The usefulness of the Rotarex thrombectomy system in the recanalization of an occluded covered stent in patients after cavo-pulmonary (Glenn) shunt

摘要

The present report describes a novel approach to in-stent thrombosis in the left pulmonary artery treated with the Rotarex thrombectomy system in patients with single ventricle anatomy after cavo-pulmonary (Glenn) shunt. We report a case of a 13-year-old girl with single ventricle anatomy (a double outlet right ventricle with a hypoplastic left ventricle) after cavo-pulmonary (Glenn) shunt, who was referred to our hospital with deteriorating exercise capacity and low arterial oxygen saturation (75%). Cardiac catheterization was performed and angiography demonstrated left pulmonary artery stenosis with significant antegrade pulmonary flow from a single ventricle (Figure 1 A). A 12 Fr Mullins long sheath was introduced and a covered stent (CP 8ZIG 45 mm, NuMED) mounted on a 14 mm diameter BiB balloon (NuMED) was implanted in the middle portion of the left pulmonary artery, and thus the antegrade pulmonary flow was closed and the pulmonary stenosis was resolved (Figure 1 B). Standard anti-platelet therapy with acetylsalicylic acid was introduced and the patient was discharged 6 days later. The patient was considered as a candidate for a Fontan operation and the next cardiac catheterization was planned in 6 months. Three months later the patient was admitted to our hospital again with signs of progressive cyanosis (arterial oxygen saturation: 65%). Urgent cardiac catheterization was performed and angiography demonstrated an occlusion of the previously implanted stent in the left pulmonary artery (Figure 1 C). Conservative medical management with heparin was administered. After 1 week of therapy, no clinical evidence of improvement had occurred. Because the patient was considered a poor surgical candidate due to numerous previous sternotomies, the decision to recanalize the left pulmonary artery with the Rotarex (Straub Medical) thrombectomy system was made. The occluded vessel was crossed through with a 0.014?? Asato guidewire (Asahi Intecc) and a 4 Fr vertebral catheter. Multiple passes through the thrombus were made with different catheters and guidewires; thus partial mechanical fragmentation of the thrombus was performed. An 8 Fr Rotarex catheter was advanced and multiple blood clots were aspirated and removed. Subsequently, an 18-mm diameter Atlas Gold balloon (Bard Medical) was inserted and inflated. Control angiography showed complete recanalization of the left pulmonary artery, but inside its branches thrombi were still...