Letter to the Editor
Acute haemolytic pancreatitis and hepatitis secondary to percutaneous pharmacomechanical thrombectomy of prosthetic vascular access for haemodialysis
Pancreatitis y hepatitis agudas por hemólisis secundaria a trombectomía farmacomecánica percutánea de acceso vascular protésico para hemodiálisis
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(A) Doppler ultrasound showing intravascular echogenicity in relation to graft thrombosis. (B) Post-thrombectomy angiography performed from the arterial end of the loop, demonstrating permeability of the graft.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Percutaneous pharmacomechanical thrombectomy is a useful treatment in the management of arterial and deep vein thrombosis, as well as in thrombosed vascular grafts for haemodialysis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> The AngioJet<span class="elsevierStyleSup">®</span> system fragments and extracts the thrombus combining pharmacological thrombolysis through infusion of a thrombolytic agent instead of occlusion with mechanical thrombectomy using hydrodynamic technology. The catheter applies a high-pressure jet of saline solution which creates a localised area of low pressure at the tip, generating a Venturi (vacuum) effect which enables thrombus fragmentation and aspiration. In the field of Nephrology, it is one of the possible therapeutic indications in vascular access thrombosis. In general, this technique is well tolerated, with a low rate of complications. The most common are vessel dissection and perforation, distal embolisation, cardiac arrhythmias, haemolysis with subsequent myoglobinuria and acute renal failure.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,3</span></a> Some cases of pancreatitis have also been reported.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 79-year-old male with chronic kidney disease (CKD) secondary to nephroangiosclerosis and diabetic nephropathy who has been on a haemodialysis programme since 2016. A loop-type left forearm humerocephalic prosthesis was used as vascular access, performed in July 2016. Subsequently, he had two episodes of juxta-anastomotic venous stenoses resolved using balloon angioplasty, and in June 2017 he presented complete thrombosis treated with thrombolysis using AngioJet<span class="elsevierStyleSup">®</span>, with no complications. In August 2017, he attended dialysis with thrombosis of the graft documented by Doppler ultrasonography (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Thrombectomy was performed using AngioJet<span class="elsevierStyleSup">®</span>, which was carried out with no immediate complications and with a good morphological and haemodynamic result (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Then, 1<span class="elsevierStyleHsp" style=""></span>h later, 60<span class="elsevierStyleHsp" style=""></span>min of dialysis was scheduled through prosthetic repair, which took place without incidents. Thirty minutes after finishing the session, the patient reported nausea, numbness of the tongue and dyspnoea. Methylprednisolone was administered, with no improvement in the symptoms. Subsequently, he presented with a fever (38.5<span class="elsevierStyleHsp" style=""></span>°C), hypertensive crisis (240/120<span class="elsevierStyleHsp" style=""></span>mmHg) and oxygen desaturation of down to 65%. Hyperlactacidaemia and neutrophilic leukocytosis were observed in the initial analysis. He was therefore monitored and empirical antibiotic therapy with vancomycin and meropenem was started. Twelve hours later, the patient was asymptomatic and stable, jaundice was observed and lab tests revealed hyperbilirubinaemia, hypertransaminasaemia and increased pancreatic amylase and lipase, together with increased lactate dehydrogenase and decreased haptoglobin (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In view of these findings, the patient was diagnosed of acute haemolysis secondary to AngioJet<span class="elsevierStyleSup">®</span> thrombectomy with hepatopancreatic involvement. Since the patient had no other predisposing factors (such as history of biliary lithiasis, previous pancreatitis or alcohol consumption), it was analysed in the context of a pancreatic reaction secondary to haemolysis. The patient remained afebrile with bowel resting for three days, with signs of gradual improvement, and was discharged six days after the onset of symptoms.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Intravascular haemolysis after pharmacomechanical thrombectomy has been attributed to entrapment and selective destruction of the thrombus by hydraulic recirculation through a high-speed retrograde current produced by the high-pressure output of saline. This current of fluid generates a pressure gradient that traps, dissolves and evacuates the thrombus by aspiration, causing red blood cell trauma and subsequent haemolysis. Pancreatitis secondary to haemolysis of various causes is well known, although its physiopathology is not so well understood.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> There is evidence from animal models that a released heme group may promote the activation of neutrophils (with proteolytic and oxidative potential), regulates the activation of alpha-2-macroglobulin (as an acute-phase reactant) and promotes the intravascular coagulation and generation of oxygen-free radicals in the microvasculature of the pancreas. All of these are mechanisms proposed for the pancreatic lesion.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> The risk of haemolysis is probably related to several factors, including the size of the thrombus, the blood flow within the vessel and the duration of the procedure. In the literature, there are 10 cases of pancreatitis after AngioJet<span class="elsevierStyleSup">®</span> thrombectomy,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,6–9</span></a> and only one case of trombectomy of a vascular prosthesis for haemodialysis.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> Symptoms may develop during the first 24<span class="elsevierStyleHsp" style=""></span>h or even after 4 days of the procedure. Progression was favourable in all cases and most of them only received conservative treatment. In our case, in addition to the pancreatic reaction, we observed acute hepatitis associated with intravascular haemolysis, which could be explained by the same pathophysiological mechanism. This is therefore the first case in the literature of hepatitis associated with haemolysis due to thrombectomy.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Percutaneous pharmacomechanical thrombectomy using AngioJet<span class="elsevierStyleSup">®</span> is a useful procedure to rescue thrombosed vascular access grafts, increasing their survival. However, it is not a risk-free technique. Although haemolytic pancreatitis is a rare adverse effect, it may be severe so the nephrologist must be alert about this possible complication.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Urdaneta J, Arroyo D, Mon C, Abadal J, Gálvez E, Ortiz M, et al. Pancreatitis y hepatitis agudas por hemólisis secundaria a trombectomía farmacomecánica percutánea de acceso vascular protésico para hemodiálisis. Nefrologia. 2019;39:104–105.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 568 "Ancho" => 1667 "Tamanyo" => 70618 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Loop-type left forearm humerocephalic prosthesis. (A) Doppler ultrasound showing intravascular echogenicity in relation to graft thrombosis. (B) Post-thrombectomy angiography performed from the arterial end of the loop, demonstrating permeability of the graft.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">ALT: alanine aminotransferase; AST: aspartate aminotransferase; LDH: lactate dehydrogenase.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Reference ranges:</span> haemoglobin, 13.0–18.0; LDH, 135–225; haptoglobin, 30–200; amylase, 25–100; lipase, 0–60; AST, 0–40; ALT, 0–41; total bilirubin, 0.0–1.2; indirect bilirubin, 0.0–0.9; direct bilirubin, 0.0–0.4.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time after thrombectomy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1 day \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2 days \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">5 days \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">8 days \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">12 days \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemoglobin (g/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LDH (IU/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3109 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">992 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">439 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">288 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">219 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haptoglobin (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">103 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><6.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">135 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">147 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Amylase (IU/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1625 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1493 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">140 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">203 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">186 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lipase (IU/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">137 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AST (IU/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1576 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">347 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ALT (IU/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1095 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">633 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">131 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total bilirubin (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Indirect bilirubin (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Direct bilirubin (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1978509.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Progression of analytical parameters after the procedure.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison of the angiojet rheolytic catheter to surgical thrombectomy for the treatment of thrombosed hemodialysis grafts. 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| Year/Month | Html | Total | |
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| 2021 August | 43 | 44 | 87 |
| 2021 July | 47 | 28 | 75 |
| 2021 June | 19 | 17 | 36 |
| 2021 May | 60 | 43 | 103 |
| 2021 April | 52 | 44 | 96 |
| 2021 March | 35 | 45 | 80 |
| 2021 February | 52 | 42 | 94 |
| 2021 January | 28 | 16 | 44 |
| 2020 December | 20 | 16 | 36 |
| 2020 November | 18 | 14 | 32 |
| 2020 October | 32 | 21 | 53 |
| 2020 September | 24 | 12 | 36 |
| 2020 August | 25 | 12 | 37 |
| 2020 July | 61 | 11 | 72 |
| 2020 June | 27 | 9 | 36 |
| 2020 May | 26 | 8 | 34 |
| 2020 April | 23 | 15 | 38 |
| 2020 March | 21 | 11 | 32 |
| 2020 February | 36 | 18 | 54 |
| 2020 January | 27 | 24 | 51 |
| 2019 December | 21 | 14 | 35 |
| 2019 November | 17 | 16 | 33 |
| 2019 October | 16 | 16 | 32 |
| 2019 September | 23 | 19 | 42 |
| 2019 August | 21 | 16 | 37 |
| 2019 July | 24 | 24 | 48 |
| 2019 June | 23 | 20 | 43 |
| 2019 May | 27 | 38 | 65 |
| 2019 April | 59 | 52 | 111 |
| 2019 March | 18 | 25 | 43 |
| 2019 February | 18 | 4 | 22 |
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