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472 Chapter 50/Percutaneous Mechanical Thrombectomy in the Treatment of Acute Deep Venous Thrombosis
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Oasis
The Oasis catheter (Boston Scientifi c, Natick, MA), originally marketed as the Shredding Embolectomy Thrombectomy catheter, is a triple-lumen catheter placed over a
guidewire that allows for the infusion of saline and simultaneous aspiration of thrombus. In contrast to the ATS
system, which requires a separate drive unit, the Oasis can
be powered by a standard power injector. The presence of
the dedicated wire lumen also avoids a reduction in suction
through the exhaust lumen that can be observed with the
ATS device.
In a canine DVT model, the Oasis catheter has an 80%
procedural success rate. All vessels exhibited endothelial
denudation that occasionally extended into the internal
elastic lamina while no injury extended to the media. Signifi cant pulmonary embolization was not observed.
55
Technical success in the treatment of thrombosed dialysis
grafts approaches 90%, and clinical success, defi ned as the
ability to access the grafts for dialysis, ranges from 76 to
56,57
81%.
Takahashi et al. reported a single case of successful
use of the Oasis thrombectomy device to treat a symptomatic mesenteric venous thrombosis in the portal and superior
mesenteric veins.
58
ProLumen
Approved for use in hemodialysis access, the ProLumen
(Datascope, Montvale, NJ) is a self-contained thrombectomy catheter that requires no additional equipment. The
device contains a 0.035″ stainless steel S-wire with a radiopaque tip. With a 5.8-Fr outer diameter, the catheter has a
handheld battery operated drive unit that rotates the sigmoid
shaped S-wire at approximately 4000. The S-wire maintains
contact with the graft wall to release adherent thrombus. No
reports are published to date using the ProLumen for treatment of DVT.
8Fr Multi-
Lumen
Catheter
Isolated Treatment Zone
FIGURE 50.4 The Trellis-8 Thrombectomy System.
Inflation/Infusion
Ports
Oscillation
Drive
Unit
bosis. In both reports, use of the TTS resulted in shorter
treatment times when compared to CDT alone, and decreased
doses of the thrombolytic agent used. No bleeding complications were reported in any of the patients described. Neither
patient described had a bleeding complication or pulmonary
embolism reported.
59,60
X-Sizer
The X-Sizer helical thrombectomy catheter (ev3, Plymouth, MN) is comprised of a rotating helical cutter that is
housed in an outer sheath. The device is attached to a vacuum
source for the aspiration of particulate matter created during
the procedure. The device has been evaluated in the coronary arterial circulation, but to date treatment of hemodialysis grafts, the peripheral arterial tree, and the venous system
has not been reported.
Trellis-8 Thrombectomy System
The Trellis-8 Thrombectomy System (Bacchus Vascular,
Santa Clara, CA) combines CDT and PMT by isolating the
thrombosed venous segment between proximal and distal
occlusion balloons. After a thrombolytic drug is infused into
this closed system, a sinusoidal wire mixes the lytic agent
into the thrombus together. The balloon occlusion limits
systemic exposure to the lytic agent and prevents pulmonary
emboli. The slurry created in the treated segment is then
aspirated to remove lysed clot and the residual active drug.
The Trellis-8 Thrombectomy System (see Figure 50.4)
has been successful in treating both upper and lower extremity venous thrombosis. Arko et al. reported use of the TTS
to treat two patients with axillosubclavian vein thrombosis.
Ramaiah et al. used the TTS to treat an iliofemoral throm-
DISCUSSION
An increasing number of patients with acute DVT are
undergoing treatment with PMT. Advantages of PMT
include immediate improvement of symptoms, decreased
treatment times and complications when compared to CDT
alone, and a possible reduction in the incidence and severity
of PTS. Although many PMT catheters are commercially
available, only the Trellis-8 Thrombectomy System and the
ATS lytic power pulse system are approved by the FDA for
treatment of acute DVT.
59
Some PMT catheters, such as those just mentioned, are
designed to allow for the concomitant infusion of thrombolytic agents in order to more thoroughly remove thrombus.
Discussion 473
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The combination of PMT and pharmacologic thrombolysis
can drastically reduce the treatment times compared to CDT
alone. Arko et al. reported complete thrombus removal in
two patients using the Trellis-8 Thrombectomy System with
Alteplase (Genentech, South San Fransisco, CA) for UE
DVT. These two patients were treated at a single setting and
received 5 mg of Alteplase over 10 minutes.
59
When evaluating these devices in the treatment of thrombosed hemodialysis access, the ATS, ATPTD, and Oasis
were found to have equivalent technical success rates when
compared to pulse-spray thrombolysis.
28,56,61
The procedure
times were signifi cantly shorter in the groups that underwent
38,56
PMT.
Complications such as bleeding requiring transfusion, pulmonary embolization, and arterial embolization
were less in the PMT arm, but statistical signifi cance was
not reached due to the small number of patients.
38
PMT most often allows patients to be treated in a single
setting, thereby avoiding multiple trips to the angiography
suite. Ramaiah et al. reported a single case of a patient that
developed increased thrombus burden while on heparin.
After failure following 36 hours of CDT with reteplase
(Centocor, Horsham, PA), PMT using the Trellis-8 Thrombectomy System was successful with complete clot lysis in
45 minutes.60 Similar results have been reported in the treatment of upper extremity DVT when using the Trellis-8
Thrombectomy System.
59
Bleeding complications may be less when compared
to CDT. In 17 patients treated with PMT for LE DVT,
Kasirajan et al. observed no hemorrhagic or access site complications.34 Bush et al. reported two patients that developed
access site hematomas and one developed a retroperitoneal
hematoma out of 20 patients treated for DVT with the ATS.
None required surgical intervention or transfusion.
33
The discovery of an underlying venous stenosis can occur
after PMT. Thirty-eight to 95% of patients have been shown
to have a lesion that is treated with percutaneous angioplasty
or primary stenting. Importance should be placed on opening
these stenoses so as to avoid outfl ow obstruction. Reducing
outfl ow obstruction helps prevent recurrent DVT and further
reduces the severity of PTS.
Many authors have described the use of various PMT
catheters in the treatment of DVT. To date no prospective
randomized in vivo trial has been performed comparing
PMT to other various methods of DVT treatment. In an
in vitro model, Müller-Hülsbeck et al. compared the ATS
without a guidewire, with a 0.016″ guidewire, and with a
0.035″ guidewire to the Hydrolyser, Oasis, and Amplatz
Thrombectomy. Interestingly, the ATS had signifi cantly less
thrombus removal using the 0.016″ guidewire compared to
other confi gurations. No signifi cant difference was found
among the other catheters. The highest percentage of embolism was noted with the ATS.
50
Delomez et al. reported use of the Amplatz Thrombectomy Device in 18 patients with symptomatic LE DVT.
Successful recanalization was reported in 83% of patients.
A permanent IVC fi lter was placed in one patient and a
temporary fi lter placed in another. No pulmonary emboli
62
were reported.
The time thrombus was present prior to
treatment ranged from four to 240 days. The age of DVT
that can still be optimally treated with PMT has not been
determined. Generally two weeks represents a common
window used by many practicioners.
47,62–64
Thrombus older
than this begin to have a denser fi brin network and are more
resistant to PMT. Moreover, older thrombi are associated
with an increased incidence of distal embolization.
63
PMT can also be used alone or in conjunction with
thrombolytic therapy. In one study comparing multiple
thrombectomy devices and lytic agents, Vendatham et al.
reported improved results when coupling the two modalities
compared to using either independently.23 This retrospective
review analyzed 20 patients who underwent 22 procedures.
Due to the retrospective nature of the study, the methods of
CDT and the timing and use of PMT could not be controlled.
Vendatham reported an 82% procedural success when both
modalities were combined. Major bleeding requiring transfusion occurred in three patients. Reduced doses and thrombolytic infusion times were observed in those undergoing
adjunctive PMT. Based on his fi ndings, he concluded that
PMT has an important role in the endoluminal therapy for
DVT.23 Siablis et al. compared the ATS to CDT for the
treatment of massive pulmonary embolism. He found signifi cant decrease in the mean urokinase dose and duration
of therapy in the ATS group.
36
Many clinical scenarios exist in daily practice in which
pharmacologic therapy with either thrombolytic agents or
anticoagulation are contraindicated. Although an IVC fi lter
can be placed for prophylaxis against PE, serious short- and
long-term sequelae can still threaten the limb. Aside from
the short-term decrease in quality of life from edema and
pain, the long-term sequelae of PTS are devastating. Multiple reports illustrate resolution of edema, pain, and disability
with the use of PMT alone.
33,34,48
Other advantages include
minimizing bleeding complications and shorter hospital
stays. The benefi ts of immediate improvement of leg edema
following the use of PMT are underestimated. Although
PMT is not indicated in some scenarios (e.g., patients with
very poor prognosis and DVT), a majority of patients may
prove to benefi t. More prospective studies are needed to help
determine who will benefi t most. As technology continues
to change rapidly, past studies can be diffi cult to interpret.
Future research must also take into account quality of life
measures in the short and long term.
Potential disadvantages of PMT are related to the individual catheter designs. Common to the catheters that utilize
the Venturi effect is the potential for fl uid overload resulting
in congestive heart failure and pulmonary edema. The
ATS, Hydrolyser, Oasis, and ATD are all designed to function in an isovolumetric manner. Müller-Hülsbeck et al.
474 Chapter 50/Percutaneous Mechanical Thrombectomy in the Treatment of Acute Deep Venous Thrombosis
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evaluated all four PMT devices in an in vitro model, and
found that none functioned isovolumetrically. The ratio of
infused saline to aspirated fl uid improved for the ATS when
the guidewire was left in place. The Oasis was noted to have
the greatest discrepancy between infused saline and aspirated fl uid.
50
Another potential disadvantage of all PMT catheters is
hemolysis. Qian et al. found no signifi cant differences
regarding the hemolytic effect when comparing the Helix
thrombectomy catheter and the ATD.65 Gandini et al. evaluated plasma free hemoglobin (PFH) levels and hematocrit
in eight patients treated for iliocaval thrombosis with the
ATD, and found no signifi cant abnormality in either parameter in any patient after treatement.66 Ufl acker reported a
signifi cant increase in PFH in 13 patients treated with the
ATD. The PFH levels returned to normal within 24 hours.47
In preclinical evaluations, treatement with the ATS resulted
in a transient increase in PFH and a concomitant decrease
in the hematocrit.31 In 18 patients treated with the ATS for
DVT, Delomez et al. reported no postoperative anemia. One
patient developed a transient increase in haptoglobin without
clinical sequelae.62 However, Danetz et al. reported two
patients with chronic renal insuffi ency who developed pancreatitis after using the ATS.67 The degree of hemolysis is
directly proportional to the length of PMT. In patients with
chronic renal insuffi ciency, minimizing the treatment time
and careful attention to the hydration status may ameliorate
the occurrence of post-treatment pancreatitis. Use of the
ATPTD has not resulted in clinically signifi cant elevation
of the PFH after treatment of thrombosed hemodialysis
38
grafts.
Based on these observations, patients with renal and
hepatic insuffi ency should proceed with caution when considering PMT. The increased PFH can result in intranephronal cast formation resulting in acute renal failure. The
increased PFH also increases heme catabolism, which
enhances the formation of tetrapyrrol unconjugated bilirubin. The unconjugated bilirubin is metabolized and excreted
by the liver. Those with abnormal liver function may not
tolerate the increased PFH.47 Although these considerations
are paramount, no case of renal failure or fulminant hepatic
failure has been reported after PMT.
CONCLUSION
PMT offers many benefi ts in short-term therapy for
DVT. Faster thrombus removal, smaller doses of thrombolytic agents, and shorter treatment times translate into
improved symptom relief, decreased complications, and
more effi cient patient care. Additionally, more rapid thrombus resolution potentially can preserve valvular function and
decrease the incidence and severity of PTS. PMT should be
considered as fi rst line therapy for patients presenting with
DVT. Advanced endovascular skills, as well as being well
versed in possible complications of PMT, are required to
provide safe and effective patient care.
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CHAPTER
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51
Mechanical Thrombectomy and Thrombolysis for
Acute Deep Venous Thrombosis
WEI ZHOU, PETER H. LIN, RUTH L. BUSH, ERIC K. PEDEN, and ALAN B. LUMSDEN
INTRODUCTION
Deep venous thrombosis (DVT) is estimated to affect 20
to 30% of all major surgical patients, and, as a result of
pulmonary embolism, is responsible for more than 60,000
deaths annually in the United States.
strategy for acute DVT largely remains systemic anticoagulation to prevent worsening of acute symptoms, pulmonary
embolism, and recurrent thromboembolic events. However,
conservative therapy with anticoagulation alone is rarely
effi cient or suffi cient in reducing clot burden to prevent postthrombotic syndrome, particularly in iliofemoral systems.
Endovascular interventions, on the other hand, provide the
capability of rapidly reestablishing patency of the affected
veins, potentially preventing post-thrombotic complications,
and timely revealing an inciting venous defect in patients
with acute DVT. This chapter emphasizes on the rationale,
various methods, and results of thrombolysis for acute
DVT.
1,2
The current treatment
EPIDEMIOLOGY
Deep venous thrombosis has been recognized as a major
health problem in the western culture. Incidence of DVT has
been estimated at over one per 1000 per year in the United
States.3 Similarly, the annual incidence in a British population studied was measured at 3.5 per 1000 per year.4 In
Sweden, the incidence has been estimated at 1.6 per 1000
per year.5 Markel and colleagues followed a series of patients
with DVT for a period of fi ve years and discovered that most
involved veins had recanalized by six months and over 80%
were recanalized at one year. By three years, all veins had
recanalized, but residual thrombus was present in 50%.
6
Additionally, they noted that symptomatic DVTs involved
the proximal segments in 95% of patients.7 The venous
registry had similar fi ndings of iliofemoral involvement in
71% and the femoro-popliteal segment in 25%.
DVT is also a signifi cant marker for mortality. The oneyear mortality rate of DVT has been found to be 16 to 30%
with most deaths occurring within the fi rst month; this is at
least three times as high as age-matched controls without
3,8
DVT.
CLINICAL PRESENTATION
AND DIAGNOSIS
The classic presentations of DVT are swelling and tenderness, elevated temperature, and a positive Homans’ sign
(calf pain on dorsifl exion of the foot) (see Figure 51.1). In
an extreme scenario, phlegmasia cerulea dolens, as evident by the painful blue appearance of the leg, can occur
due to massive thrombosis involving the iliac veins and
extending into the most distal venules in the leg. Phlegmasia
cerulea dolens is a condition frequently associated with a
hypercoagulable state or external obstruction, such as an
underlying intraabdominal malignancy or May-Thurner
syndrome.
Clinical diagnosis of DVT alone is unreliable due to only
50% of patients with evidence of DVT on venography
having clinical symptoms. Venous duplex ultrasound, as the
primary imaging technique, is extremely useful. Spectral
Doppler can detect the presence of thrombus by determining
normal or abnormal fl ow in the vessels. Normal Doppler
will be unidirectional and spontaneous with respiratory
phasicity. Flow should cease with Valsalva maneuver,
and demonstrate augmentation by distal compression. The
8
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477
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Controversies still exist over the pathophysiology of post
thrombotic syndrome. Some authors believe that the primary
mechanism is refl ux, whereas others think that it is the combination of refl ux and obstruction that leads to the most
severe symptoms. Johnson studied the natural history of
DVT by utilizing duplex ultrasound and demonstrated that
the combination of refl ux and obstruction were three and a
half times more likely in the legs with evidence of postthrombotic syndrome than in those legs that appeared
normal.11 Their fi ndings are also supported by Mohr and his
colleagues, who demonstrated a progressive increase in
post-thrombotic syndrome over 20 years.9 The highest risk
group in their study were those patients under 40 with proximal DVT, who were three times more likely to develop
FIGURE 51.1 A painful left lower extremity with severe swelling and
erythema due to acute deep venous thrombosis.
post-thrombotic symptoms than other groups.
Longer duration of venous occlusion has been shown to
increase the likelihood of secondary refl ux, and thus post-
6,12
Additionally, the extent of the
Doppler will appear abnormal when there is substantial
occlusion of the vein. Flow augmentation and Valsalva will
be diminished or absent. The most reliable method for
detecting thrombus is compression. Compressions are done
in gray scale in a transverse plane. The thrombus can only
be ruled out when vessel walls completely collapse. Partial
thrombosis may be present if the entire vein does not
collapse.
thrombotic syndrome.
original DVT, particularly multilevel disease and recurrent
thrombosis, has been associated with an increased incidence
of post-thrombotic syndrome.13 Techniques aimed at valve
preservation and restoration of venous patency theoretically
should decrease venous hypertension, thus reducing the incidence and degree of post-thrombotic symptoms. Improvements in venous hemodynamics also should lead to overall
improvement in clinical symptoms. In fact, studies have
shown that earlier clearance of the clot burden led to preserved valvular function and less symptoms.
COMPLICATIONS AND POST-
THROMBOTIC SYNDROME
8,14
The potential complications of acute DVT include venous
gangrene, pulmonary embolism, recurrent thromboembolic
events, and the development of chronic venous insuffi ciency
or post-thrombotic syndrome. Anticoagulation therapy, the
current standard of care for acute DVT, may inhibit further
clot propagation and prevent pulmonary embolism. However,
it does not in itself prevent chronic post-thrombotic complications. The consequences of chronic venous insuffi ciency
and post-thrombotic syndrome are a major medical problem
and often results in a signifi cant lifestyle compromise for the
patient. DVT can render the venous valves incompetent,
resulting in a spectrum of clinical presentations ranging
from telengectasias and varicose veins through chronic
lower extremity pain and edema to venous skin changes with
lipodermatosclerosis and ulceration. The incidence of postthrombotic syndrome following proximal venous thrombosis has been measured at 16 to 82%.
3,9
The incidence of
ulceration has been estimated at 3 to 8% following DVT.
Following extensive lower extremity deep venous thrombosis, the post-thrombotic syndrome may manifest immediately or take several months or years to full patient
debilitation.
10
SURGICAL THROMBECTOMY
Surgical thrombectomy with distal arteriovenous fi stula
creation for acute DVT is mainly of historical interest
because of its associated operative morbidity primarily
related to blood loss and poor clinical outcomes. However,
surgical thrombectomy may still be used in the clinical
setting of venous gangrene with impending limb loss. The
best reported results are from a 1999 study by Juhan et al.
These authors demonstrated an improvement in long-term
results following surgical venous thrombectomy for acute
iliofemoral DVT in their personal series.15 In a review of 77
patients, principally young trauma victims, valvular competency was preserved at fi ve years in 80%, and 90% of limbs
had either mild symptoms of chronic venous insuffi ciency
or no symptoms at all. Additionally, Meissner and colleagues reported their results of venous thrombectomy with
arteriovenous fi stula in 30 patients.16 In all but three patients,
patency of the iliofemoral segment was maintained 12
months after clot extraction. However, other series have
demonstrated only average results for this all but abandoned
technique.
15
Thrombolysis 479
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THROMBOLYSIS
In light of the morbidity of post-thrombotic syndrome,
more aggressive treatment regimens for acute DVTs have
been proposed. The early reports of surgical thrombectomy
and its impact on post-thrombotic syndrome encouraged
development of nonsurgical methods to remove clots and
achieve the same goals with minimally invasive means.
Thrombolysis of DVTs offers potential rapid clearance of
thrombus from the obstructed segments and reduction of
subsequent obstruction and refl ux. A review done by Comerota of 13 studies comparing thrombolysis versus anticoagulation confi rmed the effi cacy of thrombolysis.14 Their
review also confi rmed that successful thrombolysis was
associated with a lower incidence of post-thrombotic syndrome and improved venous function during long-term
follow-up.
There are various means of achieving thrombolysis of
occluded venous segments. The basic options are chemical
thrombolysis given either systemically or catheter-directed
into the thrombus, percutaneous mechanical thrombectomy
(PMT), or the combination of the two, termed pharmacomechanical thrombectomy.
thrombolysis due in part to more complete clot lysis combined with a lower rate of bleeding complications. By using
one of the many commercially available multiple sidehole
infusion catheters, higher drug concentrations are delivered
directly to the location of the thrombus. An analysis of
multiple studies by Comerota and Aldridge demonstrated
increased success in treating patients with iliofemoral DVT
by utilizing catheter-directed thrombolysis.
Catheter-directed thrombolysis has been advocated
because of its theoretical advantage of complete and rapid
clot dissolution. Multiple studies have documented the effi cacy of several lytic agents in the treatment of acute DVT,
with total infusion times needed for thrombus removal
19–23
ranging from hours to days.
An association between time
to lysis and the development of venous refl ux was evaluated
in patients using serial duplex scans following a DVT
episode.24 With the exception of the posterior tibial vein,
early lysis and rapid venous recanalization appears to protect
valve integrity in the lower extremity. Although catheterdirected thrombolysis results in early thrombus clearance
and thus, potential lower incidence of post-thrombotic syndrome by preservation of valvular function,19 the complicated profi le of the lytic agent and the infusion times may
limit its widespread use.
Systemic Thrombolysis
Early reports documented success in treating phlegmasia
with streptokinase, with enthusiastic reports of excellent
results “beyond expectation.” Since then, several investigators have found benefi ts of systemic thrombolysis.
8,14
Comerota and Aldridge reviewed data from 13 studies comparing
anticoagulant therapy with thrombolytic therapy for DVT in
591 patients.14 They found that complete lysis was observed
in 45% of patients who received lytic therapy vesus 4% of
patients treated with heparin alone. In addition, patients with
successful lysis had a lower incidence of post-thrombotic
syndrome and improved long-term venous function during
long-term follow-up.
Not all reports of systemic thrombolysis had favorable
results. In a report of 250 patients with received systemic or
local therapy with rt-PA, streptokinase, or urokinase, Schweizer found signifi cantly greater patency and reduced incidence of post thrombotic syndrome in the group with lysis.
17
However, when taking into account a 5% major bleeding
complication rate and an apparent increase in pulmonary
embolism, they recommended selective use of systemic
thrombolysis for limb-threatening situations only. Other
studies also echo this observation.
18
Catheter-Directed Thrombolysis
The delivery of a pharmacologic lytic agent directly into
an existing venous thrombosis has overtaken systemic
Technique for Catheter-
Directed Thrombolysis
All procedures are performed in a fully equipped operating room with endovascular capabilities. Local anesthesia
with light sedation is administered in most patients, whereas
general anesthesia is used for patients not tolerating local
anesthesia with sedation. For acute lower extremity DVT,
the popliteal vein is cannulated using ultrasound-guided
venous puncture techniques with the patient in the prone
position (see Figure 51.2). Brachial vein is commonly
accessed for acute upper extremity DVT. Following puncture of the vessel with a 21-gauge needle, a 0.014″ guidewire
is inserted and subsequently exchanged for a 0.035″ guidewire. A 6 French guiding sheath next is advanced into the
vessel. Hand injection of 10–15 cc contrast is performed to
confi rm the diagnosis as well as defi ne the anatomy and
extent of the thrombus (see Figure 51.3). A 0.035″ angled
guidewire (Boston Scientifi c, MA) frequently is used to
navigate through the occluded vein with relative ease in the
setting of acute DVT. Next, the lysis catheter (Mewissen,
Boston Scientifi c) with appropriate infusion length is
advanced over the guidewire.
We typically start infusion by injecting 1- to 2-mg tissue
plasminogen activator (tPA) through the catheter. Note that
the Mewissen catheter must have a guidewire inserted to
block the end hole and force the lytic agent through the
side-holes. The tPA then is infused at the rate of 0.5 to
480 Chapter 51/Mechanical Thrombectomy and Thrombolysis for Acute Deep Venous Thrombosis
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FIGURE 51.2 Cannulation of the popliteal vein using ultrasound-guided
venous puncture techniques with the patient in the prone position.
FIGURE 51.4 Angioplasty being performed to macerate the residual
thrombus and achieve a patent venous lumen.
FIGURE 51.3 Ascending venogram being performed following cannula-
tion of the popliteal vein to confirm the diagnosis as well as define the
anatomy and extent of the thrombus.
1 mg/hour through the catheter, and heparin at 500 units/
hour is infused concurrently through side port of sheath.
The patient subsequently is returned to the endovascular
suite after 12 to 24 hours thrombolysis. A 0.035″ guidewire
is inserted and the infusion catheter is removed. A repeat
venogram is next performed by using hand injection of the
contrast. A new catheter may be placed and repositioned to
continue infusion if necessary. Once maximal thrombus
removal has been achieved, angioplasty often is performed
to macerate the residual thrombus (see Figure 51.4). Additional stents may be used for stenotic areas. The most
common location of extrinsic venous compression is at the
junction of the left common iliac vein with the inferior vena
cava. However, stenting of all areas with residual stenosis
is performed, even if it necessitates crossing the hip joint.
Wallstents are our stent of choice for venous angioplasty,
because of the large diameters and lengths. Failure to adequately resolve stenosis will result in rethrombosis.
PERCUTANEOUS MECHANICAL
THROMBECTOMY (PMT)
Although thrombolysis, both systemic and catheterdirected, is effective in relieving clot burden early and
potentially decreasing post-thrombotic complication, the
bleeding risks due to lytic agents have limited its usage.
Therefore, PMT has emerged as an advantageous option for
the treatment of acute DVT. There are several commercially
available thrombectomy catheters (see Table 51.1). However,
a full discussion of each of the catheters is beyond the scope
of this article. The catheters fall into one of two categories
for clot extraction mechanism: microfragmentation or
thrombo-aspiration (so-called Venturi effect). Several PMT
catheters may be used in combination with adjunctive
thrombolytic agents for more complete and rapid thrombus
removal with lower lytic infusion doses and durations.
Reducing the dosage and/or time for complete thrombolysis
should translate into cost savings and lower bleeding complications. Furthermore, inciting lesions leading to thrombosis may be unmasked with PMT with or without adjunctive
lysis. Venous stenoses could be treated following PMT and/
or thrombolysis in the same operative setting. Our experience is with the AngioJet® thrombectomy system (Possis
Medical Inc., Minneapolis, MN), which will be described in
this chapter.
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TABLE 51.1 Commercially Available and Investigational
Thrombectomy Devices
Mechanism of clot Clot suctioning
Catheter name extraction capability
AngioJet (Possis, Inc.) Venturi Yes
Hydrolyser (Cordis, Inc.) Venturi Yes
Oasis (Boston Scientifi c/ Venturi Yes
Meditech)
Amplatz (Microvena) Microfragmentation No
Helix (EV3) Microfragmentation No
Treretola (Arrow Microfragmentation No
International)
Casteñeda and Cragg Microfragmentation No
Brush (Micro
Therapeutics)
Trellis infusion catheter Microfragmentation Yes
(Bacchus Vascular)
FIGURE 51.5 A three-way stopcock is placed on the AngioJet Rheolytic
catheter outflow lumen between the catheter and the aspiration tubing. The
stopcock is in the off position converting the catheter into a lytic infusion
system.
directed jets. These high-velocity jets create a localized low-
Several authors have evaluated multiple PMT catheters
in the treatment of DVT. However, to date, there is no prospective, randomized trial data available. In one review,
Vedantham et al. used percutaneous mechanical thrombectomy (several devices tested including Amplatz Thrombectomy Device, Microvena, White Bear Lake, MN; AngioJet;
Trerotola Percutaneous Thrombectomy Device, Arrow
International, Reading, PA; Oasis, Boston Scientifi c/
Meditech, Natick, MA) with catheter-directed thrombolysis
for the treatment of lower extremity DVT.25 Procedural
success was achieved in 82% of the patients with underlying
culprit stenoses uncovered and stented in 15 patients (18
limbs). These authors reported substantial thrombus removal
with the two techniques combined compared to either alone.
Another group, using only the Amplatz Thrombectomy
Device, reported successful recanalization of the thrombosed segment in 83% of patients with proximal DVT.26 At
29.6 months follow-up, 10 patients had no or minimal symptoms relating to the episode and only one patient had developed post-thrombotic sequelae.
pressure zone (Bernoulli effect) for thrombus aspiration and
maceration. The jets also provide the driving force for evacuation of thrombus particulate debris through the catheter.
The Xpeedior catheter design also has a means for radially
directed low-velocity fl uid recirculation to assist with dislodgment from the vessel wall and direction to the catheter
®
tip for evacuation. The AngioJet
system works in an isovolumetric manner: the saline infusion fl ow rate (60 cc/min)
is in balance with the evacuation rate of thrombus particulate
debris.
The infusion solution of saline may be replaced with
saline mixed with a thrombolytic agent (1000 L saline combined with 250,000 u urokinase). A three-way stopcock is
placed on the catheter outfl ow lumen between the catheter
and the aspiration tubing. The stopcock can be positioned in
the off setting, thus converting the thrombectomy catheter
into a high pressure infusion—labeled “power pulse spray”
by interventionalists who use this technique (see Figure
51.5). After lacing the thrombus with the pharmological
agent and waiting an appropriate period of time (average 20
minutes), the stopcock is resumed in the open position and
Angiojet® Rheolytic Thrombectomy
System Description
The AngioJet® rheolytic thrombectomy system consists
aspiration performed (see Figure 51.6). If concern exists for
pulmonary embolism during this procedure, a dual-purpose
removable/permanent vena caval fi lter may be placed at the
beginning prior to PMT.
of three components: a single-use catheter, a single-use
pump set, and a pump drive unit. The 6 Fr Xpeedior catheter
has a working length of 60, 100, or 120 cm, is introduced
via a percutaneous approach (6 Fr sheath) and operates over
a 0.035″ guidewire. The dual lumen catheter design consists
of one lumen supplying pressurized saline to the distal catheter tip, and a second lumen incorporating the fi rst lumen,
guidewire, and thrombus particulate debris. The drive unit/
pump generates high pressure (∼10,000 psi) pulsatile saline
fl ow that exits the catheter tip through multiple retrograde-
Technique of PMT for the Treatment of DVT
The AngioJet® rheolytic thrombectomy system is
approved by the FDA for clot removal, particularly coronary
arteries and hemodialysis grafts. The techniques described
herein represent preferences of the authors based on experience, not recommendations from a manufacturer. Subsequent interventions such as endovascular stenting depend
upon the judgment of the treating physician.
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