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FIGURE 18.13 Pathology of an old saphenous vein bypass graft. Severe atherosclerotic thrombotic changes within the grafts’ lumen. T, thrombus.
(A) (B)
FIGURE 18.14 Laser in revascularization of a heavy thrombus burden. (A) Thrombus grade 4 (within the red circle) in the proximal segment of the left
anterior descending artery. Another thrombusdwhich could have been a dislodged portion of the heavy proximal clotdis located in the middle segment
of the vessel (within the white circle). (B) The vessel’s angiographic appearance following laser thrombolysis as obtained with a 1.4-mm excimer laser
catheter. (C) Final angiogram after stenting of the vessel demonstrating complete patency of the infarct-related artery.
(C)
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FIGURE 18.15 The console of the AngioJet ULTRA system (Boston Scientific, Boston, MA, USA).
FIGURE 18.16 Schematic representation of the rheolytic thrombectomy system of the AngioJet.
study, the large JetStent prospective multicenter study was launched. The purpose was to compare the effect of the
AngioJet with direct stenting on myocardial reperfusion, infarct size, and clinical outcomes in STEMI patients [105] The
study exclusively focused on STEMI patients with angiographically visible thrombus, using only slow, single-pass
antegrade thrombectomy and a narrower temporal definition of early ST-segment resolution (i.e., more than 50%
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FIGURE 18.17 An array of the AngioJet catheters.
resolution within 30 min). In total, 501 STEMI patients with visible thrombus (TIMI thrombus grade 1e4) or with a totally
occluded infarct-related vessel (TIMI thrombus grade 5 with subsequent restratification) (see Chapter 12) were enrolled. At
baseline both groups had a thrombus grade of 3e5 in 99% and TIMI 0 flow in 83% of the patients. Platelet receptor
antagonist was used in 97% and 98%, respectively. A 93% procedural success rate was achieved in both groups.
The results demonstrated improved myocardial reperfusion with the AngioJet as determined by higher rates of early
ST-segment resolution (86% vs. 79%, respectively, P ¼ .04). A significant difference in MACE rate was observed between
the groups at 1 and 6 months: 3.1% for AngioJet versus 6.9% for direct stenting (P ¼ .05) and 12% versus 21% (P ¼ .01),
respectively. No difference was found between the two strategies regarding myocardial blush score and corrected TIMI
frame count. Multivariate regression analysis showed that randomization to rheolytic thrombectomy was a predictor of
ST-segment resolution (odds ratio [OR] 1.7, 95% CI 1.03e2.8, P < .039) and 6 months MACE rate (hazard ratio [HR] 0.5,
95% CI 0.31e0.82, P ¼ .06).
Although stent thrombosis is infrequent, it carries potentially devastating cardiac complications. The AngioJet plays an
important role in revascularization of patients with coronary stent thrombosis. Silva and colleagues were among the first to
examine the role of this device in this clinical context and conducted a multicenter study to assess the feasibility, efficacy,
and safety of rheolytic thrombectomy for treatment of stent thrombosis [106]. They enrolled 18 patients with angiographic
evidence of in-stent thrombosis (mean time to stent thrombosis 2.4 days). Device success was obtained in 94% and
procedure success was achieved in 100% of patients. TIMI 3 flow was obtained in 94%. The angiographic thrombus area
decreased very significantly from 113.7 79 to 5.5 5.7 mm
finally to 0.9 mm
2
after adjunct stenting. Procedure complications were limited to transient “no-flow” phenomena in five
2
(P < .001) after application of rheolytic thrombectomy and
patients. Only one patient developed a Q-wave MI and at 30 days follow-up no patients suffered death, need for emergency
bypass surgery, or stroke. The investigators concluded that adjunct use of rheolytic thrombectomy offers improved outcomes compared with prior results of interventions for coronary artery thrombosis and, therefore, it should be strongly
considered as a treatment option for this complication. This conclusion was supported and reconfirmed by others. Thus, at
the time of this writing, the AngioJet should be considered a critical tool, arguably the best and preferred technology for
management of stent throm bosis, especially when significant thrombus burden is present [32].
X-SIZER THROMBECTOMY SYSTEM
The power-sourced X-Sizer thrombectomy catheter (ev3, Minneapolis, MN, USA) is considered one of the most userfriendly mechanical thrombectomy devices [107] . The device consists of a helical cutt er enclosed within a protective
housing attached to a dual-bore catheter shaft containing guidewire and vacuum /extraction lumens. Activation of the
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(A) (B)
(C) (D)
FIGURE 18.18 Revascularization of a totally occluded old saphenous vein graft (SVG) with the “SVG sculpturing” technique. This multistep technique
aims at revascularization of totally occluded SVGs, which continue to account for significant ischemia. The patient underwent two coronary artery bypass
grafts prior to presentation with unstable angina of several weeks’ duration. A third-degree arteriovenous (AV) block developed, accompanied by
hypotension and worsening chronic renal failure. Angiographically, a year earlier, both the right coronary artery (RCA) and its saphenous vein bypass
graft were completely occluded; however, significant inferiorelateral ischemia persisted. (A) An 8-Fr multipurpose guide with side holes positioned firmly
at the ostium of the occluded SVG (arrow). (B) Advancement of a Whisper guidewire (Abbott Vascular, Temecula, CA, USA) into the proximal portion
of the graft (arrow) met resistance and it was enhanced with a supporting crossing catheter (QuickCross, Spectranetics, Colorado Springs, CO, USA).
(C) The guidewire reaching the distal anastomosis site (arrow). It was exchanged with the sturdy Platinum Plus supporting guidewire (Boston Scientific,
Boston, MA). (D) Rheolytic thrombectomy catheter (AngioJet) activated, slowly performing antegrade and retrograde thrombus removal along the
occluded graft, which resulted in retrieval of a large volume of thrombotic content. (E) Angiogram of the initial recanalization postthrombectomy.
(F) Selective administration of 20 mg tissue plasminogen activator (tPA) into the graft through a ClearWay (Atrium Medical, Hudson, NH) RX local
therapeutic infusion catheter (arrow). (G) Angiogram after 20 min dwelling time of tPA activity within the old graft. (H) Final angiogram after stenting of
the SVG body and the distal anastomosis site. Antegrade TIMI 3 flow was restored along the treated graft accompanied by alleviation of both chest pain
and ischemia as well as achievement of hemodynamic stability and electrocardiographic return to the baseline sinus rhythm with first-degree AV block.
The renal function improved from preprocedure creatinine level of 3.1 to the chronic baseline level of 2.0 as a result of improved cardiac output and
renal perfusion. From the chapter “Thrombus containing lesion.” In: Topol EJ, Teirstein PS, editors. Textbook of interventional cardiology. 7th ed.
Philadelphia: Elsevier; 2014. p. 439e67. With permission of the author and Elsevier.
handheld controller simultaneously rotates the helical cutter at 2100 rpm, which entraps and macerates soft atherosclerotic
plaque and thrombus, and then channels the extract into a vacuum collection bottle. The X-Sizer operates 1.5-, 2.0-, and
2.3-mm-diameter cutters and is compatible with 0.014-inch guidewires (Fig. 18.19). In the United State s, the prospective
study X-TRACT-AMI (X-Sizer for Treatment of Thrombus and Atherosclerosis in Coronary Interventions Trial in Acute
Myocardial Infarction) evaluated the safety and feasibility of the X-Sizer application prior to primary angioplasty in native
coronary arteries and SVGs in patients presenting within 24 h of AMI onset. A total of 216 patients (220 target lesions)
were enrolled in 28 sites with 90% of the thrombotic lesions located in native coronary arteries and 10% in old bypass
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(E) (F)
(G) (H)
FIGURE 18.18 cont’d
FIGURE 18.19 The X-Sizer coronary thrombectomy system.
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SVGs. TIMI 0/1 flow was present in 56% of patients, with angiographic thrombus in 76%, while normal TIMI 3 flow was
noted in only 27 % of patients. Immediate postthrombectomy TIMI 3 flow was demon strated in 81% and then in 92%
upon completion of the PCI. Abnormal myocardial blush grade 3 was present in 94% of patients at b aseline , improving to
52% postprocedure. At 30 and 360 days, 93% and 81%, respectively, of patients were free of MACE. Based on this
broad multicenter experience, the investigators concluded that th e application of the X-Sizer thrombectomy device prior
to stent implantation in thrombus-containing lesions occupying native coronary arteries and diseased SVGs was feasible
and safe and associated with high rates of normalized postprocedure epicardial blood flow and myocardial blush. In Asia,
Lee and colleagues performed 200 X-Sizer procedures from 2000 to 2005 [108]. Logistic regression analysis showed that
ostial lesion of the target vessel was the only independent predictor of device failure (OR 4.89, 95% CI 1.23e19.51,
P ¼ .024). The X-Sizer failure was independently associated with 30-day adv erse events (OR 3.42, 95% CI 1.04e11.25,
P ¼ .043).
In Europe, Napodano and colleagues studied 92 AMI patients [109], demonstrating that direct PCI for AMI with
X-Sizer thrombectomy followed by stenting significantly improves myocardial reperfusion as assessed by myocardial
blush score and ST-segment resolution. The large, prospective X-AMINE (X-Sizer in Acute Myocardial Infarction Patients
for Negligible Embolization and Optimal ST Resolution) multicenter study that followed demonstrated a device success
rate of 87% and adequate thrombus removal in 95% of the lesions [110]. The X-Sizer is curren tly in use mainly in Europe.
Fig. 18.20 illustrates the application of the X-Sizer in a vessel containing heavy thrombus load.
(A) (B)
FIGURE 18.20 X-Sizer application in a patient with ST-segment elevation myocardial infarction. (A) The infarct-related artery, the left anterior
descending, contains a heavy thrombus burden. (B) Thrombus removal with the thrombectomy device led to adequate angiographic exposure of the
underlying atherosclerotic plaques. (C) Final angiography poststenting demonstrates adequate revascularization. From the chapter Thrombus containing
lesion. In: Topol EJ, Teirstein PS, editors. Textbook of interventional cardiology. 7th ed. Philadelphia: Elsevier; 2014. p. 439e67. With permission of the
author and Elsevier.
(C)
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ULTRASOUND
Power-sourced devices producing low-frequency, high-power sonication of thrombus with resultant dissolution are a
useful technology in coronary [111,112] and peripheral arterial [113] interventions alike. Ultrasound can also be offered as
adjunctive therapy aimed at increasing the efficacy of common thrombolytic therapies [114,115]. A comprehensive
description of the ultrasound concept, research, related interventional technology, and clinical applications is presented in
Chapter 20.
SUMMARY
Patients experiencing acute or chronic coronary and peripheral atherosclerotic vascular diseases frequently exhibit intraarterial thrombus. Thrombus, whether angiographically visible or invisible, presents a considerable technical obstacle to
the attainment of revascularization goals and opti mal outcome. Thrombus is associated with an increased complication rate
and continues to influence prognosis during and after PCIs. In patients with a large clot or especially in those with heavy
thrombus burden, standard pharmacotherapy and removal with manual aspiration catheters offers considerably limited
yield. As a result, in most instances this task requires incorporation of power-sourced mechanical thrombectomy device s.
The mainstay representatives of these tools are the rheolytic thrombectomy system, various-wavelength lasers, the X-Sizer
extractor, and the ultrasonic energy catheter. Proper thrombus clearance is associated with lower mortality and a lower
incidence of recurrent MI, composite of MI and death, recurrent myocardial ischemia, severe arrhythmias, congestive heart
failure, and shock. Thus, power-sourced mechanical thrombectomy devices have a specific role in the percutaneous
management of challenging ischemic thrombotic syndromes and conditions.
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