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Purpose To evaluate access site adverse events following ClotTriever-mediated large-bore mechanical thrombectomy via small upper extremity deep veins (< 6-mm). Materials and methods Twenty patients, including 24 upper extremity venous access sites, underwent ClotTriever-mediated large-bore thrombectomy of the upper extremity and thoracic central veins for symptomatic deep vein obstruction unresponsive to anticoagulation. Patients without follow-up venous duplex examinations ( n  = 3) were excluded. Patients who had > 6-mm diameter veins accessed ( n  = 3) were excluded. Temporary purse-string sutures and manual pressure were used for access site hemostasis in all patients. Vein access site and diameter, technical success (defined as placement of the 13.5-French ClotTriever sheath followed by thrombectomy), and early (< 30-days) and late (> 30-days) access site-related adverse events (according to the Adverse Event Classification by the Society of Interventional Radiology criteria) were recorded. Results Fourteen patients (8 males, 6 females; mean age 51.7 ± 13.6 years) comprising 16 upper extremity venous access sites were included in this study. Access sites included: right brachial ( n  = 7), left brachial ( n  = 5), and bilateral brachial ( n  = 2) veins. The mean access site diameter was 4.3-mm ± 0.67-mm. Technical success was achieved via all access sites. Six (42.9%) patients underwent stent reconstruction following thrombectomy through the same accesses. After the procedure, all purse-string sutures were removed within 24 h. Three (21.4%) patients experienced small access site hematomas that did not require transfusion, intervention, or prolonged hospitalization. Initial follow-up venous duplex ultrasounds were performed at 29.3 ± 21.7 days following intervention. The mean follow-up interval to the second and third venous duplex ultrasounds were 124.3 ± 64-days and 225.1 ± 80.1 days, respectively. One (7.1%) patient developed right arm swelling six days after the procedure and was found to have thrombosis of the previously accessed right brachial vein. No other clinically or sonographically significant access site adverse events were observed. Conclusion ClotTriever-mediated large-bore thrombectomy via small upper extremity veins is safe with minimal access site adverse events.

Purpose The Protrieve Sheath (Inari Medical; Irvine, CA) is designed for embolic protection during venous thrombectomy. This report describes experience with its use. Materials and methods Between November 2022 and December 2023 (13 months), seventeen patients, including nine (52.9%) females and eight (47.1%) males (mean age 58.8 ± 13.3 years, range 37–81 years), underwent deep venous thrombectomy following the Protrieve Sheath placement for embolic protection. Gender, age, presenting symptoms, procedural indications, obstructed venous segments, the Protrieve Sheath access and deployment sites, thrombectomy devices utilized, need for stent reconstruction, technical success, clinical success, adverse events (the Protrieve Sheath maldeployment or clinically significant embolic events), removed thrombi analyses, and mortality were recorded. Technical success was defined as successful deployment of the Protrieve Sheath funnel central to the thrombectomy site. Clinical success was defined as improvement in presenting venous occlusive symptoms without procedure-related venous thromboembolism. Results The most common presenting symptom was extremity swelling ( n  = 15; 88.2%). Nine (52.9%) patients had malignant and eight (47.1%) had benign etiologies of venous obstruction. Obstructed venous segments included the inferior vena cava (IVC) and lower extremity ( n  = 9; 52.9%), isolated lower extremity ( n  = 4; 23.5%), isolated IVC ( n  = 2; 11.8%), thoracic central veins and superior vena cava ( n  = 1; 5.9%), and isolated thoracic central vein ( n  = 1; 5.9%). The Protrieve Sheath access sites included the right internal jugular vein ( n  = 15; 88.2%) for IVC and lower extremity obstructions and the right common femoral vein ( n  = 2; 11.8%) for thoracic central vein and superior vena cava obstructions. The Protrieve sheath funnel deployment locations included intrahepatic IVC in 13 patients ( n  = 13; 76.5%), suprarenal IVC in two ( n  = 2; 11.8%), and inferior cavoatrial junction in two ( n  = 2; 11.8%). Thrombectomy devices used included the ClotTriever System (Inari Medical) ( n  = 15; 88.2%), the InThrill Thrombectomy System (Inari Medical) ( n  = 4; 23.5%), the FlowTriever System (Inari Medical) ( n  = 2; 11.8%), the Lightning Flash 16 Aspiration System (Penumbra; Salt Lake City, UT) ( n  = 2; 11.8%), the Cleaner Rotational Thrombectomy System (Argon; Plano, TX) ( n  = 1; 5.9%), and the RevCore Thrombectomy System (Inari Medical) ( n  = 1; 5.9%). Ten (58.8%) patients required stent reconstruction following thrombectomy. Technical success was achieved in all patients. Clinical success was achieved in 16 (94.1%) patients. No immediate adverse events, including the Protrieve Sheath maldeployment or clinically significant embolic events, occurred. Conclusion Use of the Protrieve Sheath during large-bore venous mechanical thrombectomy resulted in favorable technical and clinical outcomes without device-related adverse events or clinically significant thromboembolic events.