus.

[Dr. Chris Beck]
You're going up and over and you're doing the diagnostic catheter and the affected limb, right?

[Dr. Alexander Ushinsky]
Yes, and I do a full runoff to the toes every time.

[Dr. Chris Beck]
Do you do it like one injection and the table will step along, or is it segmented, like pictures, reset, pictures, reset?

[Dr. Alexander Ushinsky]
I do stations to the foot. Our equipment can do step-and-shoot, the fancy stuff, but I don't know how to do it. I'll tell you, we have 9 or 10 labs that we cover at the university hospital, which means we have 40 or 50 technologists. Even in the perfect setting at 8:00 in the morning on a Monday, to find the tech who knows how to do that is difficult.

[Dr. Chris Beck]
The technology's there, but in practicality, I'm with you. I go through a lot of different labs, work with a lot of different technologists of varying skills and knowledge. I'm with you. All right. Shooting in stages, I got it.

[Dr. Alexander Ushinsky]
I'll say, it's important given that you may have technologists with different comfort levels to really be prescriptive in how you want the room set up, what kind of contrast you want, the injector. I generally use 50-50 contrast in the extremities. We usually use Visipaque as our contrast agent when we're doing extremities. I usually run through the plan with the technologist ahead of time as well to make sure that we end up with a good exam and a smooth flow to the case.

[Dr. Chris Beck]
Can you talk about, for some people that may have missed it, why you pick Visipaque for these cases?

[Dr. Alexander Ushinsky]
There's some thought that Visipaque is a little bit less painful for small vessel and extremity angiography. I'll say I've used some of the other contrast agents in the extremity from time to time, and the patients don't seem to complain about pain. I will say with CO2 injection, patients do get some discomfort sometimes in the extremity angiograms, but in general, that's why we use Visipaque. I saw a smaller contrast.

[Dr. Chris Beck]
All right. You're taking pictures, you've got good diagnostic high-quality pictures.

[Dr. Alexander Ushinsky]
Once we have a good diagnostic angiogram, identify the area of occlusion, the next thing I'll do is, the patient isn't already pretty aggressively heparinized, I'll heparinize the patient pretty aggressively for intervention. Usually, these patients come to us on a heparin drip. For the access, sometimes if I'm feeling cautious, I'll have them hold the heparin drip for a few minutes and then get access into the groin.

Sometimes just get access with the heparin drip running, knowing that I'm gonna be pretty aggressively heparinizing the patient in a few minutes anyway. I give my heparinization as just an initial bolus, and then get an ACT every 30 minutes or one hour. The bolus, I don't do in general, like a weight-based bolus dosing. I know some people do. We usually, depending on the size of the patient, start with about 7 or 10,000 units of heparin to begin with, and then check an ACT in about 30, 40 minutes and see how the patient's doing, and then assess from there.

[Dr. Chris Beck]
You ballpark it based on weight, and then check in ACT and then see where you're at in 30 minutes.

[Dr. Alexander Ushinsky]
Especially because in my practice, I deal with a lot of tibial disease in general, not as much in the acute limb ischemia space, but when I'm treating chronic limb ischemia, I generally need my patients pretty aggressively heparinized for a successful and safe procedure. I'm pretty comfortable being pretty aggressive with my heparinization for these patients as well.

Once I've heparinized the patient, I will exchange my 11-centimeter Sheath, for a long Sheath, then I'll park in a patent segment of the affected extremity. Usually, I start with a 6-French system when I'm doing these interventions.

[Dr. Chris Beck]
What do you like for your Sheath of choice? Anything that gets you up and over.

[Dr. Alexander Ushinsky]
We use destination mostly, through remote destination Sheath, nice braided Sheath. They're pretty hydrophilic. I will say the valve doesn't always stay on as well as some of the Cook Sheaths. One of my partners has a sub-special-ordered Cook Sheaths that he keeps for himself, but in general, we use the destination Sheath. With the Sheath up and over, I'll begin the true intervention here. As most of the things we do, the first step is getting wire access beyond the occlusion.

As opposed to the chronic limb ischemia patients, as you and some of the audience knows, with acute limb ischemia, it's usually pretty easy to cross the acute occlusion, the acute thrombus. It's soft, it's just like an acute DVT and the folks who are doing mostly venous disease. It's usually easy to have your wire across as opposed to chronic limb ischemia and park your wire across the occlusion.

That's also an important inflection point because there have been a couple times where I'm expecting acute limb ischemia and I have a lot of trouble getting my wire across the area of occlusion. Then you look back at the angiogram, you say, "Well actually, there's a lot of big collaterals here, and the patient's history sounded a little fishy, and I don't know that this really needs a lytic catheter. Maybe we need to just see what happens with some of our methods for chronic limb ischemia."

[Dr. Chris Beck]
It's like the wire test, right? Like the wire tells you a lot tactilely.

[Dr. Alexander Ushinsky]
Yes, exactly. Depending on where the site of occlusion is, I'll either use 035 guidewire for fem-pop, and then if there's some disease distal to the fem-pop segment, I'll usually use an 018 or 014 system for the entire procedure.

[Dr. Chris Beck]
You start crossing with an 018 or an 014 wire.

[Dr. Alexander Ushinsky]
Not infrequently, especially if I'm planning an intervention that will require that type of guidewire.

[Dr. Chris Beck]
What do you like for wires?

[Dr. Alexander Ushinsky]
We keep a reasonable stock. My favorite honestly is the Glidewire Advantage from Terumo. The 014 Glidewire Advantage more so than any of the other Glidewire Advantages. It forms an excellent knuckle at the tip, feels really atraumatic, and glides through, stays true lumen, I hope, and stays in the big capacious vessel once it forms that knuckle without going into the side branches, which just makes it really easy. I follow that with a support catheter.

I used to use the quick cross line from Spectranetics, but in the last six months or so, we've actually switched to a CSI product called the Vipercross. They have made from 014, 018, 035. It's a very, very hydrophilic support catheter. Really nice crossover. I use it, of course, mostly for my chronic limb ischemia patients where it's difficult to cross with the catheter, but since it's on the shelf and it's similar in cost to the quick cross and these simple extruded tube type catheters, I just grab that and use that.

[Dr. Chris Beck]
Great. All right. Wire goes easy, cross is easy, what next?

[Dr. Alexander Ushinsky]
Cross is easy, follow with the catheter, of course. The next step that I always teach my fellows is to do an angiogram and prove that you've crossed. You need to make sure that you're truly across the occlusion and just confirm that you're in patent Lumen. That's critical, I think, for a successful acute limb ischemia, endovascular case, and especially for lysis catheter replacement as well.

[Dr. Chris Beck]
Ideally, if you have something that's popliteal and then infra pop disease, where do you want to end up? How distal are you or you just park in a segment that's capacious?

[Dr. Alexander Ushinsky]
The first thing is that as soon as I think I'm through with the occlusion, I'll just prove that I made the vessel. That probably comes from my habits with crossing chronic occlusions. If the patient has concomitant chronic infra pop disease, I will usually, at that juncture, have a plan of whether I'm going to immediately address the infra pop disease and try to do a single session thrombectomy and treatment of chronic limb ischemia, or whether this is going to be a lysis catheter case where I'm going to address the infra pop and chronic disease at a second-day procedure.

[Dr. Chris Beck]
Alright, so you're all set up. You got your catheter, you're in a good spot distally. Are you going to talk about the next step or talk about the inflection points of what drives you to one treatment modality versus another?

(7) Decision Making in Acute Limb Ischemia Treatment Modalities

[Dr. Alexander Ushinsky]
Sure. Why don't I start with what I would have done four years ago and talk about catheter lysis before we had a lot of this single session thrombectomy tool? It's interesting because I felt like I did a lot of lysis in my training, whether it's venous or arterial. My current fellows don't do very much at all because in both spaces, venous and arterial, we have so many excellent thrombectomy devices. They're less comfortable with lysis than I think maybe you and I were at our training.

The important things I think about once I've crossed if I'm planning to do a lysis case, is making sure that my lysis catheter spans the entirety that I have. Basically, outflow for the lytic, inflow and outflow. I choose a lysis catheter that has a length that will span the thrombus and try to make sure that I have one or two side holes beyond the thrombus and the patient outflow and holes throughout the thrombus.

Hopefully, one or two holes proximal to the thrombus to make sure that that TPA really can get out and marinate throughout that thrombus. That was my pattern four years ago, five years ago. I would stitch in the Sheath and ship the patient to the ICU for an overnight lysis. Nowadays, as you suggest, now there's an inflection point. The way that I think about whether to do lysis, there's a couple of factors that come into my mind, whether to do lysis or whether to do a single session thrombectomy.

One question is just the timeframe. Is it very late at night? Do we have the time? Do we have the technologists in the facility support to do a multi-hour procedure? On-call at two in the morning with traumas coming in may not be the appropriate use of resources necessarily to do a two-hour thrombectomy procedure and back up the trauma service. It may not be a safe bet.

The other thoughts that I have are the extent of the thrombus. It's pretty difficult to thrombectimize very small vessels sometimes, and especially if there's quite a lot. If all three tubules, and there's a fem pop is just a very large thrombotic burden. I tend to err towards lysis unless I'm really prepared for an extensive slog. Those are some of my considerations there.

Then for the patient that has a pretty small amount of thrombus, I feel really strongly about some of the single-session thrombectomy devices in lieu of lysis. It's even maybe in the middle of the night, if there's really just a small amount of disease and we can solve the issue, then I will err much more towards thrombectomy devices.

[Dr. Chris Beck]
Thrombectomy, single session treatment, then you wrap it up, and it's done?

[Dr. Alexander Ushinsky]
Exactly. Then the other consideration are patients for whom lysis is high risk. Elderly patients, patients with recent abdominal or other surgery, patients who just are not good candidates to have systemic TPA. We may not have had much to offer them years ago, but now I think the single session thrombectomy approaches are reasonable for lysis patients who can be heparinized but can't receive TPA.

[Dr. Chris Beck]
All right. Thrombolysis, we can come back to it a little bit later, but it may be helpful for people to know what your solution is, what your drip rate is, and everything. Sometimes people look for that, but let's come back to it. Let's talk about the thrombectomy.

(8) Arterial Thrombectomy Expert Insights

[Dr. Alexander Ushinsky]
Well, like I said, the younger folks who are in practice that aren't doing much lysis anymore, they don't know how often are they checking the fibrinogen.

[Dr. Chris Beck]
Right. Then what's your volume? How much have you gone through? What's your heparin rate? It's always nice when one of your partners solves that for you and you already have the epic or EMR smart order set already ready to go and just click, click, click.

[Dr. Alexander Ushinsky]
That's what we have going between the phone calls from the pharmacy and things like that. It still takes a while to order that. The other challenge with lysis is ordering and maintaining the TPA. It’s burdensome. That's a lot of monitoring.

[Dr. Chris Beck]
All right. Let's take it into the thrombectomy side.

[Dr. Alexander Ushinsky]
I gave you my breakdown of the patients who I favor thrombectomy for. One thing that I think about is that there's quite a lot of thrombectomy devices on the market, and it feels like it's really been exploding between the venous and arterial thrombectomy offerings from almost every major and a lot of the minor medical device companies.

[Dr. Alexander Ushinsky]
A lot of innovation in this area, which is good.

[Dr. Alexander Ushinsky]
It's excellent. I think that it's giving a lot of opportunities for patients. There's a lot of choices now for folks who may not have been as comfortable with or didn't have access to one of the systems. Now there may be something that your hospital system approves that's on service for your system, or that you're just comfortable with. There's a lot of really nice options. We have in our practice access to maybe about four different thrombectomy devices that are appropriate for acute limb ischemia, maybe three to four.

[Dr. Chris Beck]
Wow. That's pretty impressive.

[Dr. Alexander Ushinsky]
Not all of them are primarily ordered or requested through the Interventional Radiology Department. Some of them our vascular surgeons are using primarily, but we also have access to. They're down the hall in the OR and the cath lab where they do some of their endovascular procedures. In our big hospital system, we have access to quite a few different vendor offerings. Maybe I just name a few we can go through chronologically in what we had available in our lab, maybe it is a nice way to start.

[Dr. Chris Beck]
Talking about the evolution of what you have seen and what you've moved to. Sounds good.

[Dr. Alexander Ushinsky]
Not that long ago even, the two main offerings we had on our shelves were the AngioJet, which is now by Boston Sci, and then the penumbra thrombectomy catheters, the Indigo Systems. Those were our tried and true. The nice thing about those is both those vendors have offerings for very small vessels and larger vessels. You have the 8 French AngioJet, which I don't know that a ton of people are putting in for arterial thrombectomy and the extremity, but you have all the way, and down to three or four French systems for small vessels.

AngioJet rheolytic thrombectomy has been around for quite some time. Over the wire system, the only thing that I think about is it can cause some bradycardia. We always warn our fellows about that, especially if you're using it more centrally. In our venous cases, we still use AngioJet quite a lot. Then you always warn the patient, they're going to have dark-colored urine afterwards.

To be honest, I haven't used AngioJet in an arterial thrombectomy case in a very long time because we like some of our other offerings, but I know that at some labs, that's kind of tried and true. It's been around for a very long time.

The next device that we had been using and has been on our shelf for a good while is the Indigo line from Penumbra. Again, just like AngioJet and some of the others, they have a pretty wide variety of offerings in terms of catheter size, from the smallest coming from their coronary and neurovascular lines. I think they have a 3-French version, and then going up all the way up to right now it’s 12-French. Then I think they have a 14 or 16-French offering that they're going through with a limited market release for PE. Obviously, I don't think people would use that in the lower extremity.

[Dr. Chris Beck]
Seems bold.

[Dr. Alexander Ushinsky]
The nice thing about the Penumbra system, in my opinion, and actually AngioJet is the same way, if you have the engine to pump that runs the system, you can connect any of the catheters to it. That's really nice for the lab that may be does the occasional peripheral vascular case but is otherwise a cardiology lab, but happens to have CAT RX on their shelf, you can call the rep and bring it in or just use the CAT RX, but you can call the rep and bring in the other size catheter that you may not normally keep on your shelf.

Otherwise, the system works just as you expect from your experience, whether it's in coronary thrombectomy or whether it's in venous thrombectomy. The system works the same between sizes of the catheters. We can speak more on any of these particular systems going forward and how we like to use them.

The next one that we brought on board in our lab is the offering from AngioDynamics, which is Auryon, which is a laser atherectomy system. We brought this on as an atherectomy system for chronic limb ischemia, but the two larger sides of the 6 and 7-French sizes, the 2-millimeter and 2.3-millimeter size also have a thrombectomy lumen. It's actually on label for thrombus removal thrombectomy.

We've used that really successfully in quite a number of patients because it's also approved for treatment of stent restenosis. For a lot of my patients who are coming with baseline chronic limb ischemia, may have been stented, treated in the past.

[Dr. Chris Beck]
Stent goes down?

[Dr. Alexander Ushinsky]
Exactly, the stent goes down, and the patient's foot is numb again. These are the less acute cases, the patient calls your nurse, you set them up for the next day in the lab at 8:00 AM. That has been a really nice option because it really fits the wire and catheter and Sheath profile of the way I treat chronic limb ischemia, which is much more of my volume. The other nice thing I'll say about those types of systems, and we'll talk about their competitive Rotarex in a second.

These systems that can offer both thrombectomy and atherectomy, in my mind, give you the benefit of then immediately treating not just the acute thrombus but also the underlying chronic disease that may have caused the acute thrombus to lodge. You do two aspects of the single-session treatment all at once because you're providing atherectomy plaque modification and you're providing thrombectomy at the same time.

[Dr. Chris Beck]
Well, this is one of my questions about these devices that are treating the plague and the clot, are you getting the best of both worlds or are you getting a device that does each of them okay? Do you know what I mean?

[Dr. Alexander Ushinsky]
Yes. From my perspective, if I'm looking at the devices that only do thrombectomy, I would never say that I came away super satisfied with how a peripheral acute limb ischemia case went with those. For example, the Penumbra catheters generally are not over the wire other than cataracts. You can put a wire through it, but they're not intended to be done that way.

I can tell you that in a diseased artery, I have run into the issue where the lip of the Penumbra catheter catches on a piece of plaque, and then I'm uncomfortable. Do I push on through it? Do I pull back in turn? Am I going to embolize a little plaque? Not that you couldn't embolize a plaque with another catheter, but suffice it to say that I don't think that the pure thrombectomy systems are all that superior at thrombectomy than some of these thrombectomy atherectomy systems.

Let me give you this example. When I have done thrombectomy with the Auryon system, my blood loss is about 200 ccs. When I do thrombectomy in the extremity with the Penumbra system, my blood loss is about 200 to 300 ccs. It's sucking a similar volume of free blood and hopefully thrombus as well.

I will say that both the Penumbra system clogs and the Auryon system clogs and the Rotarex system clogs. That is a challenge with all those systems in my experience. You have to pull the catheter out, flushing on the back table, get out some chronic material, some acute material, and then reintroduce it. That's definitely a frustration of these single-session procedures.

[Dr. Chris Beck]
We've named four devices, the AngioJet, the Penumbra, the Auryon, and the Rotarex. What are you guys using most frequently? What's the go-to?

[Dr. Alexander Ushinsky]
At this point, my go-to is the Auryon. I'll give you the reasons. First of all, I use it relatively frequently in my lab for chronic limb ischemia. My techs are relatively comfortable with it and I'm relatively comfortable with it. If there's a tech who doesn't know how to use the system, I can.

[Dr. Chris Beck]
You can fill the gap.

[Dr. Alexander Ushinsky]
Yes, I can fill the gap, exactly. Then, like I mentioned, I like that it does some atherectomy and that it's approved for in stent restenosis, so I know it will, to some extent, treat some of that chronic material or chronic plaque as well. It tends to follow the guidewire pretty well, and it's on that 014 system, which is what I often use initially anyway. I usually run it in over a Spartacore Guidewire once I've gotten distal access just to have support.

[Dr. Chris Beck]
To back up, it's Glidewire Advantage to cross and then get your catheter in and then you change out for the Spartacore.

[Dr. Alexander Ushinsky]
I usually will. You can run a lot of these devices over the software Glidewire Advantage. Especially when I'm working with residents, there's a lot of wire manipulation skills that we're all still learning. I'll try to put a supportive guidewire in if I'm going to do that type of intervention for sure. I think Rotarex comes with its own 018 guidewire that you run the system over as well.

My workhorse has lately been the Auryon. The other thing I'll say that's nice about that system is it's relatively easy to switch catheters. I've been in this situation where I've chosen the larger thrombectomy catheter, the 7-French, and it has trouble getting through, catches on the edge of the stench or something like this, or there's a really severe chronic stenosis.

I'll take that out and downsize to a smaller catheter and then the system's still running. It's pretty easy to hot-swap your catheters. Once you use it, you don't have to toss it. You can put it right back into the machine and reuse it afterwards once you've treated the severe stenosis with a smaller catheter, for example.

[Dr. Chris Beck]
Is it one of the systems where I haven't used it, so pardon me if this becomes a dumb question. Is it one of the ones where it's pulling out into a canister and you have the clot shot afterwards?

[Dr. Alexander Ushinsky]
It does pull out into a canister. It looks just like the wall suction canisters that you see in the patient's room that they use for like the Yankauer suction. For that system, you have two sizes that do not do thrombectomy and two sizes that offer thrombectomy plus atherectomy with laser fibers along the edge of the catheter lumen. Then the inner lumen is a suction. That goes to a little thrombectomy canister that sits on the machine.

I will say that the clot picture afterwards is never all that impressive. Really, the best clot picture that you get is when you flush the catheter on table and sometimes you get this kind of chronic yellow material, especially from that in stent restenosis. That's not the same as the atheroembolis, but I try to advise my fellows not to play into that social media clot picture.

[Dr. Chris Beck]
Sure, right.

[Dr. Alexander Ushinsky]
Whose-clot-is-bigger game. I don't know.

[Dr. Chris Beck]
That's not helpful. That's not moving the ALI service.

[Dr. Alexander Ushinsky]
We can all put pretty pictures on social media, but the real goal is to provide useful and good patient care. I think that should be where our focus is, I hope.

[Dr. Chris Beck]
All right. That's a good assumption. With any of these devices, any good well-rounded tips as far as using these devices safely, effectively like optimizing? That's like one of the struggles, there's so many devices in this space, sometimes you just have to pick one, go with it and get really, really excellent at the one that you use the most. Is there any general advice you can give to the audience about basic practice patterns that can help you work through a case and tips that you've learned over the years to stay safe but still aggressively treat clot and thrombus?

[Dr. Alexander Ushinsky]
Definitely. I think the first thing I would say is not to be intimidated by these devices. I know a lot of my colleagues in IR are not doing as much chronic limb ischemia as our field used to do, or maybe folks are just not as endovascularly-oriented. Most of these newer devices are pretty straightforward to use. They may look a little intimidating at first, but it's really the same basic good practices of guidewire and catheter technique, maintaining good back tension on the guidewire, choosing the right size guidewire for the catheter.

All these basics that we all learn in our training, maintain here, and hopefully, will make these systems a little less intimidating for someone who doesn't use them as often. The other thing I'll say is like we alluded to, a lot of these patients have some underlying chronic limb ischemia or may have stents in place. I think it's important to assess whether the device you're using is going to be safe to use in those settings.

There are some devices that I don't have much experience with. For example, there's a new thrombectomy device from Surmodics and Inari. I don't know the name of the device from Inari, but Inari has a limited market release of an arterial thrombectomy catheter, both of which pull clot out. I've spoken to our local reps at some of the conferences. Some of these devices may or may not be suited for use within stents, especially fresh stents that aren't well-endothelialized. Those are all things to be considerate of.

Other tips, I would make sure that the patient is well-heparinized. Make sure that you're able to check an ACT. I generally try to keep my ACT above 270. Like I said, I'm often working in the chronic limb ischemia space in the tibialis, and we keep it even higher for that, but definitely making sure that you're well-heparinized is another critical factor.

Another pitfall that we teach our fellows and that I would just want to remind folks is to try to avoid injecting contrast or pressurized injections within the thrombus. There are situations where your catheter is in there, you're not sure what's going on. I would really emphasize not injecting within the area of the thrombus, but really using your Sheath that should be in a patent segment high above to do your injections, to check and see how things are going. Those are the most critical pitfalls I always make sure I remind my fellows about.

The other thing I always think about is you have to know when you're succeeding and when you're not succeeding. You've done multiple passes with your thrombectomy device of choice. They're all probably good and adequate. If you're not getting a good result, then there has to be a stopping point. For me, a lot of times I'll, in my mind, have a thought of if the patient is a lytic catheter. If we've done this for a little while and we're not successful, we're not making useful progress, can I place a lytic catheter, get some benefit from that and see the patient the next day and maybe live to fight another day in that sense, rather than being bogged down in a six-hour procedure.

I was always taught that these extremely lengthy procedures are where bad outcomes happen. Those are some of the other general guidelines I'd give.

[Dr. Chris Beck]
That's a good tip. Actually, it segues nicely into one of the topics on the outline is endpoint. When are you done? Is it angiographic? Is it clinical? Is it a combination? Speak to that, but dig in a little bit further like, when is the case over whether a case you're succeeding or a case that you're succeeding at failing?

[Dr. Alexander Ushinsky]
The most important question is, how is the patient doing? There've been a couple cases where I've been doing a chronic limb ischemia case that becomes an acute limb ischemia case, and very quickly the patient is not doing well. You need to assess how quickly I can fix the immediate problem, and can I get the patient's pain under control and the patient comfortable enough to continue the procedure. We alluded to some of this earlier when we were discussing who is well-suited for an anesthesia or a deep sedation case.

Aside from that circumstance, as we're doing the procedure, my general practice is I'll pass my desired thrombectomy device a couple times and I'll assess if I'm now drawing good blood from the thrombectomy lumen. You can also get a lot of tactile sensation from some of the devices. Is it flowing through freely? For example, the AngioDynamics, the Auryon device, when it's in plaque or thrombus, there's an audible noise that comes from the catheter, maybe from the laser energy that becomes duller. Then when it's in a free lumen, it becomes sharper and easier to hear.

I use that to tip me off. If that span that is dull sounding is becoming shorter and shorter and shorter, I know that I've created some patent lumen channel. When you get some tactile and auditory feedback from the Rotarex device in that regard as well. Once I've done a few passes with these devices, I'll shoot an angiogram and see what I have. To be honest, almost always, what I end up seeing is two, three-millimeter patent lumen with some residual chronic or acute thrombus. Then if I'm unlucky, what I see is some embolus that has maybe gone down to a tubule. That's usually a point where I stop and reassess.

If I've made a really decent channel and there's no off-target embolization, I'll proceed to treating the residual chronic and maybe some acute disease. I'll usually do balloon angioplasty and possibly stenting. If needed, if there's really a chunky chronic thrombus. I've been in a couple situations where there's in-stent restenosis with this rubbery chronic material. In those cases, I'll use a stent graft to exclude that or sometimes a stent to exclude that. Otherwise, I treat the residual underlying disease most often with just balloon angioplasty.

In the setting where there's maybe some distal embolization, depending on what thrombectomy device I'm using, we have some options to go ahead and tackle the tubules. I probably would be hesitant to take the larger thrombectomy catheters from Auryon into a tubule, the 2-millimeter and the 2.3-millimeter. I'll use some of the laser catheters that are more intended for chronic limb ischemia and chronic plaque, the smaller catheters, which are intended and sized for the tubules, and take those down there and see if I can just burn through this chronic plaque.

With some of the other devices with Penumbra, you have another option, which is I think 5 French. Then the catheter 3 from the neurovascular side, which you can pretty safely take down into the tubules to try to thrombectomize those, same with the angiogram. You have that smaller omni, the small size.

Then, honestly, if there's not a massive acute thrombotic burden, I tend to have a good result with just plain or balloon angioplasty to try to macerate that thrombus and get it cleared up. If I'm able to achieve all that, my goal is to get a good angiographic endpoint as long as the patient is comfortable.

[Dr. Chris Beck]
How aggressive do you have to be for maybe the uninitiated? If you've got some distal emboli, which clots do you have to go after and which clots can you say, "We're going to heparinize them and it's going to take care of this stuff?" Can you talk a little bit about flow limiting or the degree of inclusiveness that prompts you to say, "Now we have to go and intervene further?"

[Dr. Alexander Ushinsky]
In the tubule space, if you have some embolization to the tubules, the initial question is, what's the baseline status of the tubules? In a patient with pretty severe arterial disease and maybe one or two vessel runoff below the knee, there may not be much tolerance for a small amount of embolus. Now, we have the technology to go all the way through the pedal plantar loop and perform thrombectomy. If it is an acute thrombus, it's pretty easy to get down there and to try to treat the acute thrombus.

If, on the other hand, it's a patient with a pretty healthy-looking runoff, three vessels, not a lot of arterial disease and there's a small thrombotic burden, I think it's reasonable to consider heparinization, especially in light of how long the procedure may or may not have taken up to that point.

To go after chase, perfect is the enemy of good, is the saying. To avoid a very lengthy and involved procedure with increasing risk of morbidity, it's pretty reasonable in a patient with good runoff to leave a little bit of tubule thrombus that the body can normally clean up.

[Dr. Chris Beck]
You've got your endpoint. Can we dig in a little bit to post-care? Unless you want to talk about closure?
[Dr. Alexander Ushinsky]
All I'll say about closure is, it's a question of heparin reversal at that point, what level people are comfortable closing, and whether they use a closure device or manual compression. In my practice, in a patient who I'm planning manual compression, I would like to get their ACT to the level of 200 or lower. If I'm going to use a closure device, I'm comfortable stretching the ACT a little higher to 50 occasionally if we need to.

That's an important consideration in these patients. I'll often leave them on a heparin drip for a little bit of time, especially if we do have a little bit of residual thrombus like you and I were discussing. Those are all some considerations when you do think about closure.

I don't think any particular closure device is better than any others. There are a couple that are well-suited for patients with chronic disease in the CFA or the iliacs that you can visualize or some of the suture media devices. A lot of that is operator preference and what's just available in your lab. That's all I can say about that.

(9) Arterial Thrombectomy Postoperative Care

In post-procedure management, like I said, especially if there's some residual thrombus after these single-session patients, I might keep them for the evening. Let's say, it was a morning or afternoon case, I might keep them for the evening on a heparin drip. Then if we have good pulses and we feel like we've cleaned the thrombus and they don't have an underlying reason to need to be on a heparin drip, transition them back to antiplatelet management the following day. That's the perfect case, the patient, we know why they had it.

Some of those patients, especially that setting of an outpatient who may be re-thrombus, their stent has some mild symptoms, you can clean that up and maybe even send them home later that day after some protracted monitoring, especially if they're a reliable patient. We've had some success with that. I have a few of these patients who had endovascular treatment, haven't really quit smoking, are prone to thrombosing their stents, and we've successfully treated some of the reliable ones with the same-day outpatient approach this way.

For the ones that are a little less reliable that are a little more ill that are going to be hospitalized, usually, like I said, we'll consider a transition away from heparin either to oral anticoagulant or do an antiplatelet therapy the following day as long as their pulse exam and their clinical exam in terms of their motor and sensory is doing well the next day.

That's for the slightly more acute patients.

[Dr. Chris Beck]
Afterwards, are they going to the ICU setting or whatever floor that they came from originally? Just talk a little bit to where's the appropriate spot to send them post-care.

[Dr. Alexander Ushinsky]
Definitely. Just to call back for our lysed patients, in our hospital, they're almost always in the ICU setting when they're being lysed. We do have one step-down unit that can take them, so they'll occasionally be on the step-down. They need that high level of care to have frequent neurovascular monitoring.

For the folks who have a successful single-session thrombectomy, I don't think that they need ICU level of care most of the time unless there's any concern for compartment syndrome or something similar. Then those patients, especially after a successful treatment, are pretty safe to go back to floor level of care after the requisite post-angiography, pulse, and groin monitoring that we have and that most places do.

[Dr. Chris Beck]
Do you guys have a floor that is comfortable with the IRR procedures, or basically a unit where a lot of post-angiogram patients go, or just anywhere in the hospital is pretty good?

[Dr. Alexander Ushinsky]
In general, most of our patients go anywhere in the hospital. We have a tapered groin and neurovascular exam, post-procedure orders that are generally being done.

We do have a couple of units that are specifically higher acuity for vascular patients, one that's mostly managed by our vascular surgery division, and then a couple of the surgical ICUs and step-down units.

We don't routinely have the patients go to those either the acute limb ischemia patients or any other angiography, the PEs, and things like this. The PEs will go to the ICU for monitoring afterwards. In general, most of our units will take post-angiography patients.

[Dr. Chris Beck]
All right. Well, is there anything left that I didn't ask that you thought, "Oh, there's a gap. We need to talk about that?" Any stone left unturned?

[Dr. Alexander Ushinsky]
I feel we covered most of the heavy hitters.

[Dr. Chris Beck]
I feel like we crushed it. All right, guys, to our audience, thank you for listening. If you guys enjoyed the podcast but want more, please check out the show notes of this episode. Those are going to be found at https://www.backtable.com/ . Remember, the show notes are where you can find links to free CME offered by BackTable. Check that out. For others interested in supporting the show, like, subscribe, and share the podcast on social media, or you can just go old school and tell somebody about it. Old-fashioned word of mouth is very helpful as we continue to build this community. That wraps things up. Sasha, thanks for coming on the show, man. Appreciate it.

[Dr. Alexander Ushinsky]
Chris, thank you so much. It was a pleasure. I'd just say, if any of your listeners have questions, they're welcome to reach out. My contact is on the WashU website under my name. Folks should feel comfortable with sending me an email. I'm happy to reply and share any advice or experience that I have.

[Dr. Chris Beck]
All right. We really appreciate that. I'm betting some listeners will take you up on that. Bold decision. All right. Thanks for coming on the show, man. Really appreciate it.

[Dr. Alexander Ushinsky]
Thank you.

Podcast Contributors

Dr. Alexander Ushinsky

Dr. Alexander "Sasha" Ushinksy is an interventional radiologist and assistant professor with Washington University in St. Louis.

Dr. Christopher Beck

Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.

Cite This Podcast

BackTable, LLC (Producer). (2023, April 24). Ep. 315 – Arterial Thrombectomy [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.