Case Study: Next-Generation Lightning Flash 3.0 Efficiently Clears Right-Sided PE and Lower Extremity Venous Thrombus

Dr. Clay Wiske, MD, a vascular surgeon at Stanford Health in Pleasanton, California, shares a case in which he used the Lightning Flash^® 3.0 to remove thrombus from a female patient in her early 70s suffering from a pulmonary embolism (PE). Dr. Wiske then used the same device to successfully restore patency to the left iliac vein.

The latest Lightning Flash 3.0 technology includes upgrades designed to increase clot removal speed and fluid savings. The trackability of Penumbra’s comprehensive VTE platform facilitated efficient navigation to the right pulmonary artery as well as seamless access up-and-over the iliocaval confluence. This up-and-over approach provides the ability to remove thrombus present in the inflow vessels, helping to positively impact long-term patency. Additionally, this system successfully delivered clot removal therapy in a patient with active cancer, an often underserved population from a thrombectomy standpoint. Dr. Wiske’s case, below, was originally published in Endovascular Today.

Patient Presentation

A woman in her early 70s with a relevant history of uterine carcinoma on immunotherapy with left iliac vein compression presented to the emergency depart¬ment with shortness of breath and severe pain, swell¬ing, discoloration, and numbness of the left leg. She was progressively hypoxic and hypotensive and was intubated and started on multiple pressors.

A CT scan demonstrated thrombus in the right pul¬monary artery (PA) and extensive thrombus of the left lower extremity extending from the compressed left iliac vein inferiorly throughout the left lower extremity venous system. Her physical examination was consistent with phlegmasia with high-resistance signals in the left foot compared to palpable pulses in the right foot.

The patient’s family felt that it would be consistent with the patient’s wishes to proceed with intervention. We discussed interventions for both the PE and the acutely threatened left lower extremity.

Given the concern for massive PE, as well as an acutely threatened limb, an approach was taken that would provide the best probability of survival and thus the best probability of rapidly addressing the right PA thrombus. As a secondary goal, because the left leg was acutely threatened, an approach that would potentially facilitate left leg thrombectomy in a rapid fashion was favored.

Intervention

Bilateral common femoral vein access was obtained. The right-sided access was primarily used to facilitate thrombectomy, and the left-sided access was obtained to provide a rail for up-and-over sheath and catheter advancement in anticipation of potential lower extremity thrombectomy. A 17-F, 65-cm Element™ sheath was advanced into the right PA, and a right-sided thrombus affecting multiple segmental branches was identified. The 16-F Lightning Flash 3.0 catheter was advanced over a Rosen wire into the right PA, and aspiration was turned on; near-immediate evacuation of the target thrombus was achieved and confirmed by follow-up angiography. Following successful pulmonary thrombectomy, a decrease in PA pressure was noted.