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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3823_Библиотеки_им_академика_М_И_Перельмана
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sheath should be opened to allow back‐bleeding of any
retained clot. An angiogram is performed to evaluate for
residual thrombus. If present, aspiration through the
guide catheter can be repeated after replacing the wire
(Figure 7.7).
Dedicated thrombectomy catheters such as the Export
(Medtronic, Minneapolis, MN, USA) and 5MAX ACE
(Penumbra, Alameda, CA, USA) have also been used
with success. The Export catheter has a dual lumen
design which allows for the guidewire to remain in place
while thrombus is aspirated through the second lumen.
This design facilitates multiple passes without having to
replace a wire in between aspirations. The 5MAX ACE
catheter is available in several sizes with the largest inner
diameter size of 0.068″. Aspiration of the Penumbra
family of catheters is facilitated through a proprietary
pump system. Once the Penumbra aspiration catheter is
advanced to the level of the thrombus, the wire is
removed, and the aspiration tubing is connected to the
catheter. The pump is turned on and the thrombus is
aspirated. In both aspiration systems, the device should
be completely withdrawn from the patient’s body. Any
clot should be expelled and the catheter flushed before
reintroducing it for another sweep if necessary.
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Figure 7.7 6 Fr 55 cm vascular sheath advanced into the
SMA via a right femoral approach. A Penumbra
thrombectomy catheter has been placed coaxially and is
used to aspirate thrombus.
Step 4. Angiogram
A postaspiration angiogram is performed. A residual
disease can be treated with angioplasty, thrombolysis, or
stent placement (Figures 7.8 and 7.9).
Step 5. Thrombolysis
A hydrophilic guidewire is advanced through the
thrombus. A variety of multi‐sidehole infusion catheters
are available including standard infusion and an EKOS
ultrasound augmented infusion catheter (BTG, London,
UK). A treatment length of 10 cm is sufficient. After
confirming the catheter positioning, the wire can be
removed, and infusion started. If an EKOS catheter is
used, the wire is exchanged for a transducer wire. The
transducers emit a high‐frequency, low ultrasound
energy which loosens the fibrin lattice within the clot.
This enhances the penetration of the thrombolytic agent
and exposes more plasminogen receptor sites.
Recombinant tissue plasminogen activator (TPA) is the
most commonly used lytic agent. TPA is infused through
the catheter directly into the thrombus at a rate of 0.5–1
mg/h.
Figure 7.8 Residual stenosis (arrow) after aspiration of
thrombus.
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Figure 7.9 Angioplasty of stenotic lesion in SMA using
Savvy 5 mm × 4 cm angioplasty balloon (Cordis, Milpitas,
CA) over a V‐18 wire.
Step 6. Infusion and Follow‐Up
Infusion times can range from 12 to 24 hours and can be
done in a monitored unit setting. The vascular access
sheath and infusion catheter should be secured to
prevent accidental movement or dislodgment. The
patient can then be transferred out of the angiography
suite as TPA is infusing. During infusion, arterial
punctures should be avoided. Fibrinogen and partial
thromboplastin time (PTT) should be monitored every
six hours. If fibrinogen levels fall below 150, the TPA
dose should be halved, and if below 100 – TPA should be
discontinued. After completing the infusion, the patient
will return for an angiogram, and treatment of any
underlying stenosis with angioplasty or stent placement.
Stent placement, if necessary, should be done with a
balloon‐expandable stent. The principles of stent
placement are similar to CMI.
Mesenteric Venous Thrombosis
If a diagnosis of mesenteric venous thrombosis is made,
and there is no evidence of peritonitis, medical
management with anticoagulation is first‐line therapy.
The use of intravenous systemic intravenous TPA has
been reported with success [36], though is rarely used
due to risk of bleeding. If signs of peritonitis develop,
emergency surgery with resection of necrotic bowel is
indicated. If the patient is not improving with
anticoagulation alone, a trans‐jugular intrahepatic
portosystemic shunt (TIPS) can be placed followed by
thrombectomy and/or lysis of the mesenteric venous
clot. The shunt will function as a low‐resistance outflow
tract for the effected mesenteric vein. The technique of
TIPS placement is beyond the scope of this chapter.
Follow‐Up and Outcomes
Patients will require lifelong therapy depending on the
etiology of AMI. Embolic disease will necessitate
anticoagulation therapy with coumadin or an alternate.
Those patients with arterial thrombosis should be
treated with a statin and an antiplatelet agent [28].
Patients with AMI treated with endovascular therapy
have a 12.3% in‐hospital mortality rate compared with
33.1% for open surgical revascularization. Endovascular
therapy is also associated with a lower mean
hospitalization cost and decreased risk of acute renal
failure [37].
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