Acute strokes have a huge impact on the morbidity and mortality of the world population. But medical advancements are now better able to treat major strokes than ever before. One such advancement is thrombectomy, a surgical procedure often used in conjunction with drug therapy to improve outcomes for those who suffer a severe stroke. Thrombectomy can treat the most severe cases of stroke – where the blood clot has blocked supply to an organ. Stroke experts estimate that over 20% of the most severe stroke cases should be treated with thrombectomy. The procedure certainly needs good expertise. Although, in some parts of the country, as few as 2% of the qualified patients receive this treatment. The outcomes of Thrombectomy majorly depend on taking the right patient at the right time to the right place.
What is Thrombectomy?
During a stroke, the blood supply to part of an organ is lost. This is due to an artery blockage. The blockage is usually a blood clot. Traditionally, drug therapy aims to clear the artery and restore blood flow after the stroke event. Drug therapy is effective in the case of small blood clots but is often insufficient for large clots.
The word thrombectomy derives from thrombus+ectomy. Thrombus means a blood clot formed within the vascular system of the body and impeding blood flow; -ectomy means removal. Thrombectomy means surgical removal of a blood clot from a blood vessel. During a surgical thrombectomy, the surgeon makes an incision into the target blood vessel. The clot is removed, and the blood vessel is repaired, restoring normal blood flow. In some cases, a balloon or other device may be put in the blood vessel to help keep it open. There are three techniques or mechanisms to remove the clot from the vessel.
- Mechanical: Surgeons use a mechanical device to break up or remove the blood clot at the source.
- Aspiration: In suction thrombectomy, the catheter tip is placed immediately proximal to the clot and negative pressure is applied at the distal catheter opening by suctioning through a 50 or 60 ml syringe through the proximal catheter port. This results in clot aspiration into the catheter. An advantage of this technique is that it utilizes widely available endovascular equipment and may cause fewer embolic events and vasospasm
- Rheolytic: Rheolytic thrombectomy is the procedure in which a jet of saline is directed at the thrombus in the coronary artery from the tip of a catheter using an AngioJet system. The slurry is sucked through another channel of the catheter.
How is Thrombectomy Done?
Once, your surgeon decides that you are a candidate for thrombectomy; an informed consent will be signed before undergoing the procedure. This form states that you have fully understood the risks and benefits of the Thrombectomy surgery and have all your questions answered and are willing to go ahead with the surgery. Be sure all your questions have been answered before you sign the consent letter.
You should talk to your doctor about how can you prepare for the Thrombectomy surgery. Tell him whatever medications you are taking. You may be asked to stop few medications ahead of time such as blood thinners. If you smoke, you will need to stop that before the surgery as smoking delays the healing. Discuss any allergies if you have. The doctor should know if you are pregnant. If you have ever had any problems with anesthesia, you must tell your doctor about it.
You will be asked to do some tests before the Thrombectomy surgery like ultrasound, venogram, CT scan, MRI, blood tests. You must not eat or drink after midnight the night before the Thrombectomy surgery.
You can ask your doctor what to expect during the surgery. A typical surgical thrombectomy goes like this:
- An IV line will be placed to deliver the medicines. You may receive blood thinners to avoid new clot formation during surgery.
- You will be given sedation or anesthesia to make you feel relaxed and sleepy during the surgery.
- Continuous X-ray images can be used to keep a check if the process is going well.
- The doctor will make a cut in the area above your blood clot. He or she will open the blood vessel and take out the clot. The incision will be repaired.
- In some cases, a balloon attached to a thin tube (catheter) will be used in the blood vessel to remove any part of the clot that remains. A stent may be put in the blood vessel to help keep it open.
- Your doctor will close and repair the blood vessel. This will then restore blood flow.
What to Expect After Thrombectomy?
Your healthcare providers will keep a watch on you for the next several hours. Your vital signs will be watched upon. Depending on your condition, you will be asked to stay in the hospital for a day or more.
You will be given medicines for some time to prevent clots. You can take pain medicines after consulting your doctor. You must stop smoking as this will delay the healing and it will lower your risk of clot formation in the future.
You must attend all your follow-up appointments to help the doctor keep a track of your recovery. You should call your healthcare provider in case of the following
- Pain or swelling getting worse
- Any leakage from the incision site
- Any kind of weakness or numbness in the surgical area.
- You must follow all the discharge instructions which include advice about medicines, exercise, and wound care.
Risks of Thrombectomy
All surgeries have risks. Thrombectomy includes the following risks:
- Excess bleeding that can be severe enough to cause death
- Risk of infection
- Damage to the blood vessel at the clot site
- Reaction to anesthesia
- Pulmonary embolism
- Risk of developing another clot
Your risks depend on your general health and how long you have had a clot too. So, before you sign the consent, be sure all your questions have been answered to yoursatisfaction.
Benefits of Thrombectomy
A study has shown the potential benefits of thrombectomy in treatment of strokes. However, enrollment in these trials was restricted to patients with small early infarct volumes and potentially large areas of tissue at risk. The current American Heart Association/American Stroke Association guideline — recommends consideration of thrombectomy for moderate to severe stroke and documented large vessel occlusion in which treatment can be initiated within 6 hours after symptom onset. The 2018 guidelines showed a clear benefit of “extended window” mechanical thrombectomy for certain patients with large vessel occlusion who could be treated out to 16-24 hours. It remains unknown whether it would be beneficial for emergency medical services to bypass a closer IV tPA-capable hospital for a thrombectomy-capable hospital. While such an approach may delay IV tPA administration for patients who are and who are not mechanical thrombectomy candidates, this approach would expedite thrombectomy for those who are mechanical thrombectomy candidates.
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