Hydrophilic polymer embolization after thoracic endovascular aortic repair

Abstract

Hydrophilic polymer embolization is a rare complication after endovascular procedures that is currently underappreciated. Present understanding on this phenomenon relies on sparse case reports with histologic evidence of foreign polymers in end-organ tissue. Here, we report two deaths associated with hydrophilic polymer embolization after complex thoracic endovascular aortic repair.

Evaluation of hydrophilic polymer embolization from endovascular sheath devices in an in vitro perfusion system

“…Although hydrophilic polymer coatings have improved device and vessel trauma-associated morbidity and mortality, HPE has been attributed to various complications, including distal ischemia and, even, death after common aortic and cardiac procedures such as thoracic endovascular aortic repair and transcatheter aortic valve implantation. 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 A review of the literature found many case reports of HPE secondary to percutaneous intervention. However, it is likely, given the broad scope of how this phenomenon presents clinically, that HPE is likely significantly underrecognized and subsequently underreported.…”

“…HPE can be identified clinically as distal ischemic skin lesions, renal dysfunction, stroke, respiratory complications, mesenteric ischemia or infarction, and a wide variety of clinical sequelae depending on the location of polymer embolization. 1 , 4 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 Despite the presence of these reports, studies quantifying polymer shedding in the in vitro setting and direct comparisons between products are lacking. In vitro manipulation of a Fastracker-18 infusion microcatheter (Target Therapeutics) produced particulate that shared Gram stain properties found on autopsy in four cases.…”

“…As evidenced by our own clinical experience, two deaths occurred from the sheer amount of polymer identified in multiple organ beds. 10 Furthermore, the inflammatory reaction resulting from widespread polymer embolization would likely result in a global inflammatory response and significant clinical sequela. Particle size vs particle quantity is an important clinical question not answered by the present study but should be considered for future studies.…”

“… 2 , 3 , 4 , 5 , 6 An increasing body of case reports has described hydrophilic polymer embolization (HPE) events leading to various clinical sequelae, including ischemia, infarction, and death. 6 , 7 , 8 , 9 , 10 In 2009, one of the first recorded deaths clearly attributed to widespread embolization of hydrophilic polymer material was documented by Mehta et al. 7 Their report exposed hydrophilic polymers as having the potential, not only to induce local inflammatory reactions, but also to cause distal and fatal embolic damage.…”

Cutaneous hydrophilic polymer embolism in a patient with acute kidney injury post endovascular procedure

“…HPE is a rarely reported complication of endovascular procedures [3] , whereby outcomes depend on the affected organ, ranging from spontaneous resolution to death due to occlusion of vessels in vital organs. The exact mechanism by which polymer material embolises is uncertain, but it involves several factors including irregularity of the endothelial wall, whereby the hydrophilic material 'sheds off' downstream.…”