Abstract 1122‐000212: INARI FlowTriever system: First Endovascular Clinical Experience to Treat Diffuse Cerebral Venous Sinus Thrombosis

Introduction : Cerebral Venous Sinus Thrombosis (CVST) is a rare stroke with a wide range of symptomatology at presentation ranging from headache, focal weakness, and coma. Anticoagulation remains the mainstay of treatment. However, in a subset of patients endovascular treatment can be potentially beneficial. Here we describe the first clinical experience using the INARI FlowTriever system to treat a patient presented with focal weakness and found to have diffuse cerebral venous sinus thrombosis. Methods : Case report of CSVT treated with INARI FlowTriever system. Results : A 78‐year‐old female with past medical history of Autoimmune hepatitis and hypothyroidism, was brought to the hospital with left arm weakness. CT head revealed left temporoparietal intraparenchymal hemorrhage and right frontal subarachnoid hemorrhage. CTA of the head and neck revealed extensive CVST involving superior sagittal sinus, bilateral transverse and sigmoid sinuses. She was started on heparin drip. Patient was taken for venous thrombectomy due to persistent left‐sided weakness and multicompartment bleeding while being on anticoagulation for 48 hours. She underwent successful endovascular venous thrombectomy using the INARI FlowTriever system with large clot burden extracted. She was switched to novel oral anticoagulation prior to discharge. During the 3 months follow‐up–MRI brain with and without contrast revealed near complete resolution of the clot burden in the superior sagittal sinus and left transverse/sigmoid complex and her modified Rankin score was at 0. Conclusions : Here we discussed a case of diffuse CVST who was treated initially with heparin drip then underwent endovascular venous thrombectomy using INARI FlowTriever system with large clot burden aspirated with a reasonable safety profile. The INARI medical FlowTriever system is the only mechanical thrombectomy system indicated for the treatment of pulmonary embolism. It is specifically designed for venous clots. It is composed of a trackable large bore aspiration catheter. The INARI FlowTriever Catheter; has 3 expanding nitinol mesh disks; designed to engage and disrupt venous clots and subsequently deliver it to the large bore aspiration catheter. Its larger size makes it an attractive candidate for venous sinus clot retrieval. This study illustrates the first clinical use of INARI thrombectomy device in CVST with a reasonable safety profile. Anticoagulation is the mainstay first line treatment for CVST. However, a small subset of patients would potentially benefit from endovascular treatment but it still uncertain how to select these patients and what is the best timeline to offer early endovascular treatment. Various neuro endovascular techniques has been attempted to treat cerebral venous sinus thrombosis. However; it is unclear which approach and device provides the optimal restoration of venous blood flow. Current neuro endovascular techniques and devices are not particularly designed for CVST pathology treatment and there is need for further innovation and new devices.

Phlegmasia Cerulea Dolens: A Life- and Limb-threatening Disease

Phlegmasia cerulea dolens (PCD) is a rare syndrome caused by venous thrombosis and characterised by a triad of limb oedema, cyanosis and pain. It requires early recognition as delay of treatment can cause gangrene, limb amputation and in extreme cases, death. A 67- year-old Chinese lady, with underlying hypertension, diabetes mellitus and dyslipidaemia presented to the emergency department with a 2 days history of pain, oedema and bluish discoloration over the entire left leg. She had a history of fall 6 months prior and since then she used a walking stick for mobilization. This patient underwent ultrasound doppler left lower limb , which showed features suggestive of long-segment left lower limb deep vein thrombosis. A diagnosis of PCD was made. Subsequently, she went for a CT angiogram and venography of the left lower limb which confirmed thrombosis of the left calf vein extending to the long segment of the left common iliac vein. She was commenced on intravenous heparin infusion and then underwent inferior vena cava filter insertion and catheter directed thrombolysis. Repeat venogram showed successful catheter directed thrombolysis of the left lower limb deep venous thrombosis (DVT). Treatment should be initiated as soon as the diagnosis of PCD is suspected. Currently, guidelines for treatment are lacking however 3 therapeutic options are advocated alone or in combination: anticoagulants, thrombolytic therapy, and venous thrombectomy. An early recognition of PCD and appropriate decision regarding the treatment is essential to preserve the limb.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S16

Percutaneous thrombectomy using a novel single session device for acute iliofemoral deep vein thrombosis

Summary: A 74-year-old woman presented with acute symptomatic left thigh and calf swelling; imaging demonstrated evidence of occlusive thrombosis from the upper left common iliac vein to the mid-thigh. Single session zero-thrombolysis venous thrombectomy was performed using the ReVeneTM Thrombectomy Catheter.

Oncological outcomes of primary renal malignancies other than clear cell renal carcinoma: A retrospective study from a tertiary center

IntroductionA lot of research is available about clear cell renal carcinomas (ccRCC). But there are lesser known facts about other subtypes of renal malignancies. With advances in immunohistochemical and cytogenetic techniques, new variants of renal tumors are being increasingly reported. The treatment and prognosis of such rare malignancies is still an enigma. We performed this study to analyze the incidence, clinico-pathological features, surgical treatment, and survival of non-clear cell RCC at our institution.Materials and MethodsThe histopathological reports of 77 Nephrectomy specimens who underwent surgical treatment for suspected renal tumors from 2013-2018 were retrospectively reviewed. 19 (24%) of patients had documented uncommon histologic variants of RCC. The clinical, demographic, and histologic characteristics of these patients were analyzed, and survival was evaluated. The characteristic light microscopy and immunohistochemical features of these lesions were documented.ResultsMean age was 45 years (21-67 years). Out of 19 patients, 14 (73.6%) were males, and 5 (26.4%) were females. Mean tumor size was 12 (6-31) cm in the largest dimension. 17 (22%) patients underwent radical nephrectomy, and 2 (2.5%) were treated with partial nephrectomy. Patients with collecting duct, synovial sarcoma, and primitive neuro-ectodermal tumor (PNET) had associated inferior vena caval thrombus and underwent venous thrombectomy. Adjuvant treatment in the form of chemotherapy was instituted in collecting duct, adult Wilms and pure sarcomas. There was no mortality in the papillary carcinoma, and the worst prognosis was encountered inConclusionSarcomatoid and collecting duct variants were associated with worse prognosis. Presently, aggressive surgical extirpation is the mainstay in the management of these histologic variants. Adjuvant chemotherapy and TKI inhibitors have a limited role.

Multimodal approach of venous recanalization in patients with a critical limb ischemia due to phlegmasia cerulea dolens: A case series of 17 patients in a single center

Objectives Advanced phlegmasia cerulea dolens can be a hazardous complication of a deep vein thrombosis and rapid recanalization of the deep venous system is the most important factor. Method We describe the outcome of 17 patients with critical limb ischemia due to an advanced phlegmasia cerulea dolens. Venous thrombectomy was performed by a standardized operating procedure. Results Venous recanalization was successful in all patients. An additional fasciotomy was not necessary. There were five patients with an underlying malignancy and eight patients with a simultaneous pulmonary embolism. We had one amputation of a forefoot and one death within 30 days representing a 30-day mortality and an amputation rate of 6%. Conclusions Early recanalization and recovery of the venous outflow is mandatory for success. A multimodal therapeutic approach of high urgency surgical thrombectomy in combination with endovenous strategies could be a successful treatment option for advanced phlegmasia cerulea dolens.