Publicado

2023-10-10

Trombectomía endovascular ecoguiada como alternativa en el manejo de la enfermedad arterial periférica. Reporte de dos casos

Ultrasound-guided endovascular thrombectomy as an alternative for the management of peripheral artery disease. Report of two cases

DOI:

https://doi.org/10.15446/cr.v9n2.98547

Palabras clave:

Trombectomía, Ultrasonografía doppler, Enfermedad Arterial periférica, Insuficiencia renal crónica (es)
Thrombectomy, Ultrasonography, Doppler, Peripheral Artery Disease, Renal Insufficiency, Chronic (en)

Autores/as

Resumen

Introducción. Usualmente el tratamiento de la enfermedad arterial periférica (EAP) es quirúrgico convencional o endovascular guiado mediante angiografía o ultrasonido. Existen reportes del uso del sistema de aterectomía y trombectomía mecánica Rotarex® y/o del ultrasonido dúplex (UD) como guías para trombectomías de forma separada; sin embargo, la combinación de ambos dispositivos representa una gran ventaja al convertirse en una opción con buena tasa de éxito que podría emplearse en el manejo de diferentes tipos de patologías.

Presentación de los casos. Se presentan dos casos de pacientes con antecedente de colocación de stent infrapoplíteo, quienes asistieron al servicio de urgencias de un hospital universitario de Bucaramanga (Colombia) por claudicación intermitente, discromía y dificultad en la marcha (índice tobillo-brazo en examen físico de 0.3 y 0.6). En ambos pacientes se evidenció trombosis del stent mediante dúplex arterial, por lo que se les realizó angioplastia con sistema Rotarex® guiada por UD, logrando resultados clínicos y hemodinámicos satisfactorios en el postoperatorio. Los pacientes fueron dados de alta a los 4 y 6 días después del procedimiento y en ninguno de los dos casos hubo seguimiento posterior al egreso.

Conclusiones. La trombectomía con sistema Rotarex® guiada por UD se plantea como una alternativa viable, real y costo-efectiva en pacientes con EAP. Se recomienda implementar este tipo de estrategias con el fin de realizar trabajos con mayor poder estadístico para el análisis de los resultados y que permitan obtener conclusiones reproducibles sobre tasas de éxito, permeabilidad y salvamento de la extremidad.

Abstract

Introduction: Peripheral artery disease (PAD) is usually treated with conventional or endovascular surgery guided by angiography or endovascular ultrasound. Although there are reports on the use of the Rotarex® atherectomy and mechanical thrombectomy systems and/or duplex ultrasound (DU) as separate guides for thrombectomies, the combination of both devices offers a greater advantage as this option has a good success rate and could be used in the management of different types of conditions.

Case presentation: Two cases of patients with a history of infrapopliteal stent are reported. They visited the emergency department of a university hospital in Bucaramanga (Colombia) due to intermittent claudication, dyschromia, and gait disturbance (ankle-brachial index on physical examination of 0.3 and 0.6). Both patients presented with stent thrombosis detected by means of arterial duplex and underwent angioplasty using the Rotarex® system combined with DU, achieving satisfactory clinical and hemodynamic outcomes in the postoperative period. The patients were discharged 4 and 6 days after the procedure, and there was no post-discharge follow-up in either case.

Conclusions. This combined procedure is a viable, real, and cost-effective alternative in comorbid patients at high risk of PAD. The implementation by different surgical groups of this type of strategy is recommended to carry out studies with greater statistical power for the analysis of results and to obtain reproducible conclusions on success rates, patency, and limb salvage.

98547

https://doi.org/10.15446/cr.v9n2.98547

Ultrasound-guided endovascular thrombectomy as an alternative for the management of peripheral artery disease. Report of two cases

Keywords: Thrombectomy; Ultrasonography, Doppler; Peripheral Artery Disease; Renal Insufficiency, Chronic.

Palabras clave: Trombectomía; Ultrasonografía doppler; Enfermedad Arterial periférica; Insuficiencia renal crónica.

Jaime Enrique Gómez

Hospital Universitario de La Samaritana
- Vascular Surgery and Angiology Service - Bogotá D.C. - ColombiaHéctor Conrado Jiménez

Universidad El Bosque - Faculty of Medicine
- Department of Vascular Surgery -
Bogotá D. C. - ColombiaAna María Bautista

Jesús David Sendoya

Universidad Surcolombiana
- Faculty of Health Sciences - Neiva - Colombia

Corresponding author

Jesús David Sendoya.

Facultad de Salud, Universidad Surcolombiana.

Neiva, Huila. Colombia.

Email: jdsendoya@gmail.com

Received: 19/09/2021 Accepted: 29/11/2021

Resumen

Introducción. Usualmente el tratamiento de la enfermedad arterial periférica (EAP) es quirúrgico convencional o endovascular guiado mediante angiografía o ultrasonido. Existen reportes del uso del sistema de aterectomía y trombectomía mecánica Rotarex® y/o del ultrasonido dúplex (UD) como guías para trombectomías de forma separada; sin embargo, la combinación de ambos dispositivos representa una gran ventaja al convertirse en una opción con buena tasa de éxito que podría emplearse en el manejo de diferentes tipos de patologías.

Presentación de los casos. Se presentan dos casos de pacientes con antecedente de colocación de stent infrapoplíteo, quienes asistieron al servicio de urgencias de un hospital universitario de Bucaramanga (Colombia) por claudicación intermitente, discromía y dificultad en la marcha (índice tobillo-brazo en examen físico de 0.3 y 0.6). En ambos pacientes se evidenció trombosis del stent mediante dúplex arterial, por lo que se les realizó angioplastia con sistema Rotarex® guiada por UD, logrando resultados clínicos y hemodinámicos satisfactorios en el postoperatorio. Los pacientes fueron dados de alta a los 4 y 6 días después del procedimiento y en ninguno de los dos casos hubo seguimiento posterior al egreso.

Conclusiones. La trombectomía con sistema Rotarex® guiada por UD se plantea como una alternativa viable, real y costo-efectiva en pacientes con EAP. Se recomienda implementar este tipo de estrategias con el fin de realizar trabajos con mayor poder estadístico para el análisis de los resultados y que permitan obtener conclusiones reproducibles sobre tasas de éxito, permeabilidad y salvamento de la extremidad.

Abstract

Introduction: Peripheral artery disease (PAD) is usually treated with conventional or endovascular surgery guided by angiography or endovascular ultrasound. Although there are reports on the use of the Rotarex® atherectomy and mechanical thrombectomy systems and/or duplex ultrasound (DU) as separate guides for thrombectomies, the combination of both devices offers a greater advantage as this option has a good success rate and could be used in the management of different types of conditions.

Case presentation: Two cases of patients with a history of infrapopliteal stent are reported. They visited the emergency department of a university hospital in Bucaramanga (Colombia) due to intermittent claudication, dyschromia, and gait disturbance (ankle-brachial index on physical examination of 0.3 and 0.6). Both patients presented with stent thrombosis detected by means of arterial duplex and underwent angioplasty using the Rotarex® system combined with DU, achieving satisfactory clinical and hemodynamic outcomes in the postoperative period. The patients were discharged 4 and 6 days after the procedure, and there was no post-discharge follow-up in either case.

Conclusions. This combined procedure is a viable, real, and cost-effective alternative in comorbid patients at high risk of PAD. The implementation by different surgical groups of this type of strategy is recommended to carry out studies with greater statistical power for the analysis of results and to obtain reproducible conclusions on success rates, patency, and limb salvage.

Introduction

Peripheral artery disease (PAD) is a circulatory condition in which the blood supply to the limbs (mostly lower limbs) is reduced due to the narrowing of the blood vessels. It affects more than 200 million people worldwide and has a prevalence that increases with age, reaching up to 56% in people over 25 years of age. Mortality is difficult to estimate because it is an underdiagnosed disease (1-5).

PAD is a multifactorial condition that is related to tobacco use, diabetes mellitus (DM), arterial hypertension (AHT), advanced age, among others. Most patients are initially asymptomatic, then develop leg pain that occurs during walking (intermittent claudication), and finally present critical limb ischemia (CLI) (21%) or sometimes acute limb ischemia (ALI) (1.7%) (1-7).

CLI is a severe form of PAD characterized by lower limb pain at rest that lasts for more than 2 weeks and wounds that develop gangrene or do not heal. It has a prevalence of 1.3% in patients older than 40 years and is considered one of the most challenging conditions for medical-surgical management because it contributes to an increased risk of death (95% within 10 years of the initial presentation of the disease), cardiovascular events, and limb loss (up to 40%) (8,9). On the other hand, ALI results in limb amputation in 10-15% of cases and has a 30-day mortality rate of 15-25% (9,10).

The management of PAD is based on non-pharmacological, pharmacological, and surgical therapy. The first is focused on physical activity, ambulation, and lifestyle changes (7,8); the second involves anticoagulant therapy, antiplatelet therapy, statins, antihypertensives, and other drugs; and the third is the last resort when patients do not improve clinically with the established treatment or develop CLI or ALI. Preoperative assessment is performed using duplex ultrasound (DU) or cross-sectional imaging (magnetic resonance imaging and/or computed tomography angiography) (3,8-10).

The surgical management of PAD can be endovascular, which has lower rates of morbidity and mortality and hospital stay, and/or conventional open surgery (3,6). Choosing the best method depends on the characteristics of the arterial condition of each patient, which are assessed by means of multiple instruments such as the GLASS system (Global Limb Anatomic Staging System) or the WIFI (Wound, Ischemia and Foot Infection) classification (3,6,11).

Endovascular management strategies include balloon angioplasty (conventional or medicated), stenting (conventional or medicated), and atherectomy (directional, orbital, laser and rotational), which can be angiography- or intravascular ultrasound-guided (12-14). Likewise, mechanical arterial thrombectomy has also emerged as a strategy with high success rates for less invasive procedures in patients with comorbidities (13-17). In turn, DU is a cost-effective option that reduces radiation exposure, decreases the use of nephrotoxic agents, and provides high-quality images with reliable hemodynamic parameters that allow for an immediate evaluation of postoperative results (12-17).

The following are two cases of patients with PAD and previous stent thrombosis, who were successfully treated with rotational atherectomy guided by the Rotarex® atherectomy and mechanical thrombectomy system.

Case presentation

Case 1

A 68-year-old man attended the emergency department of the Hospital Universitario de Santander in Bucaramanga, Colombia, because he had been experiencing pain in the right lower limb (RLL) and difficulty in ambulation secondary to mild distal coldness and cyanosis for the last 3 days. The patient had the following medical history: atrial fibrillation, Chagas heart disease, hypertension, chronic obstructive pulmonary disease, chronic kidney disease (CKD) and PAD that required left above-the-knee amputation and angioplasty plus endovascular stenting of the femoral popliteal artery (Lifestent) in the right lower limb (RLL) 4 months prior to admission. In addition, he had poor adherence to anticoagulant therapy (vitamin K antagonists).

On physical examination, the following findings were reported: absence of popliteal pulse and infrapatellar pulses, visual analog scale (VAS) score of 8/10, and ankle-brachial index (ABI) of 0.6; no ischemic ulcers were observed. Considering these findings and history, the patient was admitted to the inpatient service.

Admission laboratory tests showed a serum creatinine level of 1.4 mg/dL
for a glomerular filtration rate (GFR) of 51 mL/min/1.73m2 (CKD stage 3a) according to the CKD-EPI creatinine equation (18). In view of this kidney involvement, a venous duplex (VD) of the RLL was performed after admission, with negative findings for deep vein thrombosis, as well as an arterial duplex (AD) that revealed a 5mm stent surrounded by hyperechoic material in its entirety. Consequently, it was considered that the patient had subacute stent thrombosis in a segment of the popliteal femoral artery with distal recanalization by collateral circulation to compensate for the obstruction in the tibiofibular trunk (Figure 1).

Figure 1. Pre-surgical arterial duplex of the right lower limb. A) proximal segment of stent in popliteal femoral artery blocked by hyperechoic material; B) color Doppler showing stent blockage; C) tibiofibular trunk without arterial flow; D) anterior tibial artery with monophasic flow.

Source: Image obtained while conducting the study.

Based on the physical examination findings, laboratory and imaging test results, and multiple comorbidities, and in order to reduce exposure to nephrotoxic drugs as much as possible, it was decided that the patient was a candidate for stent for permeabilization by means of DU-guided endovascular mechanical thrombectomy plus angioplasty (Rotarex® system) under local anesthesia. The procedure was scheduled to be performed two days later.

However, on the second day of hospitalization, symptoms worsened, with increased RLL pain (VAS: 9/10), paresthesia, dysesthesia, progression of cyanosis, decreased ABI (0.3), and absence of distal pulses. Therefore, DU + angioplasty (Rotarex® system) was performed (Figure 2).

Figure 2. Duplex ultrasound-guided endovascular mechanical thrombectomy. A) ultrasound-
guided navigation (hydrophilic guidewire) through the blocked stent; B) axial slice showing normal localization and transintimal dissection of hydrophilic guidewire;
C) ultrasound-guided mechanical thrombectomy (light arrow: Rotarex® system, bold arrow: anterior aspect of the stent).

Source: Image obtained while conducting the study.

The following is a description of the procedure performed on the patient (DU-guided endovascular mechanical thrombectomy + angioplasty with Rotarex® stent system in a segment of the right femoral popliteal artery):

1.An initial assessment was performed in the hemodynamics room using ultrasound to identify and select the arterial segments to be treated.

2.Local anesthesia (lidocaine 1% 10cm3, without epinephrine) was injected in the puncture area of the right common femoral artery.

3.An 8Fr sheath was inserted under ultrasound guidance and following the Seldinger technique.

4.Ultrasound guided advance and navigation (0.035x260mm hydrophilic guidewire) were achieved, partially flanking the stent up to the second segment of the popliteal artery.

5.Under ultrasound-guided navigation and using a vertebral catheter to improve the support of the hydrophilic guidewire, the blocked segment of the stent was completely crossed, verifying the location of the hydrophilic guidewire in the tibiofibular trunk and the posterior tibial artery.

6.Heparin was administered systemically (unfractionated heparin at a dose of 100 IU/kg).

7.Mechanical thrombectomy was performed using the Rotarex® 6Fr system under sequential ultrasound guidance following the recommendations of the manufacturer.

8.Biphasic wave DU for stent control and ultrasound-guided conventional balloon angioplasty (Invatec Admiral Xtreme 5x120mm) were performed.

9.A follow-up AD was performed, revealing triphasic flow in the stent, the tibiofibular trunk, and the distal posterior tibial artery.

10.The hydrophilic guidewire was removed under ultrasound guidance and antiplatelet therapy was initiated with acetylsalicylic acid and clopidogrel (loading dose of 300mg each).

11.Finally, 4 hours after administration of unfractionated heparin, the sheath was removed.

After the surgical procedure, the patient showed clinical improvement (Table 1).

Table 1. Comparison of preoperative and postoperative arterial duplex findings in case 1.

Case 1

Preoperative

Postoperative

Anatomical structure

PSV

Flow

PSV

Flow

External iliac artery

69

Triphasic

98

Triphasic

Common femoral artery

88

Triphasic

103

Triphasic

Proximal superficial femoral artery

56

Triphasic

49

Triphasic

Distal superficial femoral artery

26

Biphasic

90

Triphasic

Hunter’s canal

23

Biphasic

-

P1 segment of the popliteal artery

*

Occlusion/floating thrombus

61

Triphasic

P2 segment of the popliteal artery

*

Occlusion

84

Triphasic

P3 segment of the popliteal artery

*

Occlusion

47

Triphasic

Tibiofibular trunk

*

Occlusion

64

Triphasic

Proximal anterior tibial artery

9

Monophasic

26

Monophasic

Medial anterior tibial artery

10

Monophasic

-

Distal anterior tibial artery

11

Monophasic

26

Biphasic

Proximal posterior tibial artery

*

Occlusion

-

Medial posterior tibial artery

7

Monophasic

54

Triphasic

Distal posterior tibial artery

*

Occlusion

-

Proximal peroneal artery

*

Occlusion

10

Triphasic

Medial peroneal artery

*

Occlusion

13

Triphasic

Distal peroneal artery

*

Occlusion

10

Triphasic

PSV: peak systolic velocity.

* No flow-occlusion

Source: Own elaboration.

After confirming the presence of popliteal pulses and observing a reduction in pain (VAS: 2/10), improvement in the perfusion of the RLL, and a decrease in paresthesia, 48 hours after surgery, a follow-up AD was performed, which showed stent patency in its entirety with triphasic flow (normal morphology of the arterial flow curve), acceptable infrapatellar flows (Figure 3), and pseudoaneurysm with a hematoma of 2.7x4mm at the puncture site, with no evidence of flow inside (color Doppler) that was treated with compression bandage for anticoagulation. Four days after surgery, the patient was discharged with an indication for outpatient physical therapy and anticoagulation with warfarin 4 mg/day indefinitely, with monitoring of the international normalized index.

Figure 3. Follow-up duplex ultrasound 48 hours after ultrasound-guided mechanical thrombectomy, A) popliteal femoral artery stent patency, triphasic flow with no residual stenosis; B) distal peroneal artery run-off with evidence of triphasic flow.

Source: Image obtained while conducting the study.

At the time of writing this report, there was no follow-up of the case due to a lack of adherence by the patient.

Case 2

A 75-year-old woman attended the emergency department of the Hospital Universitario de Santander after presenting symptoms of pain in the right foot secondary to necrosis of the proximal phalanx of the hallux for 5 months. The patient had a history of DM, AHT and PAD resulting in amputation of the distal phalanx of the third toe of the right foot 2 years prior to admission and angioplasty plus endovascular stenting of the popliteal artery in RLL performed to avoid limb amputation.

On physical examination, the following findings were reported: bilateral femoral pulse and left popliteal pulse, absence of bilateral right popliteal and dorsalis pedis pulse, and ABI of 0.6. Admission laboratory tests showed a serum creatinine level of 1.3 mg/dL for a GFR of 40.1 mL/min/1.73m2 according to the CKD-EPI creatinine equation (CKD stage 3a) (18).

In view of these findings, the patient was admitted to the inpatient service. An AD of the RLL was performed, which showed PAD with suprapatellar and infrapatellar involvement, stent occlusion in the right popliteal artery (segments 1 and 2) with recanalization of the tibiofibular trunk due to collaterality, occlusion of the anterior tibial artery in the middle third and posterior tibial artery, as well as occlusion of the left posterior tibial artery along its entire course (Figure 4). Therefore, the patient was rated as a PAD patient with Rutherford 5 classification for the RLL.

Figure 4. Duplex ultrasound of right lower limb on admission. A) proximal segment of distal popliteal femoral artery stent blocked by hypoechogenic material; B) collateral circulation near the stent in the second segment of the popliteal artery, monophasic flow; C) duplex with biphasic flow in collateral circulation coming from peroneal artery; D) duplex with biphasic flow at the tibiofibular trunk level.

Source: Image obtained while conducting the study.

Considering the results of laboratory and imaging tests and her multiple comorbidities, and in order to reduce exposure to nephrotoxic drugs as much as possible, the patient underwent stent permeabilization by ultrasound-guided endovascular mechanical thrombectomy plus angioplasty (Rotarex® system) on the second day of admission. This procedure was performed without complications following the same steps described in case 1 (Figure 5).

Figure 5. Ultrasound-guided endovascular mechanical thrombectomy and postoperative management. A) passage of mechanical thrombectomy system over support guidewire through the blocked stent; B) and C) 2D and color duplex with confirmation of previously occluded stent permeabilization; D) color duplex showing adequate stent patency and second segment of the popliteal artery in the immediate postoperative period.

Source: Image obtained while conducting the study.

Following the surgical procedure, the patient presented pain reduction (VAS: 2/10) and clinical improvement and better perfusion in the RLL. In the follow-up AD performed postoperatively on the same day of the procedure, a permeable femoral shaft, permeable stent in segments 1 and 2 of the popliteal artery, adequate run-off (infra patellar flow target artery up to the foot) through peroneal artery with biphasic flow, and absence of pseudoaneurysm were observed. Table 2 shows the evolution of the patient after surgery. On the sixth postoperative day, the patient was discharged with follow-up by vascular surgery and internal medicine.

Table 2. Comparison of preoperative and postoperative arterial duplex in case 2.

CASE 2

Preoperative

Postoperative

Anatomical structure

PSV

Flow

PSV

Flow

External iliac artery

88

Biphasic

88

Biphasic

Common femoral artery

86

Biphasic

86

Biphasic

Proximal superficial femoral artery

75

Triphasic

78

Triphasic

Medial superficial femoral artery

-

-

73

Triphasic

Distal superficial femoral artery

24

139

Biphasic

P1 segment of the popliteal artery

*

Occlusion

122

Triphasic

P2 segment of the popliteal artery

*

Occlusion

94

Triphasic

P3 segment of the popliteal artery

48

Monophasic

18

Triphasic

Tibiofibular trunk

47

Monophasic

14

Biphasic

Proximal anterior tibial artery

40

Monophasic

13

Triphasic

Medial anterior tibial artery

*

Occlusion

*

Occlusion

Distal anterior tibial artery

19

Monophasic

0

Monophasic

Proximal posterior tibial artery

*

Occlusion

1

Monophasic

Medial posterior tibial artery

*

Occlusion

*

Occlusion

Distal posterior tibial artery

*

Occlusion

*

Occlusion

Proximal peroneal artery

29

Monophasic

14

Biphasic

Medial peroneal artery

40

Monophasic

20

Biphasic

Distal peroneal artery

138

Monophasic

80

Biphasic

Hunter’s canal

180

Triphasic

PSV: peak systolic velocity.

* No flow-occlusion

Source: Own elaboration.

At the time of writing this report, no follow-up of the case was recorded due to the patient’s lack of adherence.

Discussion

PAD mainly affects people over 60 years of age, as in the cases presented, and has a prevalence that increases with age, being 4.4% in the general population in Colombia. This is also a condition of great public health relevance as patients with this condition have a 1-3% risk of amputation 5 years after diagnosis (3,6,8,19,20).

The risk factors for PAD are AHT, DM, CKD, obesity, hyperlipidemia, and smoking. In case 1 reported in the present study, PAD and its complications appeared early because the patient had more than 3 risk factors, which represents an increased risk of developing PAD of almost 13.2 times compared to case 2, in which the patient had only 2 risk factors (3,6,8,19,20).

During the clinical course and follow-up of patients with PAD, emphasis should be placed on vascular examination, since it allows for the detection of alterations that depend on the degree of arterial involvement, such as decreased pulses, abnormal gait, intermittent claudication, among others (6).

The use of the ABI as a screening and diagnostic method for PAD has a sensitivity of 94-97%, with abnormal values <0.9 However, when patients present with CKD and DM there may be arterial stiffness, which results in an ABI>1.3. In these cases, it is recommended to use the digit-brachial index as a complementary diagnostic method (6). In the cases reported above, the patients had an ABI<0.9 on admission, which was used to define the surgical approach to be used (6).

CLI increases the risk of death and cardiovascular events, and also involves an increased risk of loss of the affected limb, as evidenced in case 1. It has been established that the amputation rate in patients with CLI is 10-40% and the mortality rate is 20% at one year, 40-70% at 5 years, and 80-95% at 10 years. Therefore, it is important to offer different strategies aimed at trying to save the limb, thus improving the prognosis of this population (6,8-10). American and European guidelines for the management of CLI agree that outcomes are similar between endovascular and surgical approaches (21), although they favor the endovascular approach in patients with ominous comorbidities or without adequate autologous vein for arterial bypass (8,22).

On the other hand, ALI requires an emergency approach, and the revascularization strategy in these patients should be individualized on a case-by-case basis taking into account the available resources, the experience of the treating group of professionals, and the clinical presentation of the condition. Thus, the technique that leads to rapid restoration of arterial flow with the least possible risk to the patient should be selected (8). Endovascular procedures for the management of ALI and CLI are indicated as primary therapy because of their lower morbidity and mortality (23).

In the present study, taking into account that current guidelines recommend catheter-guided thrombolysis (CGT) as an effective treatment for ALI and percutaneous mechanical thrombectomy as a complement to it (22-24), in the cases presented, DU-guided mechanical thrombectomy was proposed as the initial surgical strategy due to the lack of authorization for the use of systemic thrombolytics at the peripheral arterial level, the specific characteristics of the patients (CKD, DM, AHT), and the presence of subacute and chronic thrombosis.

Endovascular mechanical thrombectomy offers multiple advantages over conventional procedures for the management of arterial thrombosis since it is a less invasive procedure where vessel recanalization is faster and there is less bleeding (25). In the case of lower limb ALI, it has been established that the clinical success rate with the Rotarex® system is between 91.4% and 97%, while the success rate for thrombolysis is between 46% and 67.9% and for surgery is 74.3%. Regarding limb salvage at one year, the Rotarex® system remains superior, with rates between 93.7% and 100%, compared to CGT (65-87%) and conventional surgery (69.9-89.6%) (25).

Mechanical thrombectomy, as well as any invasive procedure, poses risks and complications such as rethrombosis (8.1%), vascular dissection (4.1%), vascular perforation (1.4%), distal embolism (5.5%), myocardial infarction (7%), stroke (1.6%), and kidney failure (2.3%) (25). Among the cases described in this report, there was only one pseudoaneurysm at the puncture site, which was treated with medical management.

So far there are no studies that analyze the cost-benefit of the Rotarex® system, but it is clear that although its use leads to an increase in the cost of the revascularization procedure, this is outweighed by the fact that it is minimally invasive, requires less hospital stay, and does not imply the need for admission to the intensive care unit (25).

For its part, AD has great advantages as an alternative to angiography, particularly in patients with DM or CKD, since these conditions predispose them to a higher risk of developing contrast-induced acute kidney injury (AKI) (26,27). In addition, AD eliminates radiation exposure with low complication rates and allows for the dynamic and immediate assessment of post-surgical results, thus quantitatively diagnosing the presence or absence of residual stenosis suitable for further management (27) (Table 3).

Table 3. Advantages and disadvantages of the Rotarex® system and ultrasound.

System

Advantages

Disadvantages

Rotarex®

  • Minimally invasive
  • Easy to use
  • Short operative time
  • Reduced thrombus size
  • Suitable for all types of supracondylar vessels
  • Low complication rates
  • No endothelial damage
  • High revascularization success rates
  • Unmasks underlying injuries
  • No need for thrombolytic medication or vessel preparation
  • Short hospital stay required
  • No admission to the ICU
  • Affordable
  • Inefficient in angulated bifurcations and sclerotic bifurcations
  • Aortic dissection due to fissure of the intima and perforation in highly calcified vessels
  • Expensive catheter required
  • Distal embolization is required with indication of thrombectomy or lytic therapy
  • Not suitable for infracondylar vessels
  • Minimum vessel lumen of 4mm is required

Ultrasound

  • Capacity to determine the diameter and length of the stenotic lesion
  • No need for contrast medium and its associated complications, especially in patients with renal failure
  • Capacity to perform a real-time hemodynamic evaluation of the treated arterial segment
  • Useful not only to identify the exact location and severity of occlusive disease, but also to accurately measure the extent of the lesion
  • Visualization of the artery, regardless of patency, and the arterial wall, in real time, regardless of limb motion, with objective measurements of flow direction and waveform
  • Image magnification up to 5 times and multiple projections provide accurate information for balloon and stent placement
  • Immediate and accurate identification of complications associated with balloon angioplasty, such as embolization or thrombosis using duplex ultrasound, which can also be successfully treated with duplex guidance alone
  • Requires readiness to abandon this approach in favor of a standard technique because visualization of the segment to be treated may not be acceptable, such as in cases of very calcified arteries or in very obese patients in whom the arteries are >4cm deep
  • Ultrasound-guided duplex procedures on infrapopliteal arteries should be attempted only in the presence of an experienced vascular technologist and an interventionalist who is also familiar with lower extremity arterial duplexing

ICU: intensive care unit.

Source: Own elaboration based on Kithcart et al. (22), Aboyans et al. (23), Khan et al. (24), Loffroy et al. (25), Bolt et al. (26), and Ascher et al. (27).

Some studies have achieved technical success rates between 93% and 100% using DU as a guide for balloon angioplasty and stenting, with no statistically significant differences between primary and secondary occlusions. In turn, patency at one month and limb salvage rates between 95% and 100% have been reported, taking into account works mainly developed in segments of the superficial femoral artery and proximal popliteal arteries (28-30).

Consequently, ultrasound-guided therapeutic procedures have been considered as feasible, efficient and cost-effective options that allow achieving anatomical and hemodynamic improvement, regardless of the extent of the stenosis, with few limitations and with greater utility in patients allergic to the contrast medium or those with CKD or DM. In this way, the risk of renal function deterioration and the need for renal replacement therapies is reduced (31).

Conclusion

ALI and CLI are entities that can jeopardize the viability of a limb. Mechanical thrombectomy using DU-guided Rotarex® system is a viable, real and cost-effective alternative in patients with PAD, showing good short-term results. It is recommended to implement this type of strategy in order to carry out work with greater statistical power for the analysis of results and to obtain reproducible conclusions on success rates, patency, and long-term limb salvage.

Ethical considerations

Informed consent was obtained from the patients for the preparation of this case report, and the center’s protocols for the diagnosis and handling of patient data were followed for its publication.

Conflict of interest

None stated by the authors.

Funding

None stated by the authors.

Acknowledgments

To God, to our families, and to the Hospital Universitario de La Samaritana.

References

1.Fowkes FG, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermott MM, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013;382(9901):1329-40. https://doi.org/f2ggkc.

2.Hess CN, Huang Z, Patel MR, Baumgartner I, Berger JS, Blomster JI, et al. Acute limb ischemia in Peripheral Artery Disease: Insights from EUCLID. Circulation. 2019;140(7):556-65. https://doi.org/gh652.t

3.Morley RL, Sharma A, Horsch AD, Hinchliffe RJ. Peripheral artery disease. BMJ. 2018;360:j5842. https://doi.org/gf5wxp.

4.Joosten MM, Pai JK, Bertoia ML, Rimm EB, Spiegelman D, Mittleman MA, et al. Associations between conventional cardiovascular risk factors and risk of peripheral artery disease in men. JAMA. 2012;308(16):1660-7. https://doi.org/f48r7v.

5.Song P, Rudan D, Zhu Y, Fowkes FJI, Rahimi K, Fowkes FGR, et al. Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis. Lancet Glob Health. 2019;7(8):e1020-30. https://doi.org/gjvtwj.

6.Firnhaber JM, Powell CS. Lower Extremity Peripheral Artery Disease: Diagnosis and Treatment. Am Fam Physician. 2019;99(6):362-9.

7.Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(12):e686-725. https://doi.org/gf2zg2.

8.Dua A, Lee CJ. Epidemiology of peripheral arterial disease and critical limb ischemia.
Tech Vasc Interv Radiol. 2016;19(2):91-5. https://doi.org/krh3.

9.Fluck F, Augustin AM, Bley T, Kickuth R. Current Treatment Options in Acute Limb Ischemia. Rofo. 2020;192(4):319-26. https://doi.org/krh4.

10.Patel NH, Krishnamurthy VN, Kim S, Saad WE, Ganguli S, Walker TG, et al. Quality improvement guidelines for percutaneous management of acute lower-extremity ischemia. J Vasc Interv Radiol. 2013;24(1):3-15. https://doi.org/krh5.

11.Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. Eur J Vasc Endovasc Surg. 2019;58(1S):S1-S109.e33. https://doi.org/gjfjxf.

12.Bhat TM, Afari ME, García LA. Atherectomy in Peripheral Artery Disease: A Review.
J Invasive Cardiol. 2017;29(4):135-44.

13.Hiramoto JS, Teraa M, de Borst GJ, Conte MS. Interventions for lower extremity peripheral artery disease. Nat Rev Cardiol. 2018;15(6):332-50. https://doi.org/gdkg3d.

14.Sheikh AB, Anantha-Narayanan M, Smolderen KG, Jelani QU, Nagpal S, Schneider M, et al. Utility of Intravascular Ultrasound in Peripheral Vascular Interventions: Systematic Review and Meta-Analysis. Vasc Endovascular Surg. 2020;54(5):413-22. https://doi.org/gpsdpx.

15.Liu J, Li T, Huang W, Zhao N, Liu H, Zhao H, et al. Percutaneous mechanical thrombectomy using Rotarex catheter in peripheral artery occlusion diseases - Experience from a single center. Vascular. 2019;27(2):199-203. https://doi.org/gg3hnb.

16.Ascher E, Marks NA, Hingorani AP, Schutzer RW, Nahata S. Duplex-guided balloon angioplasty and subintimal dissection of infrapopliteal arteries: early results with a new approach to avoid radiation exposure and contrast material. J Vasc Surg. 2005;42(6):1114-21. https://doi.org/b2xjcw.

17.Heller S, Lubanda JC, Varejka P, Chochola M, Prochazka P, Rucka D, et al. Percutaneous mechanical thrombectomy using rotarex® S device in acute limb ischemia in infrainguinal occlusions. Biomed Res Int. 2017;2017:2362769. https://doi.org/krh6.

18.Kidney International ORG. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International Supplements. 2013;3(1).

19.Noreña-Acevedo I, Peña C, Ballén-Torres MA, Pineda-Corral MF, Aranzalez-Ramirez LH, Mockus-Sivickas IVO. Enfermedad arterial periférica y estrés oxidativo en pacientes del programa para la prevención de complicaciones de diabetes mellitus y dislipidemias. Acta Médica Colombiana. 2019;44(3). https://doi.org/krh7.

20.Urbano L, Portilla E, Muñoz W, Hofman A, Sierra-Torres CH. Prevalence and risk factors associated with peripheral arterial disease in an adult population from Colombia. Arch Cardiol Mex. 2018;88(2):107-15. https://doi.org/krh8.

21.Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FG, Gillespie I, et al. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: An intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg. 2010;51(Suppl 5):5S-17S. https://doi.org/d2z82f.

22.Kithcart AP, Beckman JA. ACC/AHA Versus ESC Guidelines for Diagnosis and Management of Peripheral Artery Disease: JACC Guideline Comparison. J Am Coll Cardiol. 2018;72(22):2789-801. https://doi.org/gn43ts.

23.Aboyans V, Ricco JB, Bartelink MEL, Björck M, Brodmann M, Cohnert T, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018;39(9):763-816. https://doi.org/gcptxh.

24.Khan S, Hawkins BM. Acute limb ischemia interventions. Interv Cardiol Clin. 2020;9(2):221-8. https://doi.org/krjb.

25.Loffroy R, Falvo N, Galland C, Fréchier L, Ledan F, Midulla M, et al. Percutaneous Rotational Mechanical Atherectomy Plus Thrombectomy Using Rotarex S Device in Patients With Acute and Subacute Lower Limb Ischemia: A Review of Safety, Efficacy, and Outcomes. Front Cardiovasc Med. 2020;7:557420. https://doi.org/krjc.

26.Bolt LJJ, Krasznai AG, Sigterman TA, Sikkink CJJM, Schurink GWH, Bouwman LH. Duplex-guided versus Conventional Percutaneous Transluminal Angioplasty of Iliac TASC II A and B Lesion: A Randomized Controlled Trial. Ann Vasc Surg. 2019;55:138-47. https://doi.org/krjd.

27.Ascher E, Marks NA, Schutzer RW, Hingorani AP. Duplex-guided balloon angioplasty and stenting for femoropopliteal arterial occlusive disease: An alternative in patients with renal insufficiency. J Vasc Surg. 2005;42(6):1108-13. https://doi.org/cbxw9x.

28.Ascher E, Marks NA, Hingorani AP, Schutzer RW, Mutyala M. Duplex-guided endovascular treatment for occlusive and stenotic lesions of the femoral-popliteal arterial segment: A comparative study in the first 253 cases. J Vasc Surg. 2006;44(6):1230-7. https://doi.org/ffpm23.

29.Pomposelli F. Arterial imaging in patients with lower extremity ischemia and diabetes mellitus. J Vasc Surg. 2010;52(Suppl 3):81S-91S. https://doi.org/bjwc62.

30.Krasznai AG, Sigterman TA, Welten RJ, Heijboer R, Sikkink CJJM, Van De Akker LHJM, et al.
Duplex-guided percutaneous transluminal angioplasty in iliac arterial occlusive disease. Eur J Vasc Endovasc Surg. 2013;46(5):583-7. https://doi.org/f5jv4d.

31.Ascher E, Gopal K, Marks N, Boniscavage P, Shiferson A, Hingorani A. Duplex-Guided Endovascular Repair of Popliteal Artery Aneurysms (PAAs): A New Approach to Avert the Use of Contrast Material and Radiation Exposure. Eur J Vasc Endovasc Surg. 2010;39(6):769-73. https://doi.org/bt25dh.

Referencias

References

Fowkes FG, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermott MM, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013;382(9901):1329-40. https://doi.org/f2ggkc. DOI: https://doi.org/10.1016/S0140-6736(13)61249-0

Hess CN, Huang Z, Patel MR, Baumgartner I, Berger JS, Blomster JI, et al. Acute limb ischemia in Peripheral Artery Disease: Insights from EUCLID. Circulation. 2019;140(7):556-65. https://doi.org/gh652.t DOI: https://doi.org/10.1161/CIRCULATIONAHA.119.039773

Morley RL, Sharma A, Horsch AD, Hinchliffe RJ. Peripheral artery disease. BMJ. 2018;360:j5842. https://doi.org/gf5wxp. DOI: https://doi.org/10.1136/bmj.j5842

Joosten MM, Pai JK, Bertoia ML, Rimm EB, Spiegelman D, Mittleman MA, et al. Associations between conventional cardiovascular risk factors and risk of peripheral artery disease in men. JAMA. 2012;308(16):1660-7. https://doi.org/f48r7v. DOI: https://doi.org/10.1001/jama.2012.13415

Song P, Rudan D, Zhu Y, Fowkes FJI, Rahimi K, Fowkes FGR, et al. Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis. Lancet Glob Health. 2019;7(8):e1020-30. https://doi.org/gjvtwj. DOI: https://doi.org/10.1016/S2214-109X(19)30255-4

Firnhaber JM, Powell CS. Lower Extremity Peripheral Artery Disease: Diagnosis and Treatment. Am Fam Physician. 2019;99(6):362-9.

Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(12):e686-725. https://doi.org/gf2zg2. DOI: https://doi.org/10.1161/CIR.0000000000000501

Dua A, Lee CJ. Epidemiology of peripheral arterial disease and critical limb ischemia. Tech Vasc Interv Radiol. 2016;19(2):91-5. https://doi.org/krh3. DOI: https://doi.org/10.1053/j.tvir.2016.04.001

Fluck F, Augustin AM, Bley T, Kickuth R. Current Treatment Options in Acute Limb Ischemia. Rofo. 2020;192(4):319-26. https://doi.org/krh4. DOI: https://doi.org/10.1055/a-0998-4204

Patel NH, Krishnamurthy VN, Kim S, Saad WE, Ganguli S, Walker TG, et al. Quality improvement guidelines for percutaneous management of acute lower-extremity ischemia. J Vasc Interv Radiol. 2013;24(1):3-15. https://doi.org/krh5. DOI: https://doi.org/10.1016/j.jvir.2012.09.026

Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. Eur J Vasc Endovasc Surg. 2019;58(1S):S1-S109.e33. https://doi.org/gjfjxf.

Bhat TM, Afari ME, García LA. Atherectomy in Peripheral Artery Disease: A Review. J Invasive Cardiol. 2017;29(4):135-44.

Hiramoto JS, Teraa M, de Borst GJ, Conte MS. Interventions for lower extremity peripheral artery disease. Nat Rev Cardiol. 2018;15(6):332-50. https://doi.org/gdkg3d. DOI: https://doi.org/10.1038/s41569-018-0005-0

Sheikh AB, Anantha-Narayanan M, Smolderen KG, Jelani QU, Nagpal S, Schneider M, et al. Utility of Intravascular Ultrasound in Peripheral Vascular Interventions: Systematic Review and Meta-Analysis. Vasc Endovascular Surg. 2020;54(5):413-22. https://doi.org/gpsdpx. DOI: https://doi.org/10.1177/1538574420920998

Liu J, Li T, Huang W, Zhao N, Liu H, Zhao H, et al. Percutaneous mechanical thrombectomy using Rotarex catheter in peripheral artery occlusion diseases - Experience from a single center. Vascular. 2019;27(2):199-203. https://doi.org/gg3hnb. DOI: https://doi.org/10.1177/1708538118813239

Ascher E, Marks NA, Hingorani AP, Schutzer RW, Nahata S. Duplex-guided balloon angioplasty and subintimal dissection of infrapopliteal arteries: early results with a new approach to avoid radiation exposure and contrast material. J Vasc Surg. 2005;42(6):1114-21. https://doi.org/b2xjcw. DOI: https://doi.org/10.1016/j.jvs.2005.08.025

Heller S, Lubanda JC, Varejka P, Chochola M, Prochazka P, Rucka D, et al. Percutaneous mechanical thrombectomy using rotarex® S device in acute limb ischemia in infrainguinal occlusions. Biomed Res Int. 2017;2017:2362769. https://doi.org/krh6. DOI: https://doi.org/10.1155/2017/2362769

Kidney International ORG. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International Supplements. 2013;3(1).

Noreña-Acevedo I, Peña C, Ballén-Torres MA, Pineda-Corral MF, Aranzalez-Ramirez LH, Mockus-Sivickas IVO. Enfermedad arterial periférica y estrés oxidativo en pacientes del programa para la prevención de complicaciones de diabetes mellitus y dislipidemias. Acta Médica Colombiana. 2019;44(3). https://doi.org/krh7. DOI: https://doi.org/10.36104/amc.2019.1257

Urbano L, Portilla E, Muñoz W, Hofman A, Sierra-Torres CH. Prevalence and risk factors associated with peripheral arterial disease in an adult population from Colombia. Arch Cardiol Mex. 2018;88(2):107-15. https://doi.org/krh8. DOI: https://doi.org/10.1016/j.acmx.2017.02.002

Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FG, Gillespie I, et al. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: An intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg. 2010;51(Suppl 5):5S-17S. https://doi.org/d2z82f. DOI: https://doi.org/10.1016/j.jvs.2010.01.073

Kithcart AP, Beckman JA. ACC/AHA Versus ESC Guidelines for Diagnosis and Management of Peripheral Artery Disease: JACC Guideline Comparison. J Am Coll Cardiol. 2018;72(22):2789-801. https://doi.org/gn43ts. DOI: https://doi.org/10.1016/j.jacc.2018.09.041

Aboyans V, Ricco JB, Bartelink MEL, Björck M, Brodmann M, Cohnert T, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018;39(9):763-816. https://doi.org/gcptxh.

Khan S, Hawkins BM. Acute limb ischemia interventions. Interv Cardiol Clin. 2020;9(2):221-8. https://doi.org/krjb. DOI: https://doi.org/10.1016/j.iccl.2019.12.002

Loffroy R, Falvo N, Galland C, Fréchier L, Ledan F, Midulla M, et al. Percutaneous Rotational Mechanical Atherectomy Plus Thrombectomy Using Rotarex S Device in Patients With Acute and Subacute Lower Limb Ischemia: A Review of Safety, Efficacy, and Outcomes. Front Cardiovasc Med. 2020;7:557420. https://doi.org/krjc. DOI: https://doi.org/10.3389/fcvm.2020.557420

Bolt LJJ, Krasznai AG, Sigterman TA, Sikkink CJJM, Schurink GWH, Bouwman LH. Duplex-guided versus Conventional Percutaneous Transluminal Angioplasty of Iliac TASC II A and B Lesion: A Randomized Controlled Trial. Ann Vasc Surg. 2019;55:138-47. https://doi.org/krjd. DOI: https://doi.org/10.1016/j.avsg.2018.07.047

Ascher E, Marks NA, Schutzer RW, Hingorani AP. Duplex-guided balloon angioplasty and stenting for femoropopliteal arterial occlusive disease: An alternative in patients with renal insufficiency. J Vasc Surg. 2005;42(6):1108-13. https://doi.org/cbxw9x. DOI: https://doi.org/10.1016/j.jvs.2005.08.024

Ascher E, Marks NA, Hingorani AP, Schutzer RW, Mutyala M. Duplex-guided endovascular treatment for occlusive and stenotic lesions of the femoral-popliteal arterial segment: A comparative study in the first 253 cases. J Vasc Surg. 2006;44(6):1230-7. https://doi.org/ffpm23. DOI: https://doi.org/10.1016/j.jvs.2006.08.025

Pomposelli F. Arterial imaging in patients with lower extremity ischemia and diabetes mellitus. J Vasc Surg. 2010;52(Suppl 3):81S-91S. https://doi.org/bjwc62. DOI: https://doi.org/10.1016/j.jvs.2010.06.013

Krasznai AG, Sigterman TA, Welten RJ, Heijboer R, Sikkink CJJM, Van De Akker LHJM, et al. Duplex-guided percutaneous transluminal angioplasty in iliac arterial occlusive disease. Eur J Vasc Endovasc Surg. 2013;46(5):583-7. https://doi.org/f5jv4d. DOI: https://doi.org/10.1016/j.ejvs.2013.08.011

Ascher E, Gopal K, Marks N, Boniscavage P, Shiferson A, Hingorani A. Duplex-Guided Endovascular Repair of Popliteal Artery Aneurysms (PAAs): A New Approach to Avert the Use of Contrast Material and Radiation Exposure. Eur J Vasc Endovasc Surg. 2010;39(6):769-73. https://doi.org/bt25dh. DOI: https://doi.org/10.1016/j.ejvs.2010.02.010

Cómo citar

APA

Sendoya , J. D., Gómez, J. E., Conrado-Jiménez, H. y Bautista, A. M. (2023). Trombectomía endovascular ecoguiada como alternativa en el manejo de la enfermedad arterial periférica. Reporte de dos casos. Case reports, 9(2). https://doi.org/10.15446/cr.v9n2.98547

ACM

[1]
Sendoya , J.D., Gómez, J.E., Conrado-Jiménez, H. y Bautista, A.M. 2023. Trombectomía endovascular ecoguiada como alternativa en el manejo de la enfermedad arterial periférica. Reporte de dos casos. Case reports. 9, 2 (oct. 2023). DOI:https://doi.org/10.15446/cr.v9n2.98547.

ACS

(1)
Sendoya , J. D.; Gómez, J. E.; Conrado-Jiménez, H.; Bautista, A. M. Trombectomía endovascular ecoguiada como alternativa en el manejo de la enfermedad arterial periférica. Reporte de dos casos. Case reports 2023, 9.

ABNT

SENDOYA , J. D.; GÓMEZ, J. E.; CONRADO-JIMÉNEZ, H.; BAUTISTA, A. M. Trombectomía endovascular ecoguiada como alternativa en el manejo de la enfermedad arterial periférica. Reporte de dos casos. Case reports, [S. l.], v. 9, n. 2, 2023. DOI: 10.15446/cr.v9n2.98547. Disponível em: https://revistas.unal.edu.co/index.php/care/article/view/98547. Acesso em: 11 feb. 2025.

Chicago

Sendoya , Jesus David, Jaime Enrique Gómez, Héctor Conrado-Jiménez, y Ana María Bautista. 2023. «Trombectomía endovascular ecoguiada como alternativa en el manejo de la enfermedad arterial periférica. Reporte de dos casos». Case Reports 9 (2). https://doi.org/10.15446/cr.v9n2.98547.

Harvard

Sendoya , J. D., Gómez, J. E., Conrado-Jiménez, H. y Bautista, A. M. (2023) «Trombectomía endovascular ecoguiada como alternativa en el manejo de la enfermedad arterial periférica. Reporte de dos casos», Case reports, 9(2). doi: 10.15446/cr.v9n2.98547.

IEEE

[1]
J. D. Sendoya, J. E. Gómez, H. Conrado-Jiménez, y A. M. Bautista, «Trombectomía endovascular ecoguiada como alternativa en el manejo de la enfermedad arterial periférica. Reporte de dos casos», Case reports, vol. 9, n.º 2, oct. 2023.

MLA

Sendoya , J. D., J. E. Gómez, H. Conrado-Jiménez, y A. M. Bautista. «Trombectomía endovascular ecoguiada como alternativa en el manejo de la enfermedad arterial periférica. Reporte de dos casos». Case reports, vol. 9, n.º 2, octubre de 2023, doi:10.15446/cr.v9n2.98547.

Turabian

Sendoya , Jesus David, Jaime Enrique Gómez, Héctor Conrado-Jiménez, y Ana María Bautista. «Trombectomía endovascular ecoguiada como alternativa en el manejo de la enfermedad arterial periférica. Reporte de dos casos». Case reports 9, no. 2 (octubre 10, 2023). Accedido febrero 11, 2025. https://revistas.unal.edu.co/index.php/care/article/view/98547.

Vancouver

1.
Sendoya JD, Gómez JE, Conrado-Jiménez H, Bautista AM. Trombectomía endovascular ecoguiada como alternativa en el manejo de la enfermedad arterial periférica. Reporte de dos casos. Case reports [Internet]. 10 de octubre de 2023 [citado 11 de febrero de 2025];9(2). Disponible en: https://revistas.unal.edu.co/index.php/care/article/view/98547

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