Wednesday, December 23, 2009

Angiojet as a Cause of AKI??


The Angiojet Rheolytic Thrombectomy System is a medical device currently used to re-establish blood flow in a variety of settings. Briefly, a catheter is introduced into an area of thrombosis and a saline stream is directed towards the thrombus of interest. These saline jets generate a localized low pressure zone via the Bernoulli principle, leading to breaking up of the thrombus. The saline and clot particles are then sucked back into the catheter, avoiding potential embolic complications.

Angiojet has been primarily used for removing thrombus from arteries--for example, in acute myocardial infarction or acute graft thrombosis, for instance. It's also been useful in restoring flow in some dialysis accesses. More recently, however, efforts to use Angiojet in the treatment of venous clots--such as DVT or pulmonary emboli--have been attempted.

At a recent Renal Grand Rounds, one of the fellows presented an interesting case of a patient who developed acute renal failure shortly after undergoing attempted Angiojet therapy for a pulmonary embolus. In addition to a rising creatinine and oliguria, the patient developed red, heme-positive urine with only a few red blood cells, and labs reflecting intravascular hemolysis. Although it is not yet rigorously defined as a cause of acute renal failure, others have reported an association between Angiojet and AKI. It is possible that the Angiojet procedure is more likely to result in hemolysis if thrombectomy is attempted in a large, open space (e.g., for treatment of DVT/PE in a larger vein), as there have generally not been such complications when Angiojet has been used in restoring flow to arteries where the area of thrombus is relatively localized.

It will be interesting to see if there are further reports of this type of AKI with Angiojet.  I purposely put TWO questions marks in the title since I fully admit that much more work needs to be done in order to actually prove causality.  

8 comments:

Amanda said...

I have seen two cases of olguric, anuric AKI with hemolysis, pigment injury due to angiojet... This is just within 6 months of going into private practice, right out of fellowship training. I never saw it as a fellow... but it is real

KDJ said...

Very interesting stuff.
I haven't seen a case yet but will keep an eye for it given this information.

nathanhellman said...

Interesting that others have reported cases of this as well. As far as I know, nobody has yet written a definitive case series describing Angiojet-AKI.

LJB said...

two patients in 2 months with AKI 2/2 hemolysis/pigment injury 2/2 angiojet thrombus removal

Anonymous said...

I'm a vascular doc who had a case of phlegmasia dolens with IVC and bilateral leg dvt partially treated with angiojet. The patient became anuric immediately and remains anephric with echogenic kidneys and normal vascularity now 14 days post-procedure. Has anybody seen this and what is the chance of recovery.
The patient is a 30 year old with previous normal kidneys.

nathanhellman said...

Regarding the vascular patient mentioned: usually echogenic kidneys are indicative of at least some element of chronic renal damage...so while the patient may have had "previously normal kidneys" based on a serum creatinine level, there's a decent chance there was some underlying dysfunction beforehand. I'm not sure what the chance of recovery would be. It would be interesting to know if the patient had a workup that included labs for intravascular hemolysis to see if the mechanism of his or her renal injury is the same as that purported for Angiojet.

Anonymous said...

Article is free--

Nat Clin Pract Nephrol. 2009 Feb;5(2):112-6. Epub 2008 Dec 17.
Acute kidney injury caused by intravascular hemolysis after mechanical thrombectomy.

Dukkipati R, Yang EH, Adler S, Vintch J.

David Geffen School of Medicine at UCLA, Interventional Nephrology, Harbor-UCLA Medical Center, Torrance, CA 90502, USA. ramdukkipati@gmail.com

BACKGROUND: A 43-year-old African-American female (gravida 5 para 0) with an 8-week intrauterine pregnancy presented to the emergency room with crampy abdominal pain, shortness of breath, and shoulder pain. She had normal renal function on admission. CT angiography of the chest revealed bilateral pulmonary emboli; therefore, the AngioJet (Possis Medical, Inc., Minneapolis, MN) device was used to perform mechanical thrombolysis. The patient subsequently developed hyperkalemia, red urine and anuria. INVESTIGATIONS: Physical examination, measurement of serum creatinine level and electrolytes, dipstick urinalysis and centrifugation of urine and blood. DIAGNOSIS: Acute kidney injury due to hemoglobinuria as a result of non-immune-mediated intravascular hemolysis following the use of a percutaneous mechanical thrombectomy device (AngioJet). MANAGEMENT: Hydration, alkalinization of urine and initiation of hemodialysis (temporarily switched to continuous venovenous hemodiafiltration). Urine output improved after the 20th day of hospitalization, at which point dialysis was discontinued. The patient's renal function completely recovered by day 25.

PMID: 19092794 [PubMed - indexed for MEDLINE]

Anonymous said...

Where these procedures performed with-in the products recomended run times?