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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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Figure 16.14 AngioVac cannula advanced to the right
pulmonary artery from a right internal jugular approach.
The wire was left in place to maintain position.
Tip: It may be easier to deliver the AngioVac to the
right pulmonary artery when using a right internal
jugular venous approach (Figure 16.14), whereas the
left pulmonary artery may be more amenable from a
right femoral venous approach.
AngioVac for Clot‐in‐Transit
In the setting of pulmonary embolism with clot‐in‐
transit, it may be advantageous to forgo general
anesthesia if possible. Anesthesia induction can cause
alterations in patient hemodynamics, which in the
setting of massive pulmonary embolism may worsen
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clinical status [12, 13] or possibly precipitate further
migration of atrial clot to the pulmonary arteries. The
AngioVac procedure in this setting can be performed
utilizing only local anesthesia using TTE or intravascular
US (IVUS) to confirm successful removal of the
thrombus.
During access and sheath placement, care should be
taken to avoid wires entering the heart to prevent
dislodgement of the atrial clot. Bilateral femoral vein
approach would facilitate this.
Inferior vena cava venography can be performed before
advancing the large cannula to exclude caval thrombus
which may become dislodged.
Flow should be optimized in the inferior vena cava, and
the cannula then advanced into the right atrium to
engage the thrombus (Figure 16.15a).
If the flow stops in the circuit, it may be due to large
thrombus obstructing the lumen (Figure 16.15b). Waiting
for a few minutes “on pump” may sometimes allow the
clot to fragment or conform to the cannula and pass.
Increasing the RPM on the pump can also facilitate
passage of clot. Another maneuver is to kink or clamp
the circuit tubing and then quickly release, which causes
an abrupt suction on the clot which may help it fragment
and pass. If these maneuvers fail, the cannula with clot
can be removed while on the pump. Placement of an IVC
filter above the cannula can ensure that large clot does
not dislodge during removal (Figure 16.15c–e).
AngioVac for Right Heart Vegetation
Patient Selection and Approach
Mobile vegetations which appear pedunculated are more
likely to be successfully removed via suction
thrombectomy, whereas firm, chronic sessile clot may
prove more difficult.
Figure 16.15 (a–e) Clot‐in‐transit is generally mobile
and can be engaged by advancing into right atrium while
on pump (a). With large clot burden, the clot could get
stuck at the tip of the cannula which can have this “ice
cream cone” appearance (b). If the cannula cannot be
cleared, a filter can be placed above cannula before
removal to prevent dislodgement (c). Most of the clot in
this case was able to be removed (d), however, much of it
got stuck in the valve of the sheath (e).
If the vegetation is originating from the septal leaflet of
the tricuspid valve, the septal side of the right atrium, or
a catheter or Pacemaker/AICD lead, a femoral venous
approach for the aspiration cannula may be
advantageous. For anterior or posterior tricuspid valve
leaflet vegetations, the anatomy favors an internal
jugular venous approach.
Technique
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It may be challenging to engage vegetations with
generation 2 AngioVac, straight or 20° angled cannulas.
The tip of the cannula can be redirected by using a large
gooseneck snare positioned between the balloon and the
funnel leaflets to direct the AngioVac cannula toward the
thrombus (Figure 16.16a). Alternatively, a 90 cm prolene
suture can be tied to the inferior most leaflet of the
cannula which the operator can use to angle cannula
outside the sheath alongside the cannula (Figure
16.16b,c). With the third‐generation device, as the distal
part of the cannula is unsheathed, the cannula can make
up to a 180° angulation.
Figure 16.16 (a–c) When using generation 2 device for
right heart vegetations it can be helpful to create
angulations on the cannula. This can be done using a
snare to angle the cannula (a), or placing a suture in one
of the leaflets (b, c).
After angulating toward the vegetation, the funnel is then
rotated toward the target with a sweeping motion by
twisting the entire cannula. Intraprocedural TEE or ICE
can be used real‐time to confirm the orientation of
cannula to the vegetation and successful removal.
References
1 Kasper, W., Konstantinides, S., Geibel, A. et al. (1997).
Management strategies and determinants of outcome
in acute major pulmonary embolism: results of a
multicenter registry. Journal of the American College
of Cardiology 30: 1165–1171.
2 Kucher, N., Boekstegers, P., Müller, O.J. et al. (2014).
Randomized, controlled trial of ultrasound‐assisted
catheter‐directed thrombolysis for acute
intermediate‐risk pulmonary embolism. Circulation
129 (4): 479–486.
3 Piazza, G., Hohlfelder, B., Jaff, M.R. et al. (2015). A
prospective, single‐arm, multicenter trial of
ultrasound‐facilitated, catheter‐directed, low‐dose
fibrinolysis for acute massive and submassive
pulmonary embolism: the SEATTLE II study. J. Am.
Coll. Cardiol. Intv. 8: 1382–1392.
4 Tapson, V.F., Sterling, K., Jones, N. et al. (2018). A
randomized trial of the optimum duration of acoustic
pulse thrombolysis procedure in acute intermediate‐
risk pulmonary embolism: the OPTALYSE PE trial. J.
Am. Coll. Cardiol. Intv. 11: 1401–1410.
5 Tu, T., Toma, C., Tapson, V. et al. (2019). A
prospective, single‐arm, multicenter trial of catheter‐
directed mechanical thrombectomy for intermediate‐
risk acute pulmonary embolism: the FLARE study.
JACC Cardiovasc. Interv. 12 (9): 859–869.
6 Pasha, A.K., Elder, M.D., Khurram, D. et al. (2014).
Successful management of acute massive pulmonary
embolism using Angiovac suction catheter technique
in a hemodynamically unstable patient. Cardiovasc.
Revasc. Med. 15 (4): 240–243.
7 D’Ayala, M., Worku, B., Gulkarov, I. et al. (2017).
Factors associated with successful thrombus
extraction with the AngioVac device: an institutional
experience. Ann. Vasc. Surg. 38: 242–247.
8 Donaldson, C.W., Baker, J.N., Narayan, R.L. et al.
(2015). Thrombectomy using suction filtration and
veno‐venous bypass: single center experience with a
novel device. Catheter. Cardiovasc. Interv. 86 (2):
E81–E87.
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
9 Hameed, I., Lau, C., Khan, F.M. et al. (2019). AngioVac
for extraction of venous thromboses and endocardial
vegetations: a meta‐analysis. J. Card. Surg. 34 (4):
170–180.
10 Starck, C.T., Eulert‐Grehn, J., Kukucka, M. et al.
(2018). Managing large lead vegetations in
transvenous lead extractions using a percutaneous
aspiration technique. Expert Rev. Med. Devices 15
(10): 757–761.
11 George, B., Voelkel, A., Kotter, J. et al. (2017). A novel
approach to percutaneous removal of large tricuspid
valve vegetations using suction filtration and veno‐
venous bypass: a single center experience. Catheter.
Cardiovasc. Interv. 90 (6): 1009–1015.
12 Hoeper, M.M. and Granton, J. (2011). Intensive care
unit management of patients with severe pulmonary
hypertension and right heart failure. Am. J. Respir.
Crit. Care Med. 184 (10): 1114–1124.
13 Ergan, B., Ergün, R., Çalışkan, T. et al. (2016).
Mortality related risk factors in high‐risk pulmonary
embolism in the ICU. Can. Respir. J. 2016.
17
Catheter‐Based Therapy for Varicose
Veins
Juan Terre and Nelson Chavarria
Division of Cardiology, Albert Einstein College of
Medicine-Montefiore Medical Center, Bronx, NY,
USA
Introduction
Management of symptomatic chronic venous
insufficiency is complex and varies with disease severity
[1–4]. In the following series, we describe the use of
minimally invasive treatment modalities employed when
venous duplex ultrasound imaging confirms the
diagnosis and identifies specific segments of venous
incompetence [5–7]. Thermal techniques including
radiofrequency (RF) ablation and endovenous laser
therapy will be discussed, as well as an emerging
technology that does not use tumescence or healing
elements, mechanico‐chemical ablation (MOCA) [8, 9].
Thermal Techniques
Two current methods used to achieve ablation of the
great or small saphenous veins involve the use of a RF
catheter and an endovenous laser ablation (EVLA)
procedure utilizing a laser‐fiber catheter, both requiring
their own respective generators. The primary difference
between the two techniques is the heat source. RF
ablation utilizes RF waves to produce steam bubbles and
heat to damage the endothelium and denature the
collagen matrix of the vein wall. Eventually leading to
inflammation and fibrosis. The EVLA method utilizes a
laser fiber to directly deliver laser energy to the vein wall
causing endothelial damage and subsequent fibrosis.
Both modalities require tumescent anesthesia to
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compress the vein around the catheter and insulate the
surrounding tissue from thermal injury. Below we
describe step‐by‐step techniques of these treatment
modalities.
Radiofrequency (RF) Ablation
Step 1. Access to the refluxing superficial vein is first
obtained at its lowest point of incompetence under
ultrasound guidance (evaluation in short‐ and long‐axis
views advised [Figure 17.1]) with a 21G introducer needle
and 0.018‐in. wire under local anesthesia (1% lidocaine).
Utilizing a modified Seldinger technique, a 4 Fr
micropuncture sheath is advanced into the vein over the
0.018‐in. wire. Techniques employed to increase first
puncture success include reverse Trendelenburg
positioning, continuous IV hydration, rubber band
ligation above the access point, or placement of a
warming pad.
Figure 17.1 Steps in accessing the saphenous vein under
ultrasound guidance (a) in short (b) and long‐axis views
(c), ultrasound guided vein puncture (d).
Figure 17.2 Steps in catheter positioning and tumescent
anesthesia administration. Catheter advanced and then
retracted 2.5 cm from the saphenofemoral junction (a).
Injection of tumescent anesthesia under ultrasound
guidance (b) creating a “thermal sink” and collapsing the
vein around the catheter (c).
Step 2. Once access is secured, the 0.018‐in. wire is
exchanged for a 0.035‐in. guidewire. The 4Fr
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micropuncture sheath is then exchanged for a 5 Fr
introducer sheath. Intraluminal position within the vein
is confirmed by aspirating non‐pulsatile venous blood
and visualization under ultrasound.
Step 3. The RF ablation catheter (Covidien
ClosureFast™, Medtronic, MN, USA) is then slowly
advanced in the saphenous vein under ultrasound
guidance and placed at least 2.5 cm distal of the
saphenofemoral junction (Figure 17.2a). Advancing the
catheter may sometimes prove difficult when making
turns. Pressing the overlying tissue to direct
advancement is often helpful.
Step 4. Once the catheter is in place, local tumescent
anesthetic solution (450 ml 0.9% normal saline, 35 ml
0.1% lidocaine, and 15 ml 0.8% sodium bicarbonate [10])
is injected under ultrasound guidance in the perivenous
space of the saphenous vein (Figure 17.2b,c). Tumescent
anesthesia can be administered either manually with
serial injections utilizing a 20 cc syringe and 21G needle
or with a filtration pump (HK Surgical Klein Infiltration
Pump™, HK Surgical Inc., San Clemente, CA, USA),
which can deliver high volumes of anesthesia through
pressure tubing. Aside from providing anesthesia,
tumescent fluid serves to separate the vein from
perivenous structures, creating a “thermal sink” to
dissipate peak temperatures and compresses the vein to
maximize treatment to the endothelial wall.
Step 5. The RF generator is then activated, providing
heat energy of 120°C for 20 seconds through the 7 cm
copper coil segment of the ablation catheter. Once the
treatment cycle is completed after 20 seconds, the
catheter is simply withdrawn to the new adjacent venous
segment and the generator is activated once again to give
another 20 seconds treatment cycle. The steps are
repeated in sequence to treat the entire length of the
vein.
Step 6. At the end of the procedure, the catheter and
sheath are removed. Hemostasis is achieved with manual
compression at the site of venous access. Compression
bandages and stockings are applied on the treated leg for
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