Technique de recanalisation: mon expérience avec Aspirex
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1 JFICV 2017, Deauville Thrombose veineuse profonde aiguë en 2017 Technique de recanalisation: mon expérience avec Aspirex Romaric LOFFROY Département de Radiologie Diagnostique et Thérapeutique CHU Hôpital François ois-mitterrand Dijon
2 Endovascular therapeutic options Thrombolysis Local CDT Manual aspiration Thrombus fragmentation Trerotola PMT or lysis-assisted MT EKOS = US-enhanced lysis Trellis = pharmaco-mt Angiojet = rheolytic pharmaco-mt Pure MT Indigo = aspiration MT Rotarex = rotational MT
3 Early clot removal: many choices!
4 The perfect system? Minimally invasive Easy to use Reduced procedural time Treat all veins Reduces thrombus burden Lowest complication rate No vessel wall damage Successful in restoring vein patency Preserves valvular function Unmask underlying lesion Targeted treatment No need for lysis drug Overall cost-effective Pure Rotational Mechanical Thrombectomy?
5 Thrombectomy devices for DVT treatment Aspirex Pure mechanical thrombectomy No thrombolytics Age of thrombus not so relevant Chance to finish in the angio- room No RCT data EKOS / Trellis / Angiojet Time consuming Additional thrombolytics Bleeding risks Re-angio after finishing treatment for stent placement (EKOS) Organized thrombus > 4 weeks = possible ineffectiveness Additional ICU stay with EKOS No RCT data, only registry data
6 The Aspirex device itself
7 Aspirex technical data Size matters!
8 Our center experience for DVT thrombectomy with the Aspirex catheter 46 Aspirex rotational MT procedures 18 DVTs lower limb All iliofemoral 16 DVTs upper limb 6 SVC 10 BCV 10 dialysis-access fistula 6 native 4 goretex 2 TIPS Technical success analysis Procedural details analysis Safety analysis 6 month follow-up patency analysis
9 DVTs lower limb summarized data Period of inclusion: 19 months (December 2015-June 2017) 18 patients 13 F / 5 M Mean age: 41.2 yrs (range: yrs) Symptomatic ilio-femoral DVT: oedema, pain, PE in 2 patients Distribution: L=12, R=6 With involvement of popliteal vein: 5/18 With involvement of IVC: 3/18 Duration of symptoms before treatment: 10 first patients < 15 days 8 last patients < 7 days May-Thurner syndrom: 12/18 (66.7%) Thrombophilic abnormality: 3/18 Preoperative CT scan: 15/18 = 83.3%
10 Technique Under local anesthesia Cook Flexor 10-Fr long sheath Endovascular approach Jugular: 5 Popliteal: 11 Both: 2 Aspirex 10-Fr 110 cm Optimed self-expandable stents (10-16mm) ALN IVC filter: 4/18 Systematic day 1 exams: chest CT scan/duplex US Post-operative medication for 3 months AC AP
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12 Key concepts Age of thrombus Coagulation Infusion mix Flow Guidewire Correct movement Motor
13 Age of thrombus Optimal moment to treat proximal vein occlusion Goal: safe valve function Age of thrombus is key of success Best results achieved with really fresh thrombus: 10 days: National Venous Registry 14 days: ATTRACT trial 21 days: CaVent trial < 14 days is optimal but as early as possible is better
14 Coagulation Always consider the coagulation Bolus of 100UI/kg of heparin every 45 min If a proper anticoagulation is not achieved The helix may be blocked Guidewire could be stuck in the catheter
15 Infusion mix Technique 250ml saline + 250ml contrast UI heparin Put the mix in a pressure bag Adjust the flow To avoid collapse of the vein during the aspiration Start the infusion until visualization of the vein Start the aspiration Stop the flow when the motor is off Benefits Get real-time information during the procedure about Status of the vein Vessel wall behavior Thrombus status Efficiency of the aspiration Vessel patency Contrast: no systemic effect because permanently aspirated by the Aspirex
16 Flow If the vein is collapsing on the Aspirex head, it means that the flow is not enough Pull back the catheter and wait for the vein to fill up again Stop the motor and wait for the vein to fill up again Keep in mind during run of catheter System is cooled by blood flow: warming of catheter indicates insufficient blood flow/cooling Consider saline infusion in occluded venous segments High aspiration capacity: keep an eye on collecting bag Flush catheter after usage
17 Guidewire Aspirex 10-Fr guidewire is always fine Aspirex 8-Fr / 6-Fr guidewire is not always fine Keep it straight Don t hesitate to take another one
18 Correct movement How to reach eccentric thrombus Used long angled 10/12-Fr sheath to increase the radius of catheter
19 Motor
20 Results Technical success: 100% Restoration of proximal iliofemoral blood flow Residual thrombus < 20% Stent rate: 100% Mean: 2.6/patient IVC temporary filter: 4/18 Amount of blood/thrombus aspirated Mean: 260 ml Range: ml Mean time PMT duration: 13 min Total procedure duration: 71 min No lytic therapy No complications No bleeding, no PE No hematoma 1 wire loss: snared Follow-up patency Discharge < 2 days for all patients IS rethrombosis in 2 patients At 3 days: re-aspirex and stenting At 2 months: failure of recanalization Secondary stent patency: 100% Follow-up: 4 days to 19 months Mean: 7.4 months No sequela
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25 IVUS role?
26 Technical limitations Subintimal position of the guidewire Chronic venous occlusion Proper anticoagulation not achieved Impossibility to pass the lesion completely with the guidewire Undersized or oversized vessel diameter With radius of curvature less than 2 cm If the catheter, the guidewire or the sheath are damaged, kinked or present unsolved resistance
27 Why is pure MT cost-effective? Fast thrombus removal No ICU stay No angiographic control No lytics required No bleeding complications Outpatient procedure? Less balloons, less stents? Catheter cost
28 On going trial
29 Conclusion DVT thrombectomy with a pure mechanical approach as first choice Is effective in venous thrombus removal Even in more organized thrombus Fast relief of acute symptoms Restores vein patency in upper and lower limb Preserves valve function Has low risk and less side effects No ICU stay End it in the angiolab No lytics Prevention of PTS
30 Still debated Jugular/popliteal approach? IVC filter? Necessity of 100% thrombus removal? IVC stenting? Treatment of superficial femoral/popliteal vein? Pure mechanical thrombectomy approach? Type/duration of post-operative medication?
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