4/14/2016 Thrombus Fragmentation and Extraction: Clinical Evidence - - PowerPoint PPT Presentation

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Vascular Surgery

Thrombus Fragmentation and Extraction: Clinical Evidence and Practical Application

Venita Chandra, MD Clinical Assistant Professor of Surgery Division of Vascular Surgery Stanford Medical School, Stanford, CA

UCSF Vascular Symposium April 14th, 2016

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• No Relevant Disclosures

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Methods of Thrombus Extraction

Catheter Directed Thrombolysis Percutaneous Mechanical Thrombectomy

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Methods of Thrombus Fragmentation & Extraction

• Rotational
• Rheolytic – uses Venturi

effect

• Aspirational
• Hydrodynamic
• Hydraulic recirculation
• Ultrasonic
• Pull Back /clot trapping
• etc.

>29 different devices >29 different devices Venous/Arterial/Dialysis Access Venous/Arterial/Dialysis Access

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TrellisTM*

• Compliant occlusion

balloons

• Compliant occlusion

balloons

• Dispersion wire is

sinusoidal shape, connected to

• scillation drive
• Infusion port
• Aspiration Port
• Dispersion wire is

sinusoidal shape, connected to

• scillation drive
• Infusion port
• Aspiration Port

* Bacchus Vascular, Santa Clara, CA

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TrellisTM

• Pros: limited systemic leakage of thrombolytics,

potentially less embolization

• Cons: limited in size

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Vascular Surgery Hypotube and jet body

AngioJetTM Catheter*

• Rheolytic Thrombectomy
• Jet flow of saline creates

low pressure zone (Venturi Effect)

• Low pressure:
• Thrombus

fragmentation

• Evacuation
• Rheolytic Thrombectomy
• Jet flow of saline creates

low pressure zone (Venturi Effect)

• Low pressure:
• Thrombus

fragmentation

• Evacuation

* Boston Scientific, Marlborough, MA

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Case- Angiojet

• Clotted Brachial-Axial AV graft
• Technique
• Access both retrograde/antegrade
• Infuse TpA through Angiojet Catheter on Power pulse mode
• Wait 20-30 minutes

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• Retrograde sheath
• Retrograde sheath
• Antegrade sheath
• Antegrade sheath
• After Power Pulse
• After Power Pulse
• After Thrombectomy
• After Thrombectomy

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AngioJetTM Catheter

• Pros:
• Less endothelial damage
• Pharmacomechanical option
• Arterial and venous uses
• variety of sizes
• Cons:
• Cost
• Hemolysis
• Hematuria
• Hyperkalemia
• Bradycardia

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Penumbra Catheter*

• Large lumen

aspiration

• Separator Tip
• Large lumen

aspiration

• Separator Tip

* Penumbra, Alameda, CA

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• Pros:
• No Thrombolysis
• Extremely trackable
• Arterial and venous uses
• Cons:
• Risk of blood loss
• Limitation of catheter sizes

PenumbraTM

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• Safety & Feasibility Studies of various devices/Case

Series/Retrospective Reviews

• Arterial
• Technical success: 70-90%
• AV access:
• Technical success: 76-91%
• DVT
• Technical success: 28.5-100%
• CDT + PMT
• CDT vs. PMT

Results of PMT

Similar outcomes, shorter hospital stays and less thrombolytics with PMT* Similar outcomes, shorter hospital stays and less thrombolytics with PMT* *Kim et. al. Cardiovasc Intervent Radiol (2006) *Lin et. al. Am Journal of Surgery 2006

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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

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Thank You!

vascular.stanford.edu

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PEARL Registry Results Venous

• 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

Garcia, JVIR June 2015, volume 26, Issue 6, pages 777-785 RT only 4% PCDT 35% CDT 9% PCDT + CDT 52%

n=329

1.4 hrs 2 hrs 22 hrs 41 hrs

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• n=283, 48% PMT+CDT, 52% PMT only
• Procedures were shorter in the PMT only

group (1.6 hrs vs. 23.0 hrs) compared to the PMT+CDT group (p<0.001)

• Increased rate of stenting in PMT only group

PEARL Registry- Arterial

Daniel A. Leung et al. J Endovasc Ther 2015;22:546-557

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Comparison of outcomes by treatment

• NOT RCT
• Just a registry!!
• NOT RCT
• Just a registry!!

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Penumbra Case

• Complicated diabetic, numerous prior interventions for CLI
• ver 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

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Penumbra Case:

Occluded remnant native SFA stent Occluded stent in cadaveric bypass graft Single disease vessel runoff (PT) Distal anastomosis of

• ccluded graft
• Hoping for limb

salvage

• Did not want

thrombolysis

• Hoping for limb

salvage

• Did not want

thrombolysis

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Penumbra Case

After passage of penumbra catheter After balloon angioplasty