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Objective To investigate the clinical efficacy and safety of two thrombus thrombectomy devices, AcoStream and AngioJet, in the treatment of acute iliofemoral vein thrombosis (AIFVT). Methods A total of 97 AIFVT patients were treated with different thrombus clearing devices according to their states of illness, and patients were divided into the AcoStream group (41 cases) and the AngioJet group (56 cases). The thrombus clearing status, degree of swelling reduction in affected limb, surgical time and intraoperative blood loss were compared between the two groups, and the need for assisted catheter contact thrombolysis (CDT) treatment, urokinase dosage, iliac vein stent placement, incidence of complications, length of hospital stay and hospitalization costs were also compared between the two groups. Regular follow-up was conducted to record for recurrence of thrombosis, the patency of the stent, deep vein thrombosis syndrome (PTS) and PTS degree were evaluated in lower limbs. Results There were no significant differences in age, gender, affected limb, time of illness, site of illness and causes of illness between the two groups (P＞0.05). The operation was successful in both groups and the thrombus removal effect was satisfactory. There were no significant differences in terms of thrombus clearance rate, the degree of swelling reduction in the limb 48 hours after surgery and assisted CDT rate between the two groups (P＞0.05). Compared with the AcoStream group, the AngioJet group had a longer surgical time, reduced intraoperative blood loss, increased hospitalization costs and higher rates of complications (P＜0.05). There was no significant difference in the recurrence rate of thrombosis between the two groups (P＞0.05), and there was no occurrence of iliac vein stent occlusion or PTS in either patients. Conclusion Two mechanical thrombus clearing devices of AcoStream and AngioJet are safe and effective for treating AIFVT. [ABSTRACT FROM AUTHOR]

Background: AngioJet rheolytic thrombectomy is associated with a higher risk of acute kidney injury due to its potential for inducing mechanical harm and intravascular hemolysis. However, previous studies have focused on a single disease entity. Purpose: To identify predictors associated with acute kidney injury after AngioJet rheolytic thrombectomy across a range of disease entities. Material and Methods: A total of 95 patients who underwent AngioJet rheolytic thrombectomy between October 2018 and April 2023 were retrospectively reviewed. In total, 11 patients were excluded due to the absence of a postprocedural serum creatinine test within 72 h; finally, 84 patients were included. Acute kidney injury was defined as a ≥1.5-fold increase or ≥0.3 mg/dL rise in serum creatinine within 72 h after the procedure. Univariate and multivariate analysis were performed to identify risk factors for acute kidney injury. Results: Technical and clinical success were achieved in all patients (84/84, 100%). Of the 84 patients (40 men [47.6%], 44 women [52.4%]; mean age = 67.2 ± 15.9 years), 15 (17.8%) had developed acute kidney injury. Multivariate analysis showed concurrent malignancy (odds ratio [OR] = 42.231, 95% confidence interval [CI] = 2.332–764.693; P = 0.011) and AngioJet rheolytic thrombectomy in arterial system (OR = 24.109, 95% CI = 1.319–440.551; P = 0.032) as statistically significant predictors of acute kidney injury. Conclusions: AngioJet rheolytic thrombectomy is a potential risk for acute kidney injury. Concurrent malignancy and AngioJet rheolytic thrombectomy in the arterial system are independent predictors of acute kidney injury. [ABSTRACT FROM AUTHOR]

Objective： To compare the clinical efficacy and safety of AngioJet thrombectomy with sequential low-dose urokinase thrombolysis versus catheter-directed thrombolysis(CDT) in the treatment of acute iliofemoral deep venous thrombosis (DVT). Methods： A total of 46 patients with acute iliofemoral DVT treated at Jiangsu Province Hospital of Chinese Medicine from January 2019 to December 2022, were randomly assigned into two groups using a random number table: 23 patients in the AngioJet thrombectomy with sequential low-dose urokinase thrombolysis group (AngioJet group) and 23 patients in the CDT group. The following outcomes were compared between the groups: the reduction rate of lower limb swelling 1 day post-surgery, venous patency rates at 1 day and 12 months post-surgery, urokinase usage, hospital stay, and safety parameters (bleeding, local infection, and thrombus recurrence). Results： On day 1 post-surgery, the AngioJet group showed a significantly higher reduction rate of lower limb swelling ［thigh: (81.35±6.78)% vs (43.56±7.32)%，t=6.107; calf: (78.16±8.45)% vs (46.54±8.62)%, t=11.735］ and a higher venous patency rate ［（90.68±17.89% vs (68.56±15.34)%, t=6.478］ compared to the CDT group (P＜0.05). The AngioJet group also used significantly less urokinase, had a lower incidence of bleeding, a shorter length of hospital stays, and a lower incidence of post-thrombotic syndrome (PTS) at 12 months (P＜0.05). There was no significant difference between the two groups in terms of catheter-related infections, thrombus recurrence, or venous patency at 12 months (P＞0.05). Conclusion： AngioJet thrombectomy with sequential low-dose urokinase thrombolysis provides faster relief of lower limb swelling, a higher venous patency rate, shorter hospital stays, and a lower incidence of PTS, with higher safety in the treatment of iliofemoral DVT.

Key Clinical Message: Percutaneous precutaneous mechanical thrombectomy has been used for clot dissolution and removal in selected cases of iliofemoral deep vein thrombosis. Intravascular Hemolysis and hemoglobinuria caused by pharmachomechanical chather directed thrombolysis (PCDT) devices like the Angiojet is associated with an increased risk of acute kidney injury (AKI). Acute tubular necrosis that is severe enough to require hemodialysis can occur. Clinicians should be aware of this potential risk to ensure early recognition and timely referral to the nephrologist, and a clear explanation of the risk of AKI should be given to the patients undergoing this procedure. Lower extremity deep vein thrombosis (DVT) is a frequently encountered medical condition, and one that can lead to death or major disability if not promptly treated. Anticoagulation alone may not always be enough for complete treatment. It has been reported that early thrombus removal can rapidly relieve symptoms and prevent disease progression in some selected cases. Percutaneous pharmacomechanical thrombectomy has been used for clot dissolution and removal in such cases. AngioJet is an increasingly used method of percutaneous mechanical thrombectomy for DVT that can cause intravascular hemolysis and potentially acute kidney injury (AKI). We report here a case of a 39 years old lady who developed severe AKI (illustrated by creatinine level of 664 μmol/L (7.5 mg/dL), bicarb of 13 mmol/L and being anuric), requiring hemodialysis secondary to intravascular hemolysis and hemoglobinuria that occurred immediately after the use of AngioJet pharmacomechanical catheter‐directed technique to treat an extensive iliofemoral DVT. [ABSTRACT FROM AUTHOR]

Background: Iliofemoral deep venous thrombosis (IFDVT) is associated with an incidence of post‐thrombotic syndrome (PTS) of up to 50%. PTS is associated with high morbidity, impaired quality of life and a significant economic burden. The aim of the current study was to assess the impact of a single session pharmacomechanical thrombectomy (PMT), dedicated venous stents and a risk mitigation protocol on the rate of PTS. Methods: Between 2015 and 2022, patients presenting with acute or subacute IFDVT treated with the same protocol of single session PMT, dedicated venous stents, and risk‐mitigation measures were included. Procedural success rate, complications, stent patency and incidence of PTS were determined. Results: Of 60 patients (58 ± 19 years; 65% male), the procedural success rate was 93%, with 7% of patients experiencing complications but no long‐term sequelae or mortality. Most (n = 52; 87%) patients were stented, including 46% across the inguinal ligament. At 3 months post‐procedure, primary, assisted primary and secondary stent patency rates were 89%, 93% and 98%, respectively, with no loss of patency or re‐interventions after that. At latest follow‐up of a median 48 months (n = 32), stent patency rate was 97%, with only three patients (9%) experiencing symptoms of PTS. Conclusion: Single session PMT, dedicated venous stents and a risk‐mitigation protocol results in high success rate, excellent long‐term stent patency and low incidence of PTS without compromising safety. These results support early intervention for iliofemoral DVT. [ABSTRACT FROM AUTHOR]

Objective: To investigate the risk factors and outcomes regarding acute kidney injury (AKI) after AngioJet thrombectomy for acute lower-extremity deep vein thrombosis (DVT). Methods: Patients were divided into AKI and non-AKI groups according to whether AKI occurred postoperatively. The demographic data, pre-operative and post-operative laboratory data and surgical differences were compared between the two groups. Logistic regression and Wilcoxon signed-rank test were used to identify the AKI risk factors and outcomes, respectively. Results: Among the 341 patients who met the inclusion criteria, 45 developed AKI (AKI group) and 296 had normal renal function (non-AKI group) post-surgery. There were significant differences between the two groups in the course (t = 10.885, P = 0.000); preoperative history of a major surgery within 3 months (3M-MS) (odds ratio [OR] = 5.492, P = 0.001); duration of aspiration thrombectomy (Z = −8.803, P = 0.000); volumes of aspiration (Z = −8.215, P = 0.000); contrast volume (Z = −3.204, P = 0.001) and pulmonary thrombectomy (OR = 18.200, P = 0.002); and preoperative complications of hypertension (OR = 4.637, P = 0.002), diabetes (OR = 18.088, P = 0.000), or pulmonary embolism (OR = 0.085, P = 0.011). Wilcoxon signed-rank test showed that the renal function of every patient in the AKI group returned to normal 3 months after the surgery. Conclusions: The course, preoperative complications of diabetes or hypertension, 3M-MS, contrast volume, duration and volume of aspiration thrombectomy, and pulmonary thrombectomy are risk factors for post–AngioJet-thrombectomy AKI, which is temporary.

Abstract Purpose The present study aimed to investigate the preliminary safety and efficacy of rheolytic thrombectomy (RT) using an AngioJet Zelante DVT catheter or a Solent Omni catheter for acute proximal deep vein thrombosis (DVT). Material and methods We conducted a retrospective review of 40 patients who were treated with an AngioJet RT between January 2019 and January 2021, and then the patients were divided into the ZelanteDVT group (n = 17) and the Solent group (n = 23). Data on demographics, clinical characteristics, technical success, clinical success, complications, and early follow-up were analysed. Results No significant differences regarding demographics were detected (all p > .05). The technical success rates were both 100%. The ZelanteDVT group had a shorter duration of RT and a higher primary RT success than the Solent group (all p .05). Apart from transient macroscopic haemoglobinuria occurring in all the patients during the first 24 hours post-RT, none of the patients in either group suffered other procedure-related adverse events or major complications. Minor complications included bleeding events in 21.7% (5/23) of the patients in the Solent group and one (5.9%) patient in the ZelanteDVT group (p > .05). At 6 months, the frequency of PTS was 5.9% (1/17) in the ZelanteDVT group and 17.4% (4/23) in the Solent group (p > .05). Conclusion Both catheters are safe and effective in managing patients with proximal DVT, thus leading to improved clinical outcomes with few complications. The ZelanteDVT catheter was more effective than the Solent catheter in thrombectomy, thus allowing for faster extraction of the DVT with a shorter run time and lower proportions of patients with adjunctive CDT.

To investigate the risk factors and outcomes regarding acute kidney injury (AKI) after AngioJet thrombectomy for acute lower-extremity deep vein thrombosis (DVT). Patients were divided into AKI and non-AKI groups according to whether AKI occurred postoperatively. The demographic data, pre-operative and post-operative laboratory data and surgical differences were compared between the two groups. Logistic regression and Wilcoxon signed-rank test were used to identify the AKI risk factors and outcomes, respectively. Among the 341 patients who met the inclusion criteria, 45 developed AKI (AKI group) and 296 had normal renal function (non-AKI group) post-surgery. There were significant differences between the two groups in the course (t = 10.885, P = 0.000); preoperative history of a major surgery within 3 months (3M-MS) (odds ratio [OR] = 5.492, P = 0.001); duration of aspiration thrombectomy (Z = −8.803, P = 0.000); volumes of aspiration (Z = −8.215, P = 0.000); contrast volume (Z = −3.204, P = 0.001) and pulmonary thrombectomy (OR = 18.200, P = 0.002); and preoperative complications of hypertension (OR = 4.637, P = 0.002), diabetes (OR = 18.088, P = 0.000), or pulmonary embolism (OR = 0.085, P = 0.011). Wilcoxon signed-rank test showed that the renal function of every patient in the AKI group returned to normal 3 months after the surgery. The course, preoperative complications of diabetes or hypertension, 3M-MS, contrast volume, duration and volume of aspiration thrombectomy, and pulmonary thrombectomy are risk factors for post–AngioJet-thrombectomy AKI, which is temporary. [ABSTRACT FROM AUTHOR]

Purpose: The present study aimed to investigate the preliminary safety and efficacy of rheolytic thrombectomy (RT) using an AngioJet Zelante DVT catheter or a Solent Omni catheter for acute proximal deep vein thrombosis (DVT). Material and methods: We conducted a retrospective review of 40 patients who were treated with an AngioJet RT between January 2019 and January 2021, and then the patients were divided into the ZelanteDVT group (n = 17) and the Solent group (n = 23). Data on demographics, clinical characteristics, technical success, clinical success, complications, and early follow-up were analysed. Results: No significant differences regarding demographics were detected (all p >.05). The technical success rates were both 100%. The ZelanteDVT group had a shorter duration of RT and a higher primary RT success than the Solent group (all p <.05), and the percentage of adjunctive catheter-directed thrombolysis (CDT) was 29.4% in the ZelanteDVT group, which was significantly lower than the 73.9% in the Solent group (p =.010). The clinical success rates for the ZelanteDVT group and Solent group were 100% (17/17) and 95.7% (22/23), respectively, and these values were high in the two groups (p >.05). Apart from transient macroscopic haemoglobinuria occurring in all the patients during the first 24 hours post-RT, none of the patients in either group suffered other procedure-related adverse events or major complications. Minor complications included bleeding events in 21.7% (5/23) of the patients in the Solent group and one (5.9%) patient in the ZelanteDVT group (p >.05). At 6 months, the frequency of PTS was 5.9% (1/17) in the ZelanteDVT group and 17.4% (4/23) in the Solent group (p >.05). Conclusion: Both catheters are safe and effective in managing patients with proximal DVT, thus leading to improved clinical outcomes with few complications. The ZelanteDVT catheter was more effective than the Solent catheter in thrombectomy, thus allowing for faster extraction of the DVT with a shorter run time and lower proportions of patients with adjunctive CDT. [ABSTRACT FROM AUTHOR]

Pharmacomechanical thrombectomy (PMT) with AngioJet (AJ) catheter is one of the most efficacious endovascular techniques for rapidly removing clots and thrombi from occluded vessels. It has a high technical success rate but at the cost of hemolysis which may lead to renal damage. Such a complication after AJ has been published but is still underreported in the literature. In this report, a case of a 68-year-old male patient with acute limb ischemia (ALI) and severe acute kidney injury (AKI) developed after the use of catheter-directed thrombolysis (CDT) and PMT AJ has been presented. [ABSTRACT FROM AUTHOR]

Abstract Background AngioJet® is an increasingly used method of percutaneous mechanical thrombectomy for the treatment of patients with arterial and venous thromboses. AngioJet® has been shown to cause intravascular haemoylsis universally. We report the case of a 29 year old patient who underwent AngioJet® thrombectomy and post-procedure developed a stage 3 Acute kidney injury (AKI.) requiring renal replacement therapy (RRT), secondary to intravascular haemolysis. We aim to explore the mechanism and potential risk factors associated with developing AKI in these patients and suggest steps to optimise patient management. Case presentation A 29 year old Caucasian male who developed a stage 3 AKI, requiring RRT, following AngioJet® thrombectomy for an occluded femoral vein stent. Urine and laboratory investigations showed evidence of intravascular haemolysis, which was the likely cause of AKI. Following a brief period of RRT he completely recovered renal function. Conclusions AKI is an increasingly recognised complication following AngioJet® thrombectomy, but remains underappreciated in clinical practice. AKI results from intravascular haemolysis caused by the device. Up to 13% of patients require RRT, but overall short-term prognosis is good. Pre-procedural risk factors for the development of AKI include recent major surgery. Sodium bicarbonate should be administered to those who develop renal impairment. Renal biopsy is high risk and does not add to management. Increased clinician awareness and vigilance for AKI post-procedure can allow for early recognition and referral to nephrology services for ongoing management.

AngioJet rheolytic thrombectomy, although a successful treatment modality for arterial thrombus removal and recanalization, has been shown to have increased rates of postoperative acute kidney injury (AKI) compared with other methods of treatment for acute limb ischemia. The postinterventional course of AKI can differ markedly from patient to patient, but typically resolves relatively quickly. Herein, we present a case of AKI secondary to AngioJet intervention that demonstrates an exceedingly prolonged but ultimately recoverable course with conservative management and without the need for renal replacement therapy.

Abstract Background Superior vena cava syndrome is a relatively rare presentation in which diminished venous return to the heart produces congestion of the neck, face and upper extremities. Typically, a mediastinal mass produces external compression on the superior vena cava and reduces venous return. However, superior vena cava syndrome can present acutely in the setting of vena cava thrombosis. Multiple scoring systems are available to assist clinicians with appropriate timing of interventions for SVC syndrome. When specific criteria are met, endovascular intervention can be beneficial to patients to prevent rapid deterioration. Case presentation A 75-year-old female with no significant past medical history presented to the emergency department with increased facial swelling, nausea and vomiting which began the night prior to presentation. The patient underwent a CT chest which revealed a 3.2 × 3.0 × 3.8 cm spiculated mass compressing the right main bronchus and right pulmonary artery. The patient was intubated and interventional radiology was consulted. The patient underwent venography which showed extensive thrombosis of the innominate veins. Rheolytic thrombectomy with AngioJet™ was performed to alleviate clot burden and minimize risk of secondary pulmonary embolism. Kissing stents were placed in the bilateral innominate veins to maintain patency after thrombectomy. After the procedure, the patient was successfully extubated and had near complete resolution of facial swelling approximately 12 h post procedure. A follow up venogram performed on post procedure day 4 showed patent bilateral subclavian, innominate, and internal jugular veins as well as a patent superior vena cava. Conclusions Acute occlusion of superior vena cava can present with life threatening symptoms such as loss of airway. AngioJet™ thrombectomy is another tool available to interventional radiologists when a patient’s clinical condition necessitates treatment.

Background: AngioJet® is an increasingly used method of percutaneous mechanical thrombectomy for the treatment of patients with arterial and venous thromboses. AngioJet® has been shown to cause intravascular haemoylsis universally. We report the case of a 29 year old patient who underwent AngioJet® thrombectomy and post-procedure developed a stage 3 Acute kidney injury (AKI.) requiring renal replacement therapy (RRT), secondary to intravascular haemolysis. We aim to explore the mechanism and potential risk factors associated with developing AKI in these patients and suggest steps to optimise patient management.Case Presentation: A 29 year old Caucasian male who developed a stage 3 AKI, requiring RRT, following AngioJet® thrombectomy for an occluded femoral vein stent. Urine and laboratory investigations showed evidence of intravascular haemolysis, which was the likely cause of AKI. Following a brief period of RRT he completely recovered renal function.Conclusions: AKI is an increasingly recognised complication following AngioJet® thrombectomy, but remains underappreciated in clinical practice. AKI results from intravascular haemolysis caused by the device. Up to 13% of patients require RRT, but overall short-term prognosis is good. Pre-procedural risk factors for the development of AKI include recent major surgery. Sodium bicarbonate should be administered to those who develop renal impairment. Renal biopsy is high risk and does not add to management. Increased clinician awareness and vigilance for AKI post-procedure can allow for early recognition and referral to nephrology services for ongoing management. [ABSTRACT FROM AUTHOR]

Catheter-directed thrombolysis in the treatment of acute lower extremity arterial occlusions often requires several interventional sessions to generate successful outcomes. It is typically an expensive procedure, necessitating extended hospital length of stay (LOS) that may be associated with an increase in both local and systemic hemorrhagic complications. Five years ago, we created the fast-track thrombolysis protocol for arteries (FTTP-A) to deal with these concerns. The goal of our protocol is to re-establish patency during the first session of thrombolysis, thus decreasing costs and complications associated with prolonged periods of thrombolytic exposure. A retrospective study of 42 patients who were treated for acute limb ischemia at our institution by FTTP-A from January 2014 to February 2019 was performed. FTTP-A includes periadventitial lidocaine injection at the arterial puncture site under ultrasound guidance, contrast arteriography of the entire targeted segment, pharmacomechanical rheolytic thrombectomy of the occluded arterial segment, tissue plasminogen activator infusion along the occluded segment, balloon maceration of the thrombus, and (if deemed necessary) placement of a stent in an area of significant (≥30%) stenosis that is refractory to balloon angioplasty and thrombolysis. After the stenosis or thrombus is cleared, patients are prescribed an oral anticoagulant agent. Primary FTTP-A (50 total interventions) was performed in 42 patients. The median age of patients was 67.2 ± 12.2 years (range, 41-98 years), and 54.8% were male; 59.5% of the procedures were performed on the left lower extremity. Initial arterial access was obtained through the common femoral artery in 39 of 42 cases (92.9%); in the remaining 3 cases, it was obtained in a left bypass access site, a right femoral-popliteal graft, and a right femoral-femoral graft. The mean operative time was 148.9 ± 62.9 minutes (range, 83-313 minutes), and the mean volume of tissue plasminogen activator infused was 9.7 ± 4.0 mg (range, 2-20 mg). The median cost including medications and interventional tools was $4673.19 per procedure. The mean postoperative LOS was 3.1 ± 4.5 days (range, 1-25 days). Median postoperative LOS was 1 day. Mean postoperative follow-up was 27 ± 19.2 months (range, 0-62 months). Single-session FTTP-A was successful in 81% (n = 34/42) of patients; the remaining 8 patients (19%) required a single additional session. Of the 42 patients, 34 (81%) required arterial stenting. Periprocedural complications consisted of one patient with hematuria, which resolved, and one patient with thrombocytopenia, which resolved. No patients experienced rethrombosis within 30 days of FTTP-A. During the 5-year study period, there was no significant local or systemic hemorrhage, limb loss, or mortality related to this protocol. FTTP-A appears to be a safe, efficacious, and cost-effective procedure in the resolution of acute lower extremity arterial occlusions. [ABSTRACT FROM AUTHOR]

The AngioJet technique combines localized thrombolysis and percutaneous mechanical thrombectomy (PMT). However, PMT may cause acute kidney injury (AKI), which has been ascribed to severe mechanical haemolysis, although no renal biopsies have been reported. We now report the first renal biopsy in a patient with AKI following PMT. There is histological evidence of haemoglobin (Hb)-induced tubular injury and podocyte stress characterized by intracellular Hb and staining for ferritin and hemo-oxygenase-1, suggestive of an adaptive response to oxidative stress. This confirms that Hb is involved in kidney cell injury and supports the existence of several different kidney cellular targets. [ABSTRACT FROM AUTHOR]

Early catheter-directed thrombolysis (CDT) for lower extremity deep vein thrombosis (LEDVT) can reduce post-thrombotic morbidity and the AngioJet thrombectomy is a new therapy that can be selected for the treatment of LEDVT. We performed a systematic review and meta-analysis of clinical trials comparing AngioJet versus CDT to assess the efficacy and safety of AngioJet thrombectomy. We systematically searched PubMed and Embase for clinical trials that published before November 1, 2020 and compared AngioJet thrombectomy and CDT in the treatment of LEDVT. We meta-analyzed effective rate of treatment, serious complications, PTS, Villalta score, duration of treatment and drug dose. AngioJet does not result in a significant difference in the effective rate (OR 1.00, CI 0.73-1.36, P = 0.98; I2 = 0%) and complications (OR 1.16 CI 0.84-1.61, P = 0.36; I2 = 39%) compare to CDT. And there was a statistically significant decrease in incidence of PTS (OR 0.58 CI 0.37-0.91, P = 0.02; I2 = 0%) and Villalta score (OR −1.86 CI −3.49 to −0.24, P = 0.02; I2 = 34%) for AngioJet compared to CDT. In addition, there was a statistically significant decrease in duration of the treatment (OR −2.45 CI −2.75 to −2.15, P < 0.0001; I2 = 95%) and drug dose (OR −3.15 CI −3.38 to −2.93, P < 0.0001; I2 = 98%) between AngioJet and CDT. AngioJet results in a low severity of PTS compared to CDT therapy. Moreover, the average duration of treatment and thrombolysis time was shorter in the AngioJet group compared to the CDT group. However, the AngioJet group was not significantly different in effective rate of treatment and serious complications compared to the CDT group. [ABSTRACT FROM AUTHOR]

To compare the percutaneous Rotarex and Angiojet thrombectomy devices with regard to effectiveness and in vitro safety. The Rotarex and Angiojet devices were evaluated in an established in vitro pulsatile flow model with a human femoropopliteal vessel phantom. First pass recanalisation and thrombus weight were assessed after thrombectomy, as well as micro- and macro-emboli. Further, histological evaluation of the vascular phantom was performed to analyse vascular injuries. Thrombus weight did not differ significantly prior to the thrombectomy between the groups, but the Rotarex showed slight advantages in thrombus removal vs. the Angiojet regarding first pass recanalisation. Micro- and macro-emboli occurred in most of the endovascular manoeuvres performed; however, significantly more macro-emboli (2.37 ± 1.51 vs. 0.87 ± 0.83; p =.048) were observed using the Rotarex than the Angiojet. Macroscopic dissections were detected in the Rotarex group (n = 3) but not in the Angiojet group. Microscopic vascular injuries were detected significantly more often in the Rotarex group (Rotarex: 531.61 μm ± 102.81 μm; Angiojet: 705.42 μm ± 61.68 μm p =.001]). Both devices showed a comparable performance, with a slight advantage for the Rotarex regarding first pass recanalisation. Significantly more thrombo-emboli, and vascular injuries were observed in the Rotarex group with the latter being obviously the more tissue preserving procedure but potentially with a lower rate of recanalisation. Based on the present results, clinical randomised trials, including long term follow up, are needed to optimise and improve the use of catheter based procedures, taking into account the thrombus entity, localisation, and clinical history. [ABSTRACT FROM AUTHOR]

A 23-year-old presenting with an acute history of back pain, leg swelling, and claudication was diagnosed with an extensive iliocaval thrombosis, extending from the popliteal veins into the inferior vena cava (IVC) and left renal vein. He was treated with a combination of endovascular techniques, including EKOS and AngioJet. An underlying congenital IVC stenosis and May-Thurner type iliac vein compression were subsequently treated with venoplasty and stenting. To our knowledge, this is the first report of the use of EKOS for renal vein thrombosis and we highlight the complementary nature of different endovascular techniques for managing complex venous thrombotic disease. [ABSTRACT FROM AUTHOR]

Coexistence of pulmonary embolism (PE) and arterial thrombosis in a single patient is rare. Management of such cases is challenging because there is no unified standard on how to treat this type of disease. We herein report a case involving a 73-year-old man who was admitted to the hospital because of a 2-day history of chest tightness. Pulmonary computed tomography angiography revealed a filling defect of the main pulmonary artery and bilateral branches as well as a left subclavian artery embolism. AngioJet mechanical thrombectomy (Boston Scientific, Marlborough, MA, USA) was used to treat the PE, and this was combined with left brachial artery incision and thrombectomy for treatment of the left subclavian artery embolism. The patient recovered well after the operation. The prognosis was good after 9 months of regular follow-up. AngioJet mechanical thrombectomy combined with left brachial artery incision thrombectomy may be a feasible treatment option for cases of PE combined with left subclavian artery embolism., Competing Interests: Declaration of conflicting interestsThe authors declare that there is no conflict of interest.

Venous thromboembolism, including deep vein thrombosis and pulmonary embolism, occur in up to 900,000 people per year in the United States. Current first-line therapy consists of systemic anticoagulation with a goal to prevent additional thrombus formation. Treatment with anticoagulation alone provides less than satisfactory results with some studies showing propagation of thrombus in almost 40% of cases. Current first-line therapy does not include active removal of thrombus and does little to alleviate acute symptoms and the damaging inflammatory response that may result in postthrombotic syndrome. As the public and clinicians continue to recognize the unmet need of venous disease, endovascular therapies, such as catheter-directed thrombolysis, mechanical thrombectomy, and pharmacomechanical catheter-directed thrombolysis, have been developed to provide minimally invasive therapy while minimizing complications. The article discusses the advantages and disadvantages of endovascular interventions for venous disease. [ABSTRACT FROM AUTHOR]

Background and objective Aspiration thrombectomy devices, such as the AngioJet Solent Omni (Boston Scientific Corporation, Marlborough, MA) have been approved by the US FDA for the treatment of thrombi in peripheral arterial disease, venous disease, and AV fistulas. However, there is a dearth of real-world data on the most common modes of failure and complications associated with the AngioJet Solent Omni. In this study, we aimed to address this scarcity of data. Methods The MAUDE (Manufacturer and User Facility Device Experience) database was queried for reports of device failure and adverse events spanning the period from October 2012 to December 2021. Results A total of 499 events were reported during the study period. After the exclusion of duplicate reports, the final analysis included 450 reports. The most common mode of failure was catheter breakage/kinking during suction thrombectomy with 137 reports (30%). The most common vessel associated with events was the superficial femoral artery or vein, which was documented in 82 reports (18.2%). The most common adverse clinical outcome was the embedding of a piece of the device in the patient, which occurred in seven reports (1.6%). There were seven (1.6%) events of death reported during the period studied. Conclusions Based on our findings, theAngioJet Solent Omni device provides promising results; however, it is important to evaluate device safety. It is associated with complications including device embedment, catheter breakage/kinking, and death, and these adverse events are linked to patient characteristics and risk factors., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Dandu et al.)

Purpose: This study was designed to investigate the incidence of arterial embolization using a peripheral protection filter device in a series of patients undergoing percutaneous mechanical thrombectomy for the management of thrombosed hemodialysis arteriovenous grafts (AVGs). Methods: This prospective, single-center study included all eligible patients presenting during an 18-month period to undergo AVG percutaneous thrombectomy. Inclusion criteria was a recently thrombosed AVG with 2 cm of artery before the next arterial branching. Primary endpoint was the incidence of distal arterial macro- and micro-embolization determined by both digital subtraction angiography and histopathological analysis of the material collected. Secondary endpoints included quantitative measurements of the specimens using a 0+ (no material) to 3+ (maximum load) score. Results: In total, 42 patients met the study's inclusion criteria. No procedure-related complications or angiographically evident arterial embolization were noted. Macroscopically evident material was present in 47.6 % (20/42 filters). Histopathology demonstrated that the embolic material was primary consisted of fibrin conglomerates and platelets (median score: 1.5, confidence interval: 1.0-3.0), whereas inflammatory cells, trapped erythrocytes, extracellular matrix, cholesterol clefts, foam cells, necrotic core, and smooth muscle cells also were detected. Mean total area of embolic material was 5.04 mm (range 0.05-5.21). The mean major axis of the largest particle was 1.83 mm (range 0.29-6.64), whereas 19 % (8/42) contained particles with major axis >1 mm and 12 % (5/42) with major axis >3 mm. Conclusions: In this study, the percentage of arterial micro-embolization was significantly higher than previously reported. However, the detrimental, long-term, clinical relevance remains to be determined. [ABSTRACT FROM AUTHOR]

Acute mesenteric ischemia is commonly treated by surgical exploration and open thrombectomy. Very few reports describe using newer, minimally invasive methods which utilize catheter-based mechanical and pharmacological thrombolysis. Herein, we report a case of acute superior mesenteric embolism successfully treated with AngioJet hydrodynamic mechanical thrombectomy and EKOS catheter pharmacological thrombolysis. A 76-year-old man with new onset atrial fibrillation presented with abdominal pain of 48 hours duration. Subsequent contrast computed tomography scan of the abdomen revealed a filling defect in the superior mesenteric artery (SMA), suggestive of an acute embolus, which was confirmed by SMA angiogram. The AngioJet aspiration device was used for hydrodynamic suction thrombectomy. The repeat angiogram demonstrated only a partial restoration of blood flow, and thus the EKOS tissue plasminogen activator catheter was left in the SMA for continuous thrombolysis. The patient underwent continuous thrombolysis for two days, with two subsequent sessions of angiography. Thereafter, the patient improved symptomatically and serum lactate was normalized. In conclusion, the AngioJet suction thrombectomy and pharmaco-mechanical thrombolysis using the EKOS catheter is associated with minimal morbidity and can be rapidly performed. It may be used as an alternative to open surgical thrombectomy in selected cases of acute SMA embolism. [ABSTRACT FROM AUTHOR]

Purpose: We describe a case of severe acute pancreatitis after percutaneous mechanical thrombectomy (PMT) and review the literature for the occurrence of this complication. Materials and Methods: A 53-year-old man with a history of bilateral external iliac artery stent placement sought care for acute onset of lifestyle-limiting left claudication. Angiography confirmed left external iliac stent occlusion, and PMT with the AngioJet Xpeedior catheter (Possis Medical, Minneapolis MN) was performed. Results: After PMT of the occluded external iliac artery, a residual in-stent stenosis required the placement of a second iliac stent. The procedure was complicated by severe acute pancreatitis. Other causes of pancreatitis were eliminated during the patient's hospital stay. A literature review revealed nine cases of acute pancreatitis after PMT. Conclusion: Although rare, pancreatitis can be a devastating complication of PMT. The development of pancreatitis seems to be related to the products of extensive hemolysis triggering an inflammatory process. To prevent this complication, we recommend that close attention be paid to the duration and extent of PMT, thereby avoiding extensive hemolysis and subsequent complications. [ABSTRACT FROM AUTHOR]

Deep vein thromboses (DVT) along with its clinical sequelae represent a major health care challenge in our society. An acute massive DVT can result in pulmonary embolism resulting in sudden death. Although oral or systemic anticoagulation therapy may minimize thrombus propagation, it remains ineffective in removing thrombus burden and consequently does not prevent postthrombotic syndrome. Recent advances in catheter-based interventions have led to the development of a variety of minimally invasive endovascular strategies to remove venous thrombi. These technologies use various principles, including catheter-directed thrombolytic infusion, rheolytic thrombectomy, mechanical fragmentation, or ultrasound energy to remove intraluminal thrombi. This article reviews the current advances in this technology and discusses the techniques of percutaneous treatment strategies of venous thrombotic conditions using various devices, including the AngioJet Power Pulse system, Trellis, and ultrasound-accelerated EkoSonic system. Finally, the authors’ institutional experiences using these interventional treatment strategies in patients with acute and chronic DVT are discussed. [ABSTRACT FROM PUBLISHER]

To compare the efficacy of catheter-directed thrombolysis (CDT) alone versus CDT with rheolytic percutaneous mechanical thrombectomy (PMT) for upper and lower extremity deep vein thrombosis (DVT). A retrospective cohort of consecutive patients with acute iliofemoral or brachiosubclavian DVT treated with urokinase CDT was identified, and a chart review was conducted. Demographic characteristics, treatment duration, total lytic dose, clot lysis rates and complications were compared in patients treated with urokinase CDT alone or combined CDT and rheolytic PMT. Forty limbs in 36 patients were treated with urokinase CDT alone. Twenty-seven limbs in 21 patients were treated with urokinase CDT and rheolytic PMT. The mean treatment duration for urokinase CDT alone was 48.0 ± 27.1 hr compared with 26.3 ± 16.6 hr for urokinase CDT and rheolytic PMT ( p = 0.0004). The mean urokinase dose required for CDT alone was 5.6 ± 5.3 million units compared with 2.7 ± 1.8 million units for urokinase CDT with rheolytic PMT ( p = 0.008). Complete clot lysis was achieved in 73% (29/40) of DVT treated with urokinase CDT alone compared with 82% (22/27) treated with urokinase CDT with rheolytic PMT. Percutaneous CDT with rheolytic PMT is as effective as CDT alone for acute proximal extremity DVT but requires significantly shorter treatment duration and lower lytic doses. Randomized studies to confirm the benefits of pharmacomechanical thrombolysis in the treatment of acute proximal extremity DVT are warranted. [ABSTRACT FROM AUTHOR]

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Infective endocarditis is a condition that has the potential to cause significant morbidity and mortality. Potential complications include sepsis, heart failure, atrioventricular block, embolic stroke, septic emboli, and intracardiac abscess formation. The backbone of treatment is intravenous antibiotics; however, in certain clinical scenarios, surgical management is also indicated to reduce complications and mortality. There exists a challenging subset of patients who require surgery but carry a high perioperative mortality risk. Percutaneous management of endocarditis is emerging as a potential treatment for this high-risk group of patients: it allows for an attempt at source control while avoiding the high risks of surgery. Herein, we present the case of a 35-year-old male presenting with hemoptysis secondary to pulmonary septic emboli in the setting of Enterococcus faecalis tricuspid endocarditis. He was determined to be a poor surgical candidate and underwent catheter-directed debulking of the tricuspid vegetation with excellent results., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Kelschenbach et al.)

We present two cases of massive pulmonary embolism with persistent systolic hypotension but both have contraindications for thrombolysis. Therefore, rheolytic thrombectomy using AngioJet was performed and immediate haemodynamic improvement was achieved including blood pressure and symptoms. According to guidelines, catheter embolectomy or fragmentation may be considered as alternative to surgical treatment in massive pulmonary embolism patients when thrombolysis is absolutely contraindicated or has failed. Percutaneous catheter-based interventional techniques include thrombus fragmentation, rheolytic thrombectomy, suction thrombectomy and rotational thrombectomy. With the existing literature review and our case, rheolytic thrombectomy for treatment of massive pulmonary embolism using AngioJet achieves a high procedural success rate (approximately 90%) n terms of improvement of haemodynamics, pulmonary perfusion and angiographic result but low complication rate. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the short- and medium-term clinical efficacy of TIPS approach combined with AngioJet thrombus aspiration technology treatment in acute portal vein thrombosis. Methods: 63 cases with acute portal vein thrombosis treated in our center from May 2017 to July 2019 were studied retrospectively, including 49 males and 14 females, aged 35-61 (46 ± 5) years. TIPS approach (with/without) combined with Angiojet thrombus aspiration and gastroesophageal varices embolization was performed simultaneously according to the patient's condition. Regular follow-up for 3-33 (22 ± 3) months after surgery was used to observe the curative effect. Results: The technical success rate was 100%. Portal vein and superior mesenteric vein blood flow were returned to normal after the operation. Two cases of biliary tract injury were untreated. Simultaneously, two cases of intrahepatic arteriovenous fistula were treated with superselective arterial embolization. During the follow-up period, 47 cases (74.61%) had complete portal vein recanalization, 13 cases (20.63%) had partial recanalization, 3 cases (4.76%) had complete portal cavernoma, 7 cases (11.11%) had symptomatic hepatic encephalopathy, 1 case had received artificial liver treatment (1.59%), 1 case had peptic ulcer (11.11%), 6 cases (9.52%) had lost to follow-up, and there was no portal hypertension-related bleeding or death. Conclusion: TIPS approach combined with AngioJet thrombus aspiration technology is safe, effective and feasible in the treatment of acute portal vein thrombosis, and the short- and medium-term clinical effects are satisfactory.

Background: This study aimed to assess the short-term effect of residual thrombus of the lower extremity after pharmacomechanical catheter-directed thrombolysis (PCDT) on the incidence of post-thrombotic syndrome (PTS) and iliofemoral vein patency rate in patients who underwent PCDT., Methods: There were 94 continuous patients with severe deep vein thrombosis (DVT) of the lower extremities admitted to our hospital between March 2016 and June 2018; 73 cases receiving PCDT and verified with iliac vein compression syndrome (IVCS) were assigned into two groups. Thirty-nine patients without thrombus of the popliteal and infrapopliteal veins were assigned to the proximal DVT group. The remaining 34 cases were placed in the extensive DVT group. The thrombus scores, including venous registry index (VRI) score, Marder score, and Society for Vascular Surgery (SVS) score before and after PCDT, the primary two years' cumulative rate of iliofemoral patency, and the rate of PTS, and complications were analyzed retrospectively., Results: Ultimately, 27 patients in the proximal DVT group and 26 cases in the extensive DVT group completed the study. The two groups had no significant differences in terms of basic characteristics, complication and the rate of PTS (P>0.05). However, there were significant differences in terms of postoperative mean thrombus score and the mean degree of thrombosis removal score by Marder and SVS scores, residual thrombus by lower thrombosis classification (LET) and the two years' cumulative iliofemoral vein patency rate (P<0.05). And the logistic regression analysis demonstrated the residual thrombus of LET class II [odds ratio (OR), 4.619, 95% confidence interval (CI), 1.090-19.567, P=0.038] was an independent risk factor for iliofemoral vein occlusion., Conclusions: The residual thrombus of LET class II is an independent risk factor for iliofemoral vein occlusion. It is very important to keep the patency of the popliteal vein when deciding to use a stent to maintain iliofemoral vein patency. Furthermore, the anterior tibial vein approach and crisscross technique may be two important alternative methods that can be used to address the thrombus of popliteal vein for patients with extensive DVT., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-20-5459). The authors have no conflicts of interest to declare., (2020 Annals of Translational Medicine. All rights reserved.)

Background: Superior vena cava syndrome is a relatively rare presentation in which diminished venous return to the heart produces congestion of the neck, face and upper extremities. Typically, a mediastinal mass produces external compression on the superior vena cava and reduces venous return. However, superior vena cava syndrome can present acutely in the setting of vena cava thrombosis. Multiple scoring systems are available to assist clinicians with appropriate timing of interventions for SVC syndrome. When specific criteria are met, endovascular intervention can be beneficial to patients to prevent rapid deterioration. Case presentation: A 75-year-old female with no significant past medical history presented to the emergency department with increased facial swelling, nausea and vomiting which began the night prior to presentation. The patient underwent a CT chest which revealed a 3.2 × 3.0 × 3.8 cm spiculated mass compressing the right main bronchus and right pulmonary artery. The patient was intubated and interventional radiology was consulted. The patient underwent venography which showed extensive thrombosis of the innominate veins. Rheolytic thrombectomy with AngioJet™ was performed to alleviate clot burden and minimize risk of secondary pulmonary embolism. Kissing stents were placed in the bilateral innominate veins to maintain patency after thrombectomy. After the procedure, the patient was successfully extubated and had near complete resolution of facial swelling approximately 12 h post procedure. A follow up venogram performed on post procedure day 4 showed patent bilateral subclavian, innominate, and internal jugular veins as well as a patent superior vena cava. Conclusions: Acute occlusion of superior vena cava can present with life threatening symptoms such as loss of airway. AngioJet™ thrombectomy is another tool available to interventional radiologists when a patient's clinical condition necessitates treatment. [ABSTRACT FROM AUTHOR]

Objective: To assess the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) combined with AngioJet mechanical thrombectomy for liver cirrhosis with extensive portal vein thrombosis. Methods: From March 2018 to April 2019, a total of 11 patients with liver cirrhosis and extensive portal vein thrombosis were treated by TIPS combined with AngioJet mechanical thrombectomy, including 6 males and 5 females, with the age of 37-71 (46±9) years old, 3 cases of Child-Pugh grade A, 8 cases of grade B and 0 cases of grade C. The intraoperative immediate thrombus clearance rate, perioperative complication rate, postoperative thrombus recurrence rate, rebleeding rate, the incidence of hepatic encephalopathy and the rate of stent patency of all cases were collected and analyzed. Results: All the patients were treated successfully. The immediate complete thrombus clearance (grade Ⅲ) rate of portal vein trunk was 9/11, and grade Ⅱ was 2/11, The average dose of urokinase was 30-60 (40±5) ten thousand U, slight puncture point bleeding occurred in 3 cases, and recurrence of PVT in portal vein trunk occurred in 1 case with Ⅱ grade clearance rate after operation, rebleeding occurred in 1 case, hepatic encephalopathy occurred in 2 cases, the primary patency rate of stents was 9 cases. Conclusion: TIPS combined with AngioJet mechanical thrombectomy can treat the liver cirrhosis with extensive portal vein thrombosis effectively and safely, and postoperative portal vein patency rate and intrahepatic shunt patency rate are high.

Objective: Catheter-directed thrombolysis in the treatment of acute iliofemoral deep venous thrombosis (IFDVT) often requires more than one interventional session to yield successful outcomes. Catheter-directed thrombolysis is generally expensive, requiring prolonged hospital stay that may be associated with increased local and systemic hemorrhagic complications. We developed the fast-track thrombolysis protocol (FTTP) to address these issues. The goal of FTTP is to restore patency during the initial session of thrombolysis, thereby minimizing costs and complications associated with prolonged thrombolysis., Methods: A retrospective analysis of 38 patients treated for acute IFDVT using FTTP at our institution from January 2014 to February 2019 was performed. The protocol includes periadventitial injection of lidocaine at the venipuncture site under ultrasound guidance, contrast venography of the entire target segment, pharmacomechanical rheolytic thrombectomy of the occluded venous segment, tissue plasminogen activator infusion along the occluded segment, balloon maceration of the thrombus, and, if indicated, venous stent placement in areas of significant (≥50%) stenosis refractory to thrombolysis and balloon angioplasty. Once the thrombus was cleared, patients were prescribed oral antithrombotic therapy., Results: Thirty-eight primary FTTPs (45 total interventions) were performed in 38 patients. The median age was 66 years (range, 39-93 years); 60.5% were female. Initial venous access was most often obtained through the popliteal vein, followed by the femoral and great saphenous veins. The mean operative time was 122 minutes (range, 59-249 minutes), and the median volume of tissue plasminogen activator infused was 10 mg (range, 4-20 mg). The median cost per procedure, including devices and medication, was $5374.45. Median postoperative length of stay was 1 day (range, 1-45 days). Successful single-session FTTP, as determined by completion venography, was accomplished in 81.5% (n = 31/38) of cases. The remaining seven cases (18.5%) required one additional session. Of the 38 patients, 30 (79%) required iliac vein stenting. Periprocedural complications consisted of one patient with retroperitoneal hemorrhage that was managed conservatively. No patients experienced rethrombosis within 30 days of FTTP. During the 5-year study period, there were no cases of pulmonary embolism, significant local or systemic hemorrhage, limb loss, or mortality., Conclusions: FTTP, as presented herein, appears to be a safe, effective, and cost-effective technique in the resolution of acute IFDVT., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to investigate the risk of postoperative acute kidney injury (AKI) in patients with acute iliofemoral deep venous thrombosis (IFDVT) who underwent percutaneous pharmacomechanical thrombectomy (PMT) using AngioJet (Boston Scientific, Marlborough, Mass) or catheter-directed thrombolysis., Methods: Electronic medical records of patients with acute IFDVT from January 2014 to September 2017 were reviewed. Those who received PMT with AngioJet (AJ-PMT group) or catheter-directed thrombolysis (CDT group) were included in this study. Baseline characteristics were recorded and compared. Postoperative serum creatinine concentration was compared with baseline serum creatinine concentration to determine the occurrence of postoperative AKI. Hemolysis was diagnosed on the basis of the decrease of hematocrit (HCT) and the occurrence of hematuria. The incidence of postoperative AKI in the two groups was analyzed. Univariable analysis and logistic regression analysis were used to determine risk factors that contribute to postoperative AKI., Results: A total 198 patients with acute IFDVT were included (79 in the AJ-PMT group, 119 in the CDT group). Baseline data of the two groups were of no statistical difference. The AJ-PMT group suffered more from acute hemolysis (P = .018). Compared with baseline HCT, the absolute HCT reduction of each group was of statistical significance (P < .01). The percentage change of absolute HCT of the two groups was of statistical significance (P < .01). Univariate analysis and multivariate analysis demonstrated that percutaneous AJ-PMT (odds ratio [OR], 2.82; 95% confidence interval [CI], 1.16-6.82; P = .02), history of major surgery within 3 months of endovascular intervention (OR, 8.51; 95% CI, 2.90-24.94; P < .01), and HCT drop >14% (OR, 2.73; 95% CI, 1.08-6.87; P = .03) are independent risk factors that raise the odds of postoperative AKI., Conclusions: In patients with acute IFDVT, AJ-PMT will raise the risk of postoperative AKI compared with CDT, especially in patients with a history of major surgery within 3 months of endovascular intervention. AJ-PMT causes more hemolysis and hematuria. An HCT drop >14% may indicate upcoming AKI., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Venous thromboembolism, including deep vein thrombosis and pulmonary embolism, occur in up to 900,000 people per year in the United States. Current first-line therapy consists of systemic anticoagulation with a goal to prevent additional thrombus formation. Treatment with anticoagulation alone provides less than satisfactory results with some studies showing propagation of thrombus in almost 40% of cases. Current first-line therapy does not include active removal of thrombus and does little to alleviate acute symptoms and the damaging inflammatory response that may result in postthrombotic syndrome. As the public and clinicians continue to recognize the unmet need of venous disease, endovascular therapies, such as catheter-directed thrombolysis, mechanical thrombectomy, and pharmacomechanical catheter-directed thrombolysis, have been developed to provide minimally invasive therapy while minimizing complications. The article discusses the advantages and disadvantages of endovascular interventions for venous disease., (Copyright © 2018 Elsevier Inc. All rights reserved.)