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a comprehensive review of the PMT catheters and descrip-
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tions of more common treatment techniques.
TECHNIQUE
In order to successfully perform PMT, several general
premises must be considered. ese include whether to
place a temporary vena cava lter, determining optimal
site for venous access, and how to traverse the thrombosis.
Although the technique unique to each PMT catheter is
highly variable, these general principles apply to most clinical scenarios in treating DVT. Following thrombus removal,
subsequent interventions such as balloon angioplasty and/
or stenting can be performed if necessary.
TEMPORARY INFERIOR VENA CAVA IVC
FILTER PLACEMENT
e risk of fatal PE during thrombolytic therapy of iliac
24
vein thrombus has been reported as high as 6%.
All PMT
devices, including those that aspirate during treatment,
generate small particles that can migrate to the pulmonary
circulation. e placement of a retrievable IVC lter has
become a valuable adjunct to PMT. ere are many types of
temporary IVC lters available with di erent time periods
for retrieval (see Table47.1). Additionally, each lter varies
in the approach to deployment and retrieval. ese important issues must be considered prior toPMT.
An in vitro model of early large-volume DVT demonstrated that in placing an IVC lter prior to PMT, 99% of
particles larger than 500µm were either macerated by the
25
device or captured by the lter.
Trerotola etal. demonstrated a signi cant number of clinically signi cant segmental and subsegmental pulmonary emboli while evaluating
the Arrow-Trerotola Percutaneous rombectomy Device
(Arrow International, Reading, PA) in a canine model.
26
Further investigations determined that use of a temporary
IVC lter reduced the number of pulmonary emboli as
27
diagnosed by pulmonary angiography.
In the majority of patients, placement of a retrievable IVC lter should be performed just prior to PMT.
Generally, access to the deployment site should be void of
thrombus, and guide wire traversal should be observed with
uoroscopy for any deviation or di culty that may indicate
the presence of thrombus. Avenogram should be obtained
prior to deployment of the IVC lter to identify the renal
veins and to further ensure the proposed deployment location is devoid of any thrombus. Alow threshold to perform
venography by selective catheterization should be considered if nonselective venography fails to show important
28
venous tributaries.
Depending on the results of PMT, the lter can be
removed immediately or remain in place 1 to 3 weeks during
the healing process. e IVC lter should remain in place if
contraindications to anticoagulation arise, development of
recurrent DVT, or increases in DVT riskoccur.
V E N O U S A C C E S S
If possible, the same venous access for IVC lter placement
should be used when selecting an access site to perform
PMT. e ipsilateral common femoral vein is the optimal
access site for thrombus con ned to the iliocaval segments.
In this clinical scenario, the IVC lter should be placed via
the contralateral femoral vein. If the thrombosis is con ned
to a single lower extremity, possible access sites include
either common femoral vein or the ipsilateral popliteal vein.
e internal jugular vein can also be used to access DVT in
the lower extremities.
Generally, access to lower extremity DVT from the
external iliac vein to the super cial femoral vein is from the
contralateral common femoral vein. Selective catheterization comes over the iliac vein bifurcation and the involved
contralateral venous segments are accessed in a retrograde
direction. If the thrombus burden is high or there is anticipated di culty in performing a retrograde cannulation,
antegrade access through the ipsilateral popliteal vein is
preferred.
e antegrade approach through the ipsilateral popliteal
vein to treat iliofemoral DVT remains the most common
alternative to the contralateral approach. With the patient
in the prone position, duplex ultrasound is required for
needle guidance. Amicropuncture kit that uses a 22-gauge
needle and a 0.014-inch wire aids in providing a nontraumatic, safe access. Advantages of antegrade access through
Table47.1 RETRIEVABLE IVC FILTERS
ALN (ALN Implants Chirurgicaux, Ghisonaccia,
France)
Recovery (Bard Peripheral Vascular, Tempe, AZ) X X X X X X
Günther Tulip (Cook Medical, Bloomington, IN) X X X X X
OptEase (Cordis Endovascular, Warren, NJ) X X X
SafeFlo (Rafael Medical, Caesarea, Israel) X X
F I LT E R INSERTION SITES RETRIEVAL SITES
F E M O R A L J U G U L A R A N T E C U B I T A L F E M O R A L J U G U L A R A N T E C U B I T A L
X X X X
398 • VENOUS THROMBOEMBOLISM
the popliteal vein include ease of traversing valves and mini-
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mal need for selective catheterization.
Other more remote sites such as the jugular and subclavian veins have been used to gain access to DV T. More commonly these access sites may be required for direct access
to the con uence of the common iliac veins. Occasionally,
common iliac vein stenosis in combination with thrombosis can be negotiated only via a retrograde approach from
the brachiocephalic veins. Treating iliofemoral DVT may
require dual access with the use of a snare to pull the wire
from one access site to another, thereby providing for more
stable access to treat with PMT. In the case of upper extremity DVT treatment, venous access generally is obtained at
the ipsilateral basilic vein. is also requires ultrasound
guidance and use of a micropuncturekit.
TRAVERSING THE THROMBUS
A er de ning the venous segment by venography as an
entry point to the thrombus, stable access with a sheath
or guiding catheter usually is required. A sti hydrophilic
guide wire (Boston Scienti c; Natick, MA) allows optimal
manipulation and guidance in gaining access into thrombus. As the wire is advanced, a catheter is advanced over the
wire to maintain crossing and increase stability. Usually a
straight catheter such as a 4-Fr. glidecath (Boston Scienti c,
Natick, MA) is used in combination with a sti angled
guide wire (Boston Scienti c, Natick, MA). Alternatively,
an angled catheter such as a Kumpe catheter (Cook;
Bloomington, IN) can be used with a straight guide wire
(Boston Scienti c; Natick, MA). ese combinations are
particularly useful when traversing thrombus in a retrograde direction. Valve lea ets can be negotiated with slow
directed movements under magni ed uoroscopy.
Another technique that can facilitate crossing thrombs
is forming the guide wire into a long “J” con guration.
is maneuver takes advantage of the sti portion of the
guide-wire while preventing trauma to the vein wall because
the oppy tip is in a “J” shape. When pushing antegrade
through older thrombus, this technique may prove useful.
Emphasis should be placed on not forcing wires, catheters,
and PMT systems into position. Careful continuous uoroscopic imaging is mandatory when moving wires and catheters and observing their tracking path is vital to avoiding
injury. Amanifold hand injection system with the ability
to withdraw contrast and dilute with saline is helpful in
facilitating quick, periodic views to assure correct catheter
position.
D E V I C E S
PMT catheters can be categorized a variety of ways. One
important distinction is whether the catheter has complete or incomplete wall contact. Advantages of complete
wall contact include more thorough thrombus dissolution.
Potential disadvantages include endothelial and valvular
damage. PMT catheters also can be categorized by their
method of thrombus dissolution. ese mechanical methods include rheolytic aspiration, rotational thrombectomy,
and ultrasonic fragmentation. Rheolytic devices remove
thrombus based on the Venturi e ect. is adaptation of
the Bernoulli e ect states that uid moving at high speeds
generates low pressure zones. ese low pressure zones create a partial vacuum, termed the Venturi e ect. In rheolytic
thrombectomy devices, high speed saline jets are directed
into the thrombus creating low pressure zones near the catheter where the fragments are aspirated through the device
via the vacuum e ect. eoretic advantages of rheolytic
aspiration include less valvular damage and decreased endothelia damage.
e rotational devices are designed to spin at varying
speeds within the thrombus causing fragmentation. is
mechanism also can result in increased endothelial damage. Ultrasonic fragmentation occurs through the delivery
of high-frequency, low-energy ultrasound. e ultrasound
waves cause the aggregated brin strands to dissociate,
resulting in both increased permeability of the thrombus and
exposure of new plasminogen activator sites on the brin
strands. rombolytic drugs are forced into the thrombus
by the radial pressure generated by the ultrasoundwaves.
Finally, PMT catheters are designed to either aspirate fragmented thrombus or create a near liquefaction
of thrombus that migrates into the venous circulation.
Ultimately, the microemboli are propelled to the pulmonary circulation, where endogenous lysis takes place. e
aspiration catheters can increase blood loss associated with
the procedure, and, therefore, the operator must be vigilant
in monitoring the aspirated volume. Clinically signi cant
sequelae of pulmonary emboli from the nonaspiration
catheters have not been reported a er treatment for DVT.
Table47.2 includes the commercially available devices subsequently discussed in this chapter.
ANGIOJET
THROMBECTOMYSYSTEM
Indications for use approved by the US Food and Drug
Administration (FDA) of the AngioJet thrombectomy
system (ATS; Possis Medical, Minneapolis, MN) include
treatment of peripheral arterial occlusions, thrombosed
hemodialysis gra s, and DVT. is dual lumen catheter
(see Figure 47.1) operates on the Bernoulli-Venturi principles. Saline or a thrombolytic drug are infused by the
drive unit to generate approximately 10,000 psi of pressure
within the catheter. e infusate is ejected from the catheter
in retrograde-directed, pulsatile jets. e jets generate low
pressure zones that allow for thrombus maceration and aspiration. An exhaust port near the tip of the catheter allows
for aspiration thereby avoiding the potential for localized
PERCUTANEOUS MECHANICAL THROMBECTOMY IN THE TREATMENT OF DVT • 399
Table47.2 PMT DEVICES
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DEVICE METHOD OF
AKonya Eliminator
Arrow-Trerotola
AngioJet
XMI
XVG
Xpeedior 120
AVX
XMI-RX+
DVX
Castaneda Over-the-Wire Brush
Helix Clot Buster rombectomy
Device (Amplatz Device)
Lysus Infusion System
Oasis rombectomy System
ProLumen
rombex PMT
Trellis Infusion System
X-Sizer Catheter System
THROMBUS
REMOVAL
Mechanical
Mechanical
Rheolytic
Rheolytic
Rheolytic
Rheolytic
Rheolytic
Rheolytic
Mechanical
Mechanical
Ultrasonic
Rheolytic
Mechanical
Mechanical
Mechanical
Mechanical
WA L L
CONTACT
Mechanical
Complete
Incomplete
Incomplete
Incomplete
Incomplete
Incomplete
Incomplete
Complete
Incomplete
Incomplete
Complete
Incomplete
Incomplete
Incomplete
endothelial damage from a more eccentrically placed vortex. Ninety-nine percent of the particulate matter generated
29
by the ATS is 0 to 12µm in diameter.
Aseparate pump
drive unit is necessary for the catheter to function with dual
lumen tubing that delivers the infusate and collects the e uent. e system functions in an isovolumetric manner with
30
60 cc/min being infused and aspirated simultaneously.
Multiple catheters have been designed for use in vessels of
varying diameters and locations (see Table47.3). Additionally,
di erent types of tubing are available to allow for saline infusion or power pulsation. Power pulsation is designed to force
standard pharmacologic thrombolytics into the thrombus. In
contrast, traditional CDT uses lacing , whereby the drug seeps
from the multiple side holes of an infusion catheter.
Sharafuddin et al. evaluated endothelial damage
incurred a er use of the ATS compared to the Fogarty balloon embolectomy in a canine model. e ATS-treated vessels had signi cantly more endothelial coverage than vessels
ASPIRATION
CATHETER
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
N o
N o
N o
Ye s
Yes
Yes
treated with the Fogarty balloon.
FDA APPROVED INDICATION
rombosed AVF and dialysis gra s
rombosed AVF and dialysis gra s
Coronary or vein gra lesions >2mm
rombosed infrainguinal arteries >3mm
rombosed infrainguinal arteries >3mm
rombosed dialysis gra s
rombosed infrainguinal arteries >2mm
rombosed infrainguinal arteries >3mm
rombosed dialysis gra s
rombosed AVF and dialysis gra s
Selective infusion of medication into
peripheral vessels
rombosed dialysis gra s
rombosed dialysis gra s
rombosed dialysis gra s
rombosed dialysis gra s
31
Segments treated with
the ATS showed no di erence in endothelial coverage or
valvular damage when histologically compared to untreated
control segments.
rombus extraction rates using the ATS range from 52
22
to 95%.
to the adjunctive use of pharmacologic thrombolysis.
is wide range of variability appears to be related
32
e ATS has been used in the treatment of symptomatic
lower extremity DVT with success. Bush etal. reported the
use of the ATS in the treatment of twenty-three limbs in
twenty patients. Technical success was achieved in een of
the twenty-three treated limbs. e remaining limbs demonstrated varying degrees of thrombus removal. Seven of
twelve patients being treated for iliofemoral DVT had prophylactic IVC lters placed. Marked clinical improvement
within 24 h of therapy was noted in 74% of patients. Only
three minor bleeding complications were noted, and no one
33
required a blood transfusion.
Figure47.1 (A) Demonstration of the Bernoulli-Venturi e ect as used by the Angiojet thrombectomy system. (B) e free-standing pump drive unit
for the Angiojet thrombectomy system.
B
A
400 • VENOUS THROMBOEMBOLISM
Table47.3 ANGIOJET THROMBECTOMY SYSTEM CATHETERS
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C AT H E T E R M I N . V E S S E L
XMI-OTW
XMI-RX+
XVG
Xpeedior
D V X
DIAMETER
>2mm
>2mm
>3mm
>3mm
>3mm
W O R K I N G
LENGTH
135cm
135cm
140cm
120cm
90cm
Kasirajan et al. reported similar results in seventeen
patients treated with the ATS. rombus extraction rates
were lower with only 24% having >90% thrombus removal.
Adjunctive thrombolytic therapy was used in nine of thirteen that demonstrated less than 90% thrombus extraction. Eighty-two percent of patients had signi cant clinical
34
improvement, and no complications were reported.
e ATS also has been successfully used in the management of Paget-Schroetter’s syndrome, PE, and mesenteric
35–37
venous thrombosis.
AKONYA ELIMINATOR
e Eliminator catheter (IDev Technologies, Houston,
TX) is a nonmotor-driven thrombectomy device approved
by the FDA for thrombectomy of dialysis gra s. e device
uses a 6-Fr. adjustable basket that can accommodate vessels
from 2 to 10mm in diameter. e catheter has directional
control that allows easy navigation of tortuous vessels. e
catheter has no drive unit, and through manipulation in
an axial direction or manual rotation, the thrombus can be
stripped from the veinwall.
A R R O W T R E R O T O L A
PERCUTANEOUS
THROMBECTOMYDEVICE
e Arrow-Trerotola Percutaneous rombectomy Device
(ATPTD) fragments thrombus using a self-expanding
9-mm fragmentation cage. e device comes as either an
over-the-wire con guration or the original design whereby
the cage is constrained by a sheath. e latter device must
be positioned across the thrombus before withdrawing
the sheath and releasing the fragmentation cage. In both
devices, the cage rotates at 3,000 rpm and is pulled through
the thrombus. e rotating cage strips and macerates thrombus from the vein wall creating a slurry that can be aspirated
through the sheath. Two passes of the device usually provide
38
optimal clot fragmentation.
Damage to the veins a er thrombectomy with the
ATPTD was assessed in an experimental canine model.
e device was passed ve times in the antegrade direction
through thrombosed lateral saphenous veins. e venous
segments were assessed for endothelial loss, the presence of
thrombus, and valvular damage. Compared to valves designated as controls in untreated thrombosed lateral saphenous
GUIDEWIRE
COMPATIBILITY
0.014″
0.014″
0.014″
0.035″
0.035″
S H E A T H
COMPATIBILITY
4 Fr.
4 Fr.
5 Fr.
6 Fr.
6 Fr.
veins, valves in the experimental group treated with ATPTD
39
had signi cantly less in ammatory cell in ltrates.
Technical success rates are reported between 92 and
100% when treating thrombosed dialysis gra s.
38,40,41
Procedure times are markedly shortened when compared to
38
pulse-spray thrombolysis.
from 39 to 70%.
38,41
Ninety-day patency rates range
Preliminary work has begun to evaluate the ATPTD for treating DVT. Animal studies indicate
promising local success rates, but segmental and subsegmental pulmonary emboli were demonstrated with concomitant
increases in mean and systolic pulmonary arterial pressure.
Increasing pCO
and acidosis were also observed. 42 e
2
thrombus fragments produced by the device range in size
42
from <1mm to as high as 3mm.
Truong etal. reported
successful PMT using the ATPTD in a patient that presented with a subacute iliocaval thrombosis. Atemporary
Günther basket lter was placed prior to intervention. At
3 months, magnetic resonance imaging (MRI) demon-
43
strated no recurrent thrombosis in the treated vessels.
HELIX CLOTBUSTER
Previously marketed as the Amplatz rombectomy
Device, the HELIX Clot Buster (ev3, Plymouth, MN)
was the rst device approved by the FDA for percutaneous
treatment of thrombosed dialysis gra s. Basic components
include an impeller mounted on a drive sha that is powered by a compressed air turbine. Rotation of the impeller at
150,000 rpm creates a vortex at the distal tip of the catheter
that draws in the thrombus and recirculates the particulate
matter. Particles from this PMT catheter are less than 1,000
44
microns.
thrombosed dialysis gra s range from 79 to 93%.
Success rates of the HELIX for treatment of
45,46
e
blunt tip design of the HELIX make it di cult to navigate
tortuous vessels.
Successful treatment of venous thrombosis has been
reported in multiple vascular segments using the HELIX.
U acker reported treatment of nine acute and subacute
venous thromboses in the IVC and iliac veins (n = 3),
SVC and subclavian veins (n = 3), portal vein and transjugular intrahepatic portosystemic shunt (TIPS) (n=2),
and an IVC to pulmonary artery Fontan conduit (n=1).
romboses had been present from 2 d to four weeks. ree
patients had failed prior CDT with urokinase. PMT was
successful in all CDT failures, but each required an adjunctive measure to ensure long-term patency. One patient being
PERCUTANEOUS MECHANICAL THROMBECTOMY IN THE TREATMENT OF DVT • 401
treated for an iliocaval thrombosis developed intraproce-
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dural shortness of breath attributed to pulmonary embo-
47
lism despite placement of an IVC lter.
Similarly, Smith
etal. reported using the HELIX in patients with DVT who
had relative or absolute contraindications to pharmacologic
thrombolysis. Treatment of DVT was performed in the
superior mesenteric vein, bilateral femoral veins, and the
48
SVC and brachiocephalic veins.
has been used to treat major and minor pulmonary emboli.
HYDROLYSER
Additionally, the HELIX
49
is multilumen catheter (Cordis, Warren, NJ) is designed
for over-the-wire use. It utilizes the Venturi e ect to fragment thrombus (see Figure47.2). Simultaneous infusion of
thrombolytic drugs or saline is possible through an injection port. Aspiration takes place through a 6-mm elliptical
exhaust port that is located 4mm proximal to the distal tip
of the catheter.
Disadvantages of the Hydrolyser (see Figure47.3) can
include possible uid overload and hemolysis. Additionally,
the guide wire may obstruct the exhaust port and decrease
the amount of thrombus extracted. e eccentrically located
exhaust port creates an imbalanced vortex. is may result
in tenting of the vessel toward the low pressure region and
22
increase the endothelial damage.
e Hydrolyser was compared to the ATS in an in
50
vitro model to determine the degree of embolization.
e
catheters were also compared with and without the guide
wires in place, as previous data has indicated decreased
e ectiveness when the guide wire remained. e Hydrolyser
demonstrated greater thrombus resolution and less distal embolization when compared to the ATS. rombus
destruction was improved for both catheters when the
51
guide wire remained in the catheter.
Successful cases of PMT using the Hydrolyser for the
treatment of acute DVT and pulmonary embolism have
been reported.
52–54
Henry et al. reported 83% technical
success in a variety of patients with arterial, bypass gra ,
53
and venous thrombosis.
rombus less than 10 d old
provided the optimal therapeutic window when using the
Hydrolyser, and segments treated took less than 4 min on
53
average.
Poon et al. reported on three women that had
IVC thromboses treated with the Hydrolyser. None of
these patients could receive heparin or thrombolytics due
to neurosurgical problems. All patients were successfully
treated with the Hydrolyser and had complete resolution of
their lower extremity edema. Each patient had an IVC lter
placed, and one patient required a second treatment with
54
the Hydrolyser.
LYSUS INFUSION CATHETERSYSTEM
e Lysus Infusion Catheter System (EKOS Corporation,
Bothell, WA) uses high-frequency, low-powered ultrasound
to lyse thrombus. A er traversal of the thrombus with guide
wire, a multiholed drug delivery catheter is advanced over
the guide wire. e guide wire is removed and the ultrasound core is placed within the catheter. e ultrasound
core contains many ultrasound transducers along its length,
and a separate control system regulates the ultrasound output and temperature. e core is actively cooled by a saline
infusion that exits the distal tip of the catheter during treatment. rombolytic drugs are infused via the multiholed
delivery catheter and the radial force generated by the ultrasound propels the drug away from the catheter and deeper
into the more permeable thrombus.
Figure47.2 e Venturi e ect as used in the Hydrolyser Catheter (Cordis
Endovascular, Warren,NJ).
EXHAUST LUMEN
INJECTION LUMEN
402 • VENOUS THROMBOEMBOLISM
O A S I S
e Oasis catheter (Boston Scienti c, Natick, MA),
originally marketed as the Shredding Embolectomy
rombectomy catheter, is a triple-lumen catheter placed
over a guide wire 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. e 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
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SALINE INJECTION (MAD. 750 PSI)
HIGH PRESSURE CATHETER EXTENSION3-WAY STOPCOCK
INJECTION LUMEN
CUIDE WIRE
CLIP
100
200
300
400
500
600
700
800
900
1000
CLIP
Figure47.3 e Hydrolyser set-up.
1000
900
800
700
600
500
400
300
200
100
3-WAY STOPCOCK
EXHAUST LUMAN
HEMOSTASIS DEVICE
INJECTION BY HAND ONLY
COLLECTION BAG
internal elastic lamina, while no injury extended to the media .
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55
Signi cant pulmonary embolization was not observed.
Technical success in the treatment of thrombosed dialysis gra s approaches 90%, and clinical success, de ned as
the ability to access the gra s for dialysis, ranges from 76 to
56,57
81%.
Takahashi etal. reported a single case of successful
use of the Oasis thrombectomy device to treat a symptomatic mesenteric venous thrombosis in the portal and supe-
58
rior mesenteric veins.
extremity venous thrombosis. Arko etal. reported use of the
TTS to treat two patients with axillosubclavian vein throm-
59
Ramaiah etal. used the TTS to treat an iliofemo-
bosis.
ral thrombosis. In both reports, use of the TTS resulted in
shorter treatment times when compared with 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 compli-
59,60
cation or PE reported.
P R O L U M E N
Approved for use in hemodialysis access, the ProLumen
(Datascope, Montvale, NJ) is a self-contained thrombectomy catheter that requires no additional equipment. e
device contains a 0.035-inch 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 4,000 rpm.
e S-wire maintains contact with the gra wall to release
adherent thrombus. No reports are published to date using
the ProLumen for treatment ofDVT.
TRELLIS8 THROMBECTOMYSYSTEM
e Trellis-8 rombectomy System (Bacchus Vascular,
Santa Clara, CA) combines CDT and PMT by isolating the
thrombosed venous segment between proximal and distal
occlusion balloons. A er a thrombolytic drug is infused into
this closed system, a sinusoidal wire mixes the lytic agent
into the thrombus together. e balloon occlusion limits
systemic exposure to the lytic agent and prevents pulmonary
emboli. e slurry created in the treated segment is then
aspirated to remove lysed clot and the residual activedrug.
e Trellis-8 rombectomy System (see Figure47.4)
has been successful in treating both upper and lower
8Fr Multi-
Lumen
Catheter
Figure47.4 e Trellis-8 rombectomy System.
Isolated Treatment Zone
Ination/Infusion
Ports
Oscillation
Drive
Unit
X S I Z E R
e X-Sizer helical thrombectomy catheter (ev3, Plymouth,
MN) is composed of a rotating helical cutter that is housed
in an outer sheath. e device is attached to a vacuum source
for the aspiration of particulate matter created during the
procedure. e device has been evaluated in the coronary
arterial circulation, but to date treatment of hemodialysis
gra s, the peripheral arterial tree, and the venous system has
not been reported.
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 rombectomy System and the
ATS lytic power pulse system are approved by the FDA for
treatment of acuteDVT.
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.
e combination of PMT and pharmacologic thrombolysis
can drastically reduce the treatment times compared to CDT
alone. Arko etal. reported complete thrombus removal in
two patients using the Trellis-8 rombectomy System with
Alteplase (Genentech, South San Francisco, CA) for upper
extremity DVT. ese two patients were treated at a single
59
setting and received 5 mg of Alteplase over 10min.
When evaluating these devices in the treatment of
thrombosed hemodialysis access, the ATS, ATPTD, and
Oasis were found to have equivalent technical success rates
28,56,61
when compared to pulse-spray thrombolysis.
e
procedure times were signi cantly shorter in the groups
38,56
that underwent PMT.
Complications such as bleeding
requiring transfusion, PE, and arterial embolization were
less in the PMT arm, but statistical signi cance was not
38
reached due to the small number of patients.
PMT most o en allows patients to be treated in a single
setting, thereby avoiding multiple trips to the angiography suite. Ramaiah etal. reported a single case of a patient
404 • VENOUS THROMBOEMBOLISM
that developed increased thrombus burden while on hepa-
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rin. A er failure following 36 h of CDT with reteplase
(Centocor, Horsham, PA), PMT using the Trellis-8
rombectomy System was successful with complete clot
60
lysis in 45 minutes.
Similar results have been reported
in the treatment of upper extremity DVT when using the
59
Trellis-8 rombectomy System.
Bleeding complications may be less when compared to
CDT. In seventeen patients treated with PMT for lower
extremity DVT, Kasirajan etal. observed no hemorrhagic
34
or access site complications.
Bush et al. reported two
patients that developed access site hematomas and one
that developed a retroperitoneal hematoma out of twenty
patients treated for DVT with the ATS. None required sur-
33
gical intervention or transfusion.
e discovery of an underlying venous stenosis can
occur a er PMT. irty-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 out ow
obstruction. Reducing out ow obstruction helps prevent
recurrent DVT and further reduces the severity ofPTS.
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 etal. compared the ATS
without a guide wire, with a 0.016-inch guide wire, and
with a 0.035-inch guide wire to the Hydrolyser, Oasis, and
Amplatz rombectomy. Interestingly, the ATS had signi cantly less thrombus removal using the 0.016-inch guide
wire compared to other con gurations. No signi cant difference was found among the other catheters. e highest
50
percentage of embolism was noted with theATS.
Delomez etal. reported use of the Amplatz rombectomy Device in eighteen patients with symptomatic lower
extremity DVT. Successful recanalization was reported in
83% of patients. Apermanent IVC lter was placed in one
patient and a temporary lter placed in another. No pulmo-
62
nary emboli were reported.
e time thrombus was present prior to treatment ranged from 4 to 240 d. e age of
DVT that can still be optimally treated with PMT has not
been determined. Generally 2 weeks represents a common
47,62–64
window used by many practicioners.
rombi older
than this begin to have a denser brin network and are more
resistant to PMT. Moreover, older thrombi are associated
63
with an increased incidence of distal embolization.
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
23
compared to using either independently.
is retrospective
review analyzed twenty patients who underwent twenty-two
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 ndings, he
concluded that PMT has an important role in the endolumi-
23
nal therapy for DVT.
Siablis etal. compared the ATS with
CDT for the treatment of massive pulmonary embolism. He
found signi cant decrease in the mean urokinase dose and
36
duration of therapy in the ATS group.
Many clinical scenarios exist in daily practice in which
pharmacologic therapy with either thrombolytic agents
or anticoagulation are contraindicated. Although an IVC
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,
33,34,48
pain, and disability with the use of PMT alone.
Other
advantages include minimizing bleeding complications and
shorter hospital stays. e bene 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 bene t. More prospective studies are needed to help determine who will bene t most. As
technology continues to change rapidly, past studies can be
di cult to interpret. Future research must also take into
account quality-of-life measures in the short and longterm.
Potential disadvantages of PMT are related to the individual catheter designs. Common to the catheters that utilize
the Venturi e ect is the potential for uid overload resulting
in congestive heart failure and pulmonary edema. e ATS,
Hydrolyser, Oasis, and ATD are all designed to function in
an isovolumetric manner. Müller-Hülsbeck etal. evaluated all
four PMT devices in an in vitro model, and found that none
functioned isovolumetrically. e ratio of infused saline to
aspirated uid improved for the ATS when the guide wire
was le in place. e Oasis was noted to have the greatest
50
discrepancy between infused saline and aspirated uid.
Another potential disadvantage of all PMT catheters
is hemolysis. Qian et al. found no signi cant di erences
regarding the hemolytic e ect when comparing the Helix
65
thrombectomy catheter and the ATD.
Gandini etal. evaluated plasma free hemoglobin (PFH) levels and hematocrit
in eight patients treated for iliocaval thrombosis with the
ATD, and found no signi cant abnormality in either param-
66
eter in any patient a er treatment.
U acker reported a sig-
ni cant increase in PFH in thirteen patients treated with the
47
ATD. e PFH levels returned to normal within 24 h.
In
preclinical evaluations, treatment with the ATS resultedin
a transient increase in PFH and a concomitant decrease in
31
the hematocrit.
In eighteen patients treated with the ATS
for DVT, Delomez etal. reported no postoperative anemia.
One patient developed a transient increase in haptoglobin
PERCUTANEOUS MECHANICAL THROMBECTOMY IN THE TREATMENT OF DVT • 405
without clinical sequelae. 62 However, Danetz etal. reported
https://t.me/med1917
two patients with chronic renal insu ciency who developed
67
pancreatitis a er using the ATS.
e degree of hemolysis
is directly proportional to the length of PMT. In patients
with chronic renal insu ciency, minimizing the treatment
time and careful attention to the hydration status may ameliorate the occurrence of posttreatment pancreatitis. Use of
the ATPTD has not resulted in clinically signi cant elevation of the PFH a er treatment of thrombosed hemodialy-
38
sis gra s.
Based on these observations, patients with renal and
hepatic insu ciency should proceed with caution when
considering PMT. e increased PFH can result in intranephronal cast formation resulting in acute renal failure.
e increased PFH also increases heme catabolism, which
enhances the formation of tetrapyrrol unconjugated bilirubin. e unconjugated bilirubin is metabolized and
excreted by the liver. ose with abnormal liver function
47
may not tolerate the increased PFH.
Although these considerations are paramount, no case of renal failure or fulminant hepatic failure has been reported a erPMT.
C O N C L U S I O N
PMT o ers many bene 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 e 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 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 e ective patientcare.
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PERCUTANEOUS MECHANICAL THROMBECTOMY IN THE TREATMENT OF DVT • 407
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