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Intravascular Hemolysis Following Peripheral Atherectomy with the Pathway Jetstream Catheter
Abstract
Intravascular hemolysis has been reported with a variety of atherectomy devices. We report a case of hemolysis after the use of the rotational aspiration Pathway Jetstream® catheter in the treatment of severe superficial femoral artery stenosis.
Key words: atherectomy, peripheral vascular disease
VASCULAR DISEASE MANAGEMENT 2010;7:E110–E111
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Case Presentation
We describe a 77-year-old female ex-smoker with a known past medical history of stable coronary artery disease (CAD), diabetes mellitus, hypertension, dyslipidemia and mild carotid disease who presented with gradual worsening of left calf pain over a 2-week period. Her history was notable for extensive symptomatic peripheral arterial disease requiring revascularization (Rutherford Category 3, ankle-brachial index [ABI] of 0.65). Her initial peripheral intervention consisted of percutaneous transluminal angioplasty and stenting of a long total occlusion of the left superficial femoral artery (SFA). The total occlusion started at the mid SFA and spanned a length of 150 mm, demonstrating reconstitution at the distal SFA level. The iliac artery system was patent, and there was 2-vessel runoff below the knee. Following the procedure, she became a Rutherford Category 1, with improvement in the ABI to 1.04. Seven months thereafter, she presented with progressively worsening left lower extremity claudication (Rutherford Category 3, ABI 0.68). Physical examination did not reveal any skin changes or wounds, but the left dorsalis pedis and posterior tibialis pulses were faint. Arterial duplex studies showed multiple hemodynamically significant stenoses within the left SFA stents with peak systolic velocities approaching 430 cm/sec. After discussion with the patient regarding treatment options, the decision was made to undergo repeat percutaneous intervention. Angiography revealed a severe de novo lesion at the ostium of the left SFA, multiple areas of severe in-stent restenosis of the mid SFA and a subtotal in-stent restenosis within the distal SFA segment (Figure 1A). The total length of the diseased segment was 280 mm. Two-vessel runoff was observed.
Procedure. Access was obtained via the right common femoral artery using a 7 Fr 45 cm crossover sheath. The SFA lesions were crossed with a 0.014 inch x 300 cm guidewire supported by a 0.018 inch x 90 cm support catheter. Rotational atherectomy of the ostial SFA and the entire SFA in-stent restenosis was performed using the Pathway Jetstream® revascularization catheter (Pathway Medical Technologies, Inc., Kirkland, Washington) (Figure 1B). Three runs were performed using the 2.1 mm profile for a total of 5.5 minutes followed by three additional runs using the 3.0 mm profile for 6.2 minutes. Excellent luminal gain was noted in the mid-distal SFA in-stent restenosis segments with less than 20% residual stenosis (Figure 1C). No dissection was observed.
Post-procedure course. The intervention was completed uneventfully. During the routine post-procedure monitoring, the patient was noted to have dark-brown urine. A urinalysis revealed large hemoglobinuria and absent red blood cells. A peripheral blood sample was analyzed for markers of intravascular hemolysis showing a rise in the lactate dehydrogenase (LDH) from baseline 1,155–2751 U/L (reference range: 313–618 U/L) along with a low haptoglobin (Discussion Currently, a variety of percutaneous treatment modalities are available to address peripheral arterial occlusive disease. Aside from conventional percutaneous transluminal angioplasty and stent implantation, there has been a resurgence of interest in plaque debulking technologies.1,2 As such, there are several different types of atherectomy devices that have been added to the current armamentarium, including directional atherectomy (SilverHawk®, ev3, Inc., Minneapolis, Minnesota), orbital atherectomy (DiamondBack 360®, CSI, Minneapolis, Minnesota) and rotational atherectomy (Pathway Jetstream®, PMT, Inc., Kirkland, Washington). The newest rotational aspiration atherectomy system (Pathway Medical PV device) uses expandable, rotating scraping blades (“flutes”) at a speed of 60,000 rpm. Aspiration ports located just proximal to the flutes enable active aspiration of fluid and debris, thus theoretically minimizing the risk of distal embolization. To date, there have been only two pilot studies reporting on the efficacy and safety of this device. In 15 femoral-popliteal lesions, Zeller et al reported a technical success rate of 100% and a 6-month primary patency of 73%. They reported 3 adverse events including perforation, false aneurysm, dissection and distal embolism.3
In another report of 23 femoral-popliteal lesions, Wissgott et al demonstrated a technical success rate of 100% and a 6-month primary patency rate of 92%. They described 2 complications including dissection and distal embolization.4 This is the first report to document the occurrence of intravascular hemolysis following the use of the Pathway Jetstream rotational aspiration atherectomy device. There were no clinical sequelae in this case. There have been multiple reports of hemolysis occurring following atherectomy with the use of other devices. Peripheral rotational atherectomy treatment has been associated with a 5–13% incidence of hemoglobinuria in multiple studies of patients undergoing femoral-popliteal interventions.5,6 In these studies, the severity of hemolysis correlated with the ablation time, size of burr and the length of treated lesion. In addition, there has been a case report of orbital atherectomy leading to hemolysis-induced pancreatitis.7 Rheolytic thrombectomy in the pulmonary and hepatic vascular beds has also been linked to intravascular hemolysis.8,9 The process by which hemolysis occurs in rotational atherectomy is likely through a non-immune-mediated mechanical destruction of circulating red blood cells. Several mechanisms have been postulated linking intravascular hemolysis to its potential clinical consequences of renal failure and pancreatitis, mostly involving the oxidative stress caused by the release of heme protein.9 While there are a number of ways the body safeguards against the proinflammatory effects of hemoglobin byproducts, marked hemolysis may overwhelm these protective mechanisms. Nitric oxide has been observed to neutralize the oxidative stress imposed by free hemoglobin; however, this scavenging process results in rapid depletion of nitric oxide, resulting in endothelial dysfunction with consequent vasoconstriction.10 Nevertheless, this process appears to be short-lived as recent work focusing on the clinical implications of intravascular hemolysis resulting from orbital atherectomy has shown a rapid peak and fast clearance of plasma-free hemoglobin within 24 hours post intervention.
In conclusion, this report raises the awareness of the possibility of intravascular hemolysis with this newer rotational atherectomy device. Given the potential deleterious effects of plasma-free hemoglobin, one should be diligent in taking measures to limit red blood cell destruction. Intuitively, shortening the atherectomy time and implementing sufficient hydration protocols should limit the potential clinical consequences of intravascular hemolysis. Larger, prospective studies should be designed to further understand the predisposing factors to hemolysis and the measures required to limit its impact.
References
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From the Cardiovascular Department, Saint Vincent’s Medical Center of New York, New York. The authors report no conflicts of interest regarding the content herein. Address for correspondence: Cezar S. Staniloae, MD, Cardiovascular Department, Saint Vincent’s Hospital Manhattan, New York, NY 10011. E-mail: cstaniloae@aol.com
