Methods of Thrombus Fragmentation & Extraction. Methods of Thrombus Extraction
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1 Thrombus Fragmentation and Extraction: Clinical Evidence and Practical Application No Relevant Disclosures Venita Chandra, MD Clinical Assistant Professor of Surgery Division of Stanford Medical School, Stanford, CA UCSF Vascular Symposium April 14th, 2016 Methods of Thrombus Extraction Catheter Directed Thrombolysis Percutaneous Mechanical Thrombectomy Methods of Thrombus Fragmentation & Extraction Rotational Rheolytic uses Venturi effect Aspirational Hydrodynamic Hydraulic recirculation Ultrasonic Pull Back /clot trapping etc. >29 different devices Venous/Arterial/Dialysis Access 1
2 Trellis TM* Dispersion wire is sinusoidal shape, connected to oscillation drive Infusion port Aspiration Port Trellis TM Pros: limited systemic leakage of thrombolytics, potentially less embolization Cons: limited in size Compliant occlusion balloons * Bacchus Vascular, Santa Clara, CA AngioJet TM Catheter* Case- Angiojet Hypotube and jet body Rheolytic Thrombectomy Jet flow of saline creates low pressure zone (Venturi Effect) Low pressure: Thrombus fragmentation Evacuation * Boston Scientific, Marlborough, MA Clotted Brachial-Axial AV graft Technique Access both retrograde/antegrade Infuse TpA through Angiojet Catheter on Power pulse mode Wait minutes 2
3 After Power Pulse AngioJet TM Catheter Retrograde sheath Antegrade sheath Pros: Cons: Less endothelial damage Cost Pharmacomechanical option Hemolysis Arterial and venous uses Hematuria variety of sizes Hyperkalemia Bradycardia After Thrombectomy Penumbra Catheter* Penumbra TM Large lumen aspiration Separator Tip Pros: No Thrombolysis Extremely trackable Arterial and venous uses Cons: Risk of blood loss Limitation of catheter sizes * Penumbra, Alameda, CA 3
4 Results of PMT Safety & Feasibility Studies of various devices/case Series/Retrospective Reviews Arterial Technical success: 70-90% AV access: Technical success: 76-91% DVT Technical success: % CDT + PMT CDT vs. PMT with PMT* Similar outcomes, shorter hospital stays and less thrombolytics *Kim et. al. Cardiovasc Intervent Radiol (2006) *Lin et. al. Am Journal of Surgery 2006 Conclusions Numerous options for PMT Appear to associated with less thrombolytics, less treatment time (less ICU stay) and potentially less hospital costs compared to CDT Limited quality data to guide treatment Clinical decisions: Experience/Comfort level Case by case PEARL Registry Results Venous Thank You! vascular.stanford.edu 58.5% had 100% clot burden reduction 96% had >50% clot burden reduction No significant difference in terms of clot burden reduction Significant differences in treatment time PCDT + CDT 52% 41 hrs n=329 CDT 9% RT only 4% 1.4 hrs PCDT 35% 22 hrs 2 hrs Garcia, JVIR June 2015, volume 26, Issue 6, pages
5 PEARL Registry- Arterial n=283, 48% PMT+CDT, 52% PMT only Procedures were shorter in the PMT only group (1.6 hrs vs hrs) compared to the PMT+CDT group (p<0.001) Increased rate of stenting in PMT only group Comparison of outcomes by treatment NOT RCT Just a registry!! Daniel A. Leung et al. J Endovasc Ther 2015;22: Penumbra Case Complicated diabetic, numerous prior interventions for CLI over many years Infected SFA Viabahns after bout of sepsis Partial resection of SFA Viabahns, and cadaveric fem-pt bypass Occlusion of cadaveric bypass re-opened with CDT Pseudoaneurysm/degeneration of bypass treated with covered stent Occlusion of bypass treated with CDT, complicated by bleeding Presents with re-occluded bypass, rest pain and tissue loss Penumbra Case: Hoping for limb salvage Did not want thrombolysis Occluded remnant native SFA stent Occluded stent in cadaveric bypass graft Single disease vessel runoff (PT) Distal anastomosis of occluded graft 5
6 Penumbra Case After passage of After balloon penumbra angioplasty catheter 6
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