Rheolytic thrombectomy of an acutely thrombosed transjugular intrahepatic portosystemic stent shunt

Transjugular intrahepatic portosystemic shunt complications: prevention and management

Transjugular intrahepatic portosystemic shunt (TIPS) insertion has been well established as an effective treatment in the management of sequelae of portal hypertension. There are a wide variety of complications that can be encountered, such as hemorrhage, encephalopathy, TIPS dysfunction, and liver failure. This review article summarizes various approaches to preventing and managing these complications.

Suspected pulmonary artery disruption after transvenous pulmonary embolectomy using a hydrodynamic thrombectomy device: clinical case and experimental study on porcine lung explants

PURPOSE

To use porcine lung explants for reconstructing possible situations in which a vessel wall disruption might have occurred in a patient suffering fatal hemoptysis after pulmonary embolectomy with a hydrodynamic thrombectomy device.

METHODS

A 76-year-old woman with massive pulmonary embolism underwent transvenous pulmonary embolectomy using a 6-F AngioJet Xpeedior catheter according to manufacturer's instructions. While activating the device in the middle lobe artery (approximately 8 mm diameter), massive and ultimately fatal arterial bleeding occurred through the tracheal tube. Because no autopsy was authorized, an experimental study was designed to examine possible causes for the vessel disruption. Five fresh porcine heart-lung preparations were examined inside a dedicated chest phantom. Access to the pulmonary vessels was provided through catheters inside the right and left ventricular outlets. A low-flow circulation was maintained with an external pump. The 6-F AngioJet thrombectomy device was activated at 42 sites inside vessels from 2 to 10 mm in diameter; in one lung, 8 activations were made after deliberately withdrawing the guidewire.

RESULTS

Vessels >6 mm in diameter remained intact. Vessel wall disruption occurred in 4 of 7 vessels between 4 and 6 mm in diameter and in 13 of 14 segmental arteries <4 mm in diameter (regardless of whether or not a guidewire was used). The signs of vessel wall disruption included extravasation of contrast material, arteriovenous fistula, and laceration of distal airspaces with contrast inside the bronchus.

CONCLUSIONS

The application of this system has to be considered potentially dangerous when activated inside vessels with diameters <6 mm. The use of this device appears to be safe only inside main branches of the lung vessels at this time. Additional experiments will be required to substantiate these initial results.

Rheolytic Thrombectomy of Acute Stent Thrombosis of Cervical Vertebral Artery

A new Xpeedior rheolytic thrombectomy catheter has been successfully used to extract thrombus from an acutely thrombosed vertebral artery stent without apparent distal embolism. The ease of use and the speed of thrombectomy suggest that this system may be useful for the treatment of acute ischemic stroke.

Esophageal varices. II. TIPS (transjugular intrahepatic portosystemic shunt) and surgical therapy

The role of surgery in the prevention and treatment of variceal hemorrhage is reviewed. Types of available surgery, their physiologic basis, and literature supporting their use are discussed in the context of the natural history of variceal hemorrhage. The evolution of transjugular intrahepatic portosystemic shunt (TIPS) as a treatment modality for variceal hemorrhage is reviewed. The effects of TIPS on portal and systemic hemodynamics and clinical usefulness in the management of variceal hemorrhage are discussed. A treatment algorithm for the integrated use of the various treatments is provided.

Mechanical thrombectomy of acute thrombosis in transjugular intrahepatic portosystemic shunts

RATIONALE AND OBJECTIVES

To evaluate the feasibility of mechanical thrombectomy with the use of the Amplatz thrombectomy device (ATD) in restoring patency to acutely thrombosed stent-shunts after transjugular intrahepatic portosystemic shunt (TIPS) placement.

METHODS

Mechanical thrombectomy with the ATD was performed in 10 consecutive patients with angiographically documented complete thrombosis of the stent-shunt (mean +/- SD, 6.6 +/- 3.4 cm), which occurred an average of 2.8 months (range, 0-11 months) after the TIPS procedure.

RESULTS

In all patients, immediate restoration of patency of the stent-shunt was achieved after thrombectomy alone (n = 1), thrombectomy plus percutaneous transluminal angioplasty (PTA; n = 4), and thrombectomy, PTA, and stenting (n = 5). The mean activation time of the ATD was 253 +/- 43 seconds. The pressure gradient for portal decompression decreased from 23 +/- 6 mmHg before to 11 +/- 3 mmHg after the procedure. The primary patency rate was 80% at 3 months and 60% at 11 months.

CONCLUSIONS

Mechanical thrombectomy with the ATD in acutely thrombosed TIPS is technically feasible. Mechanical thrombectomy is a potential alternative to thrombolysis.

Rheolytic hydrodynamic thrombectomy for percutaneous treatment of acutely occluded infra-aortic native arteries and bypass grafts: midterm follow-up results

RATIONALE AND OBJECTIVES

To evaluate the efficacy of a rheolytic thrombectomy catheter (RTC) for treatment of acutely occluded infra-aortic native arteries and bypass grafts and to determine midterm primary patency, death, and amputation-free survival rates.

METHODS

From March 1995 to September 1997, 112 patients with occluded arteries or bypass grafts were primarily treated with RTC at two centers. Thrombus removal was evaluated by two angiographers.

RESULTS

More than 75% of the thromboembolic material could be removed with RTC alone. Mean activation time of RTC was 280 +/- 163 seconds. Residual mural or organized thrombi (29%) required adjunctive fibrinolytic therapy or aspiration thrombectomy. Remaining stenoses were treated with percutaneous transluminal angioplasty and additional stent implantation. For acute reocclusions, surgical intervention was required. Technical success after the entire procedure was 88.4%. RTC-associated complications included distal embolization, dissection, vessel perforation, and technical failure of RTC. Mean follow-up time was 14.8 months +/- 11.5, rates of primary patency, secondary patency, death, and amputation-free survival were 60%, 84%, 16%, and 75% after 2 years, respectively.

CONCLUSIONS

RTC is a rapid and efficient technique for mechanical thrombectomy of acutely thrombosed native leg arteries and bypass grafts. Midterm results are comparable to the results of alternative treatment modalities such as Fogarty balloon thromboembolectomy or local fibrinolysis.

A new thrombectomy catheter device (AngioJet) for the disruption of thrombi: An in vitro study

In this study we examined a new thrombectomy catheter device. Different kinds of in vitro generated thrombi and cadaver thrombi were disrupted in test tubes. The mean disruption rate (and disruption time for 1 g of thrombus) was 225 +/- 65 mg/sec (5 +/- 2 sec) for whole-blood, 117 +/- 60 mg/sec (12 +/- 9 sec) for fibrin, 41 +/- 18 mg/sec (30 +/- 18 sec) for mixed, 70 +/- 42 mg/sec (17 +/- 5 sec) for unorganized, 45 +/- 8 mg/sec (22 +/- 4 sec) for partly, and 5 +/- 1 mg/sec (216 +/- 29 sec) for completely organized cadaver thrombi (P < 0.05). More than 99% of fragmented particles of whole-blood thrombi were 0-12 microm in diameter. The particle size of fibrin, mixed, and cadaver thrombi was similar, with 25%-40% of particles between 0-12 microm, 55%-71% >12-24 microm, and 2%-7% >24 microm. The device may be effectively used in the therapy of massive pulmonary embolism or acute peripheral and coronary artery syndromes when medical thrombolysis is contraindicated and organization of thrombus is absent. Further studies need to be performed to investigate the potential effects of particle microembolization. Cathet. Cardiovasc. Intervent. 47:381-389, 1999.

In vitro effectiveness study for hydrodynamic thrombectomy devices of the second generation

RATIONALE AND OBJECTIVES

To determine the efficacy of clot removal and the amount of applied saline and aspirated fluid and to compare procedure-related particle embolization for the hydrodynamic thrombectomy devices the LF 140 Angiojet (LF 140), the double-lumen Hydrolyser (double HL), and the triple-lumen Hydrolyser (triple HL) in an in vitro flow model.

METHODS

Thrombectomy of clots (n = 42) from 7-day-old porcine blood (9.8 g) was performed with the LF 140, the double HL, and the triple HL in a flow model (flow 1 L/min) made of silicone tubes (7 mm inner tube diameter). All catheters were used according to the manufacturer's recommendations.

RESULTS

Mean time of thrombectomy ranged from 20 seconds (triple HL) to 58 seconds (LF 140, P < 0.05). Only for the triple HL was remaining thrombus found within the tubes (41 mg). None of the tested devices worked isovolumetrically: the mean ratio of applied saline and aspirated fluid for the devices ranged from 0.79 (triple HL) to 0.89 (double HL, P < 0.05). Mean embolus weight and percentage of embolism from original thrombus were 675 mg/6.7% (LF 140, P < 0.05), 38 mg/0.4% (double HL), and 26 mg/0.3% (triple HL).

CONCLUSIONS

Thrombectomy time and embolus weight depend on the device chosen. The ratio of applied to aspirated fluid, indicating the capability to work nearly isovolumetrically, is acceptable for all tested devices. In vitro, the triple HL seems to be the most appropriate device for rapid mechanical, hydrodynamic thrombectomy. Because of the high in vitro particle embolization rate, the LF 140 seems to be strictly limited to small-caliber vessels.

Rheolytic thrombectomy: a new treatment for stent thrombosis

Coronary stent thrombosis, a rare complication after stent deployment, carries major morbidity and mortality. Traditional treatments for stent thrombosis include local or systemic delivery of thrombolytic agents and balloon angioplasty, both with far from optimum results. We report on two cases of coronary stent thrombosis successfully treated with rheolytic thrombectomy as an adjunct to balloon angioplasty.

In vitro effectiveness study of three hydrodynamic thrombectomy devices

PURPOSE

To determine the in vitro efficacy of three hydrodynamic thrombectomy devices.

MATERIALS AND METHODS

Thrombectomy of clots was performed with three thrombectomy devices (Angiojet [AJ], Possis Medical, Minneapolis, Minn; Hydrolyser [HL] Cordis Europe, Roden, the Netherlands; and the Shredding Embolectomy Thrombectomy [SET] catheter, HP-Medica, Augsburg, Germany) in a flow model.

RESULTS

Mean thrombectomy time ranged from 10.22 seconds (HL) to 37.73 seconds (AJ with guide wire). For the AJ and HL, the use of guide wires prolonged thrombectomy time (P < .01). The AJ with and without a guide wire and the HL with a 0.018-inch guide wire worked isovolumetrically, whereas the mean ratio of applied saline and aspirated fluid for the other devices was different from 1, ranging from 0.54 to 0.72. Mean embolus weight with the AJ alone (56.44 mg) was significantly higher than that with the SET catheter alone (3.15 mg) and with a guide wire (1.31 mg, P < .01 for both) and the HL alone (3.9 mg, P < .05), as was the embolus weight with the HL with a 0.018-inch guide wire (66.5 mg) compared with the SET catheter with and without a guide wire (P < .01), AJ with a guide wire (22.33 mg, P < .05), the HL alone (P < .01), and the HL with a 0.025-inch guide wire (24.86 mg, P < .05).

CONCLUSION

The devices showed performance differences. The SET catheter alone and with a guide wire and the HL may bear an increased risk of procedure-related anemia. In clinical applications, hydrodynamic thrombectomy might substantially reduce the need for thrombolytic therapy.

Thrombectomy with AngioJet catheter in native coronary arteries for patients with acute or recent myocardial infarction

The AngioJet thrombectomy catheter removes thrombi by rheolytic fragmentation and suction. The purpose of this study was to identify the efficacy and safety of this new device. Myocardial infarction (MI) is associated with intracoronary thrombus. Intracoronary thrombus has been identified as a risk factor of unfavorable outcome after percutaneous transluminal coronary angioplasty. To what extent the AngioJet is applicable or effective for acute or recent MI in native coronary artery is not clear. Thrombectomy with the AngioJet was attempted in 31 patients with 31 native coronary arteries selected from 304 patients with acute or recent MI. Follow-up angiography was performed at 3 to 6 months. Procedure success was achieved in 29 patients (94%). Adjunctive balloon angioplasty was performed after AngioJet thrombectomy in 30 patients (97%), and in only 1 patient (3%) AngioJet thrombectomy was the sole procedure. Subsequent stenting after balloon angioplasty was attempted successfully in 12 patients (40%) without thrombotic complications. Thrombolysis In Myocardial Infarction trial flow grading increased from 0.70 +/- 0.97 before to 2.61 +/- 0.88 after AngioJet thrombectomy (p <0.0001), to 2.84 +/- 0.64 after adjunctive procedures (p = 0.070). At follow-up angiography restenosis rate was 21% but Thrombolysis In Myocardial Infarction flow 3 was present in all patients. The restenosis rate of stented patients was 8%. There were no major events during in-hospital and follow-up. The AngioJet can be used safely and successfully to remove thrombus from the native coronary artery of patients with MI. Thrombus removal makes subsequent stenting safe and uncomplicated. The restenosis rate was considered to be acceptable.

Experimental treatment of early chronic iliac vein thrombosis with a modified hydrodynamic thrombectomy catheter: preliminary animal experience

PURPOSE

To evaluate the efficacy and safety of a new hydrodynamic catheter for removal of chronic iliac vein thrombus.

METHODS

Unilateral iliac vein thrombosis was induced in seven pigs by combining permanent coil and temporary balloon occlusion. Thrombectomy was performed with a new hydrodynamic catheter (10 F S.E.T.) 3 days after thrombus induction. After thrombectomy, the animals were killed and the iliac veins were examined histologically.

RESULTS

Complete thrombectomy (100% thrombus removal) was achieved in three of seven animals, 75% removal in three of seven animals, and only 30% removal in one animal. The average thrombus removal was 75%. Successful re-establishment of flow was achieved in five of seven cases. Histologically, the thrombi were partially organized, meeting the histologic criteria for early chronic venous thrombosis. Minor venous wall damage caused by the thrombectomy procedure without acute hemodynamic consequences was observed in four of seven cases.

CONCLUSION

The 10-F S.E.T. catheter was reasonably effective in removing chronic iliac vein thrombus with no hemodynamically significant complications.

Rheolytic thrombectomy in the treatment of acute limb-threatening ischemia: immediate results and six-month follow-up of the multicenter AngioJet registry. Possis Peripheral AngioJet Study AngioJet Investigators

We tested the efficacy of rheolytic thrombectomy in treating 21 patients (mean age 68+/-12 years; 66% male) and 22 vessels (limbs) who presented to the hospital within 2 weeks of the development of limb-threatening ischemia. Fifty-two percent had contraindications to use thrombolytics, and 57% had severe comorbidities. All of the vessels were occluded with thrombus on the initial angiogram. Procedural success was achieved in 20 limbs (91%). Three patients expired in the hospital, and one expired at follow-up due to nonvascular causes. Acute limb salvage was achieved in 18 of 19 limbs (95%) in the 18 survivors, and 6-month limb salvage was achieved in 16 of 18 limbs (89%) in the 17 survivors. Rheolytic thrombectomy is effective in restoring immediate blood flow in acute limb-threatening ischemia, especially in high-risk surgical patients or patients with contraindications to thrombolytic therapy.

Stenting after thrombectomy with the AngioJet catheter for acute myocardial infarction

The presence of massive intracoronary thrombi may contraindicate stenting. The AngioJet catheter rheolytic thrombectomy prepared the road for an easy and uneventful stenting in 2 patients with acute myocardial infarction (AMI) and thrombi. This combination provides a promising strategy for patients with AMI and angiographic evidence of massive thrombi.

A new treatment for severe pulmonary embolism: percutaneous rheolytic thrombectomy

BACKGROUND

The rheolytic thrombectomy catheter has been specially designed to remove intravascular thrombus from coronary and peripheral arteries. It demonstrates a practical application of Bernoulli's principle relating to a low-pressure zone in the region of a high-velocity jet. In this device, this effect is created by direct high-pressure saline jets located at the tip. Thrombus is drawn into this region and, because of the large pressure difference, undergoes mechanical thrombolysis due to the powerful mixing forces. The resulting microparticles are aspirated through the same catheter and removed from the body.

METHODS AND RESULTS

We report the use of this device in two patients presenting with severe pulmonary embolism and contraindications to thrombolytic therapy. The two procedures were successfully performed with an excellent immediate angiographic result at the site of the rheolytic thrombectomy. In both cases, the clinical improvement was maintained at follow-up with the same good angiographic result and a decrease to a normal level of the systolic pulmonary pressure.

CONCLUSIONS

This preliminary results suggest that this easy technical method may be useful in the treatment of life-threatening pulmonary embolism in patients with absolute contraindications to thrombolytic therapy. A larger cohort of patients is necessary to determine whether this treatment should be proposed as an alternative to the use of fibrinolytics in selected patients.