10 years ago and refers to the removal of acute throm- bus using non-surgical methods [1, 2]. Thrombectomy is achieved by thrombus dissolution, thrombus fragmen- tation, aspiration of thrombus or a combination of these methods. Percutaneous thrombectomy techniques can be broadly divided into percutaneous aspiration thombectomy (PAT) in which thrombus is aspirated through catheters, and mechanical thrombectomy (MT) procedures, which involve maceration of thrombus or fragmentation and removal of thrombus. Mechanical thrombectomy usually involves specialized devices, whereas aspiration thrombectomy can be achieved with catheters and guidewires available in most interven- tional radiology suites. Percutaneous thrombectomy can be a primary procedure in which the operator sets out to clear the occluded vessel by percutaneous thrombectomy alone, or in combination with transcatheter throm- bolysis. Percutaneous thrombectomy can be used to remove thrombus from arteries, veins or vascular grafts. Similar to thrombolysis, thrombectomy is relatively ineffective if the thrombus is organized and best results are obtained in acute occlusions of less than two weeks duration. When the concept of mechanical thrombectomy (MT) was first introduced, it was hoped that MT would obviate the need for thrombolysis in many cases. While this is undoubtedly true for some applications such as haemodialysis fistulae, thrombolysis is still the main method used to remove thrombus in a substantial pro- portion of procedures. With increasing experience and refinements in the designs of the devices themselves, the role of MT is becoming better defined [3, 4, 5]. Indications Arteries The main indications for thrombectomy in the arterial system include: (a) removal of acute emboli from the EUR 10.10.01 10:36 Seite 1 CYAN MAGENTA YELLOW BLACK FIRMENGRUPPE APPL FIRMENGRUPPE APPL Eur. Radiol. (2002) 12:205217 DOI 10.1007/s003300101014 VASCULAR- INTERVENTIONAL Robert Morgan Anna-Maria Belli Percutaneous thrombectomy: a review Received: 7 May 2001 Accepted: 21 May 2001 Published online: 26 July 2001 Springer-Verlag 2001 R. Morgan ( ) ) A.-M. Belli Department of Vascular Radiology, St. George's Hospital, Blackshaw Road, London SW17 0QT, UK E-mail: robert.morgan@stgeorges.nhs.uk Phone: +44-20-87251076 Fax: +44-20-87252936 Abstract Percutaneous thrombec- tomy (PT) is an established tech- nique for the removal of acute thrombus in occluded arteries, veins and vascular grafts. Percutaneous thrombectomy can be used as an adjunctive treatment to other meth- ods of thrombus removal such as thrombolysis or as sole therapy. The two main methods are percutaneous aspiration thrombectomy in which thrombus is removed by suction with the aid of wide-bore catheters, and mechanical thrombectomy us- ing a variety of automated devices to fragment or remove thrombus. As- piration thrombectomy is often used as an adjunct to thrombolysis in acute arterial occlusion, or as sal- vage therapy to remove distal em- boli following iliac or femo- ropopliteal angioplasty. Mechanical thrombectomy is useful for the treatment of thrombosed dialysis grafts and is being increasingly used for the treatment of massive pulmo- nary emboli and ileofemoral or ileocaval deep venous thromboses. Keywords Thrombectomy Arteries Thrombosis Veins Grafts Interventional procedure Stenosis or thrombosis Thrombolysis D o k u m e n t : e u r - 1 0 1 4 . 1 V d o c ; S e i t e : 1 ; A u s z u g : V o l l f a r b e ; D a t u m : 2 1 . 1 2 . 1 0 1 ; U h r z e i t : 1 2 : 0 6 : 1 5 distal circulation following angioplasty or stent proce- dures; (b) the removal of de novo emboli from the distal circulation; (c) the clearance of thrombus from acutely occluded vascular grafts; and (d) the clearance of thrombus from acute native vessel occlusions. Percuta- neous thrombectomy is usually performed in the lower extremity arteries, although it can also be used in upper extremity and visceral arteries. Veins The main indications for percutaneous thrombectomy in the venous system are the treatment of: (a) acute ileocaval thrombosis; (b) ileofemoral vein thrombosis; (c) acute superior vena cava thrombosis; and (d) re- moval or fragmentation of massive pulmonary emboli (PE) in severely ill patients. Dialysis grafts One of the main roles of percutaneous thrombectomy in recent years has been the treatment of acutely throm- bosed dialysis grafts, particularly prosthetic dialysis grafts. Contraindications Percutaneous thrombectomy should not generally be performed if removal of thrombus cannot be achieved safely. Thrombectomy should not be performed across the aortic bifurcation from the contralateral femoral ar- tery, because of the risk of passing embolic material into the ipsilateral normal circulation. Equipment Aspiration thrombectomy The equipment required for this technique is relatively simple and consists of a thin-walled guiding catheter (e.g. Britetip, Cordis, Ascot, Berkshire, UK), a vascu- lar sheath with a removable hemostatic valve (William Cook, Europe, Bjaeverstock, Denmark), and a 50-ml syringe with a luer lock connector. The removable haemostatic valve is necessary to prevent retention of aspirated thrombus within the sheath upon removal from the artery. Aspiration catheters are available in straight versions and with a variety of shaped-tip con- figurations. The thin wall of the aspiration catheter ensures the maximum internal luminal diameter for aspiration of thrombus. Aspiration catheters are available in sizes from 6 to 10 F, but aspiration via 4- or 5-F catheters can be performed in the tibial circu- lation. Mechanical thrombectomy devices In the past decade there have been many types of thrombectomy catheter produced for use in the coro- nary and peripheral circulations. These devices have all been designed to achieve rapid clearance of acute oc- clusions in arteries, bypass grafts and veins, and avoid the morbidity and increased procedural time required for thrombolysis. Some designs have met with clinical success and remain on the market. Many others have been withdrawn because of poor performance. The de- vices most commonly used in current practice are de- scribed below. The MT devices can be broadly divided into two categories: 1. Hydrodynamic recirculation devices. The method of action of these devices is dependent on the Venturi effect produced by retrogradely directed high-speed saline jets. Local thrombus is sucked into the aper- ture of the device and macerated by the high local shear forces. Removal of the products of fragmenta- tion is usually accomplished by an exhaust lumen in the device. Examples include the Hydrolyser device and the Oasis system. 2. Rotational recirculation devices. These devices pro- duce clot fragmentation by production of a hydrody- namic vortex, which is created by a high-speed rotat- ing impeller or basket. Examples include the Am- platz thrombectomy device and the Arrow-Trerotola PTD. There are many devices available and new ones are un- der development. The most commonly used devices are described below. Devices which utilize saline injection are usually powered by standard angiographic pump in- jectors. Purely mechanical devices are usually supplied with a motor. Hydrolyser system The Hydrolyser system (Cordis, Johnson and Johnson, Miami, Fla.) is a hydrodynamic mechanical thrombec- tomy device and has been in clinical use since 1993. It consists of a 6- or 7-F double-lumen, 65-cm-long cathe- ter with a 6-mm oval side hole 4 mm from the distal tip. The smaller-injection lumen ends in a hairpin loop at the device tip. Heparinized saline is injected through the injection lumen by an angiographic pump at a rate of 3 mls/s at 750 psi and is directed by the hairpin loop retrogradely into the exhaust lumen. At the site of the 206 EUR 10.10.01 10:36 Seite 2 CYAN MAGENTA YELLOW BLACK FIRMENGRUPPE APPL FIRMENGRUPPE APPL D o k u m e n t : e u r - 1 0 1 4 . 1 V d o c ; S e i t e : 2 ; A u s z u g : V o l l f a r b e ; D a t u m : 2 1 . 1 2 . 1 0 1 ; U h r z e i t : 1 2 : 0 6 : 1 6 oval side window this saline jet creates a local reduction in pressure (Venturi effect) which sucks adjacent thrombus into the hole and disrupts it. The thrombus fragments are carried away in the exhaust lumen by the reversed saline flow and collected in a vacuum bag. The system can be used over a 0.025-in. guidewire and in- troduced through a 7-F sheath. Oasis thrombectomy system The Oasis thrombectomy system (Boston Scientific, Galway, Ireland) is similar to the Hydrolyser catheter and is available in 6-, 8- and 10-F sizes, and 65- and 100-cm lengths, and accepts an 0.018-in. guidewire. The device consists of two lumens in addition to the guide- wire lumen. A jet of heparinized saline is directed in a reverse direction into a larger exhaust lumen from a shepherd's hook catheter at the tip of the device. This jet creates a pressure reduction at the site of the Venturi effect which solubilizes the thrombus and propels the microfragments into the outflow lumen (Fig. 1). The device is designed for clearing peripheral arterial occlu- sions and dialysis grafts. Angiojet rheolytic thrombectomy catheter The Angiojet rheolytic thrombectomy catheter (RTC; Possis Medical, Minneapolis, Minn.) is a hydrodynamic recirculation device that is also similar in action to the Hydrolyser device. It consists of a 5-F double-lumen catheter which accepts an 0.018 in. guidewire. High- speed saline jets are injected through the smaller cathe- ter lumen and are directed retrogradely into the exhaust lumen producing a Venturi effect. In addition, there are three low-speed jets which emerge from the catheter tip in a radial fashion and enhance the recirculation cur- rent. Thrombus is fragmented by the Venturi and recir- culation vortices and is carried away in the exhaust lu- men. Amplatz thrombectomy device The Amplatz thrombectomy device (ATD; Microvena technologies, White Bear Lake, Minn.) is a recirculation thrombectomy device which has undergone several re- finements over the years. It consists of an 8-F 120-cm- long catheter with a 1-cm-long metallic capsule mount- ed in its distal end (Fig. 2). Within the protective capsule is a sharp rotating blade or impeller, which is rotated at speeds of up to 150,000 rpm by a compressed air tur- bine. The high rotation speed of the impeller creates a strong recirculation vortex. Adjacent thrombus be- comes attracted by the vortex into the end hole of the capsule and becomes macerated by the rapidly rotating impeller blades before passing out of the capsule through three large side holes. A second channel within the device allows injection of contrast medium, saline or thrombolytic agents. One of the main drawbacks of the ATD is that it is not an over-the-wire device and cannot be steered. The device should be used with an angled-tip 207 EUR 10.10.01 10:37 Seite 3 CYAN MAGENTA YELLOW BLACK FIRMENGRUPPE APPL FIRMENGRUPPE APPL Fig. 1a, b The Oasis thrombectomy system. a The Oasis throm- bectomy catheter and close-up view of the catheter tip. b Mecha- nism of action of the catheter tip. A jet of heparinized saline cre- ates a Venturi effect at the distal tip of the catheter. This rapidly fragments the thrombus and the microfragments are propelled into the outflow lumen D o k u m e n t : e u r - 1 0 1 4 . 1 V d o c ; S e i t e : 6 ; A u s z u g : V o l l f a r b e ; D a t u m : 2 1 . 1 2 . 1 0 1 ; U h r z e i t : 1 2 : 0 6 : 1 9 guiding catheter which can direct the catheter around curves. If a guiding catheter is not used, care should be taken when advancing the device because of the risk of vessel trauma. Arrow-Trerotola percutaneous thrombolytic device The Arrow-Trerotola percutaneous thrombolytic device (PTD; Arrow International, Reading, Pa.) was devel- oped specifically for the clearance of thrombosed dialy- sis grafts. The device consists of a rotating nitinol bas- ket, which is driven at 3000 rpm by a hand-held motor. The basket is contained in a 5-F catheter, which can be introduced through a 5.5-F sheath. The rotating basket disrupts the thrombus into small pieces less than 3 mm in diameter, the majority being smaller than 1 mm di- ameter. The resulting fragments can be aspirated through the side-arm of the introducer sheath. The main advantages of the PTD are its simplicity and low manu- facturing costs compared with other devices; however, the PTD causes substantial endovascular denudation when it is used in native veins and as a result its use should be confined to PTFE grafts [6]. Applications of percutaneous thrombectomy Arterial occlusions Percutaneous aspiration thromboembolectomy Percutaneous aspiration thromboembolectomy (PAT) was first described by Starck et al. [1] and Sniderman et al. [2] and is currently mainly used for acute arterial and graft occlusions below the inguinal ligament. Per- cutaneous aspiration thromboembolectomy can also be used to treat acute occlusion in the iliac arteries and su- prainguinal grafts; however, total clearance of thrombus from these areas is seldom achieved because of the larger calibre of iliac arteries and grafts with regard to the size of the catheters. There is also a potential risk of dislodging thrombus into the infrainguinal circulation. Although embolism into the infrainguinal circulation arising from PATof iliac thrombus could also be cleared by thrombectomy, this would necessitate an additional arterial puncture in the reverse (i.e. antegrade direc- tion). Percutaneous aspiration thromboembolectomy is not generally used for venous occlusions because of the larger calibre of the occluded veins relative to the size of the catheters. Technique Ideally, the largest-calibre catheter available (i.e. 9 or 10 F) should be used for PAT of femoral or popliteal occlusions. In practice, the largest catheters often used are 8 F. Some operators consider 8 F to be too large for routine PAT through an antegrade femoral puncture, and initially attempt PAT with 6-F catheters and work up to larger catheters if PAT is unsuccessful. Smaller catheters should be used in the infrapopliteal vessels. Tibioperoneal trunk occlusions can be treated with 6-F catheters. Although thin-walled catheters are not avail- able for the treatment of thrombi in the tibial arteries, it is possible to remove thrombi from these vessels using standard 4- or 5-F catheters (Fig. 3). Percutaneous aspi- ration thromboembolectomy in the popliteal and tibial arteries should be accompanied with bolus intra-arterial injections of a vasodilator (e.g. Glyceryl trinitrate, 150600 mcg) to prevent arterial spasm induced by the repeated passage of large-aspiration catheters. In the case of native vessel occlusion, the catheter is advanced under fluoroscopic guidance through the sheath over a guidewire into the distal part of the thrombotic occlusion. The guidewire is removed and suction is applied to the syringe by an assistant. If graft thrombectomy is performed, and the sheath tip has been advanced into the graft (either via a common femoral artery access or a direct graft puncture technique), the catheter can be advanced into the graft thrombus with- out a guidewire. Under continuous suction, the catheter is moved slowly back and forth through the thrombus until blood ceases to pass into the syringe indicating oc- clusion of the catheter by thrombus. Taking care to maintain suction to avoid dislodgement of the captured material, the catheter is withdrawn proximally. Just be- fore the catheter tip enters the end of the sheath, the sheath valve is disconnected and the catheter and sheath 208 EUR 10.10.01 10:39 Seite 4 CYAN MAGENTA YELLOW BLACK FIRMENGRUPPE APPL FIRMENGRUPPE APPL Fig. 2 The Amplatz thrombectomy device D o k u m e n t : e u r - 1 0 1 4 . 1 V d o c ; S e i t e : 7 ; A u s z u g : V o l l f a r b e ; D a t u m : 2 1 . 1 2 . 1 0 1 ; U h r z e i t : 1 2 : 0 6 : 2 0 valve are withdrawn simultaneously until the catheter has been removed completely from the patient. The as- sistant should stop the flow of blood from the detached sheath by digital pressure while the operator discon- nects the valve from the catheter, flushes it to remove any retained debris and replaces it onto the sheath. The contents of the catheter are expelled by injection of sa- line into a basin draped with gauze, which separates the aspirated material from the blood. The progress of thrombus aspiration is monitored by contrast injections through the side arm of the sheath (Fig. 4). The procedure can be repeated several times as re- quired. Sometimes, the sheath lumen itself becomes obstructed by a large piece of thrombus (this even hap- pens with removable hub sheaths). In this situation it is necessary to insert a guidewire into the vessel and ex- change the sheath for a new one. Percutaneous aspiration thromboembolectomy alone is often effective at clearing short occlusions and small amounts of thrombus. Although it is possible to clear longer occlusions (e.g. total femoropopliteal graft occlusions) with PAT, adjunctive thrombolysis is often required to achieve complete clearance. The main ad- vantage of PAT is that thrombus is rapidly removed and flow restored, which enables the procedure to be com- pleted in a single session if PAT is successful alone. Results of PAT Despite the widespread use of this technique, data on the clinical use of PAT are surprisingly limited [7, 8, 9]. Most papers involve heterogeneous groups and contain patients with both acute de novo emboli and patients with emboli arising from complications of endovascular interventions. One exception is the series reported by Wagner and Starck who achieved technical success fol- lowing PATin 87.3% of 102 patients with acute de novo lower extremity embolic occlusions; however, adjunc- tive methods were required in 60% of cases. These methods included disruption of the thrombus with bas- kets and balloon dilation, and local thrombolysis with bolus injection of 100,000 units of Urokinase. Presum- ably the technical success for PAT alone in the treat- ment of acute emboli is therefore somewhat less than the 87.3% reported [7]. The use of PAT for the treatment of embolic com- plications of angioplasty seems to be higher than for de novo emboli. This is probably linked to the smaller vol- ume of embolic material in these situations. Cleveland et al. reported technical success for PAT in 87% of 15 patients with acute emboli complicating angioplasty or atherectomy (1 patient). The reported success rates for PAT of residual thrombus following local thrombol- 209 EUR 10.10.01 10:39 Seite 5 CYAN MAGENTA YELLOW BLACK FIRMENGRUPPE APPL FIRMENGRUPPE APPL Fig. 3a, b Percutaneous aspi- ration thombectomy of embolic occlusion of the tibial vessels. a This patient had just under- gone a successful right iliac an- gioplasty. Angiography of the run-off vessels after angioplasty showed occlusion of previously patent anterior and posterior tibial arteries. This was consis- tent with acute embolization as a complication of the iliac an- gioplasty procedure. b Aspira- tion thromboembolectomy was performed using a 4-F Cobra catheter. After several passes of the catheter into both occluded tibial vessels, the angiogram showed successful removal of the embolic material and reso- lution of patency to the run-off vessels D o k u m e n t : e u r - 1 0 1 4 . 1 V d o c ; S e i t e : 8 ; A u s z u g : V o l l f a r b e ; D a t u m : 2 1 . 1 2 . 1 0 1 ; U h r z e i t : 1 2 : 0 6 : 2 1 ysis are also high with success rates of 100% reported by Cleveland in 6 patients [9]. Complications of PAT Serious complications are uncommon. Material may embolise more distally, although it is usually possible to also remove this by further aspiration. Dissection of the arterial wall may occur due to blind passage of catheters through the occluded vessel. If the dissection is flow- limiting, it can be treated by prolonged low-pressure balloon inflation, stenting or atherectomy. If PAT is used as a primary treatment for acute oc- clusions and is not completely successful, residual thrombus is usually treated by a thrombolysis infusion. In this situation, the risk of hemorrhage around the in- troducer sheath may be increased if a large access sheath has been required for the PAT procedure. Finally, it is possible to remove large volumes of blood during PAT. If successive passes of the aspiration catheter only yield full 50-cc syringes of blood with very small volumes of thrombus, it is likely that further pass- es of the catheter will not produce further improve- ments and that PATshould be discontinued. Mechanical thrombectomy Mechanical thrombectomy may be used as an adjunct to thrombolysis or instead of thrombolysis. In common with thrombolysis, MT is less successful with increasing age of thrombus and should probably be limited to oc- clusions less than 14 days old [10, 11], although some newer devices are being developed to address subacute thrombus. Technique The method of thrombectomy is broadly similar for all of the devices. None of the devices are suitable for use distal to the popliteal arteries because of their size. The Hydrolyser is relatively flexible and can be used across the aortic bifurcation through a Balkin sheath (Cook Europe, Bjaeverstock, Denmark). The ATD is relative- ly inflexible and is not suitable for use from the con- tralateral side. Over-the-wire devices (Oasis, Hydroly- ser and the Angiojet) are generally easier to use than devices without guidewires because they can be manip- ulated around corners. Devices without guidewire lu- mens, such as the ATD, should optimally be used with guiding catheters. Some authors have advocated placing a blood pressure cuff around the limb below the throm- bus and inflating it above arterial pressure to prevent distal embolization [12]. After vascular access has been achieved and a sheath of appropriate size has been inserted, a catheter and guidewire are advanced if possible into the oc- cluded segment. The device is advanced into the thrombus and the power activated. The device is ad- vanced back and forth within the thrombus and fre- quent check angiograms are performed through the sheath to assess the progress of the procedure. Small 210 EUR 10.10.01 10:40 Seite 6 CYAN MAGENTA YELLOW BLACK FIRMENGRUPPE APPL FIRMENGRUPPE APPL Fig. 4ac Percutaneous aspiration thrombectomy of acute embol- ic occlusion of the distal popliteal artery. a A 77-year-old male pa- tient with an acute embolic occlusion of the right popliteal artery. b This patient was treated by aspiration thromboembolectomy us- ing a 7-F aspiration catheter. This image was obtained after re- moval of the embolus and shows a patent distal popliteal artery, tibioperoneal trunk, and peroneal and posterior tibial arteries. c This image shows the embolus obtained by PAT presented on a gauze swab. The tip of the aspiration catheter is shown alongside D o k u m e n t : e u r - 1 0 1 4 . 1 V d o c ; S e i t e : 9 ; A u s z u g : V o l l f a r b e ; D a t u m : 2 1 . 1 2 . 1 0 1 ; U h r z e i t : 1 2 : 0 6 : 2 2 residual distal thrombi or emboli can be removed by adjunctive PAT. If significant thrombus persists despite the best efforts of MT or PAT, local thrombolysis should be instituted (Fig. 5). If it is not possible to pass a guidewire into the thrombus, the thrombus may be organised and resistant to thrombectomy [10, 13]; however, it is still worthwhile attempting thrombectomy in these cases by activating the device above the thrombus and advancing the de- vice tip into the thrombus. Results The data from some of the largest series of mechanical thrombectomy in the lower extremity are presented in Table 1. Although each device has its own particular advantages and disadvantages, the results are broadly similar and no single device seems to be better than the others. There seems to be no significant difference in the results of MT for native artery occlusions or bypass graft occlusions. The reported success rates for MT in the lower extremities range from 66 to 90% [10, 11, 12, 13, 14, 15]; however, adjunctive thrombolysis (usually overnight) is required in 2042% of patients [10, 11, 12, 13, 14]. Adjunctive PAT and balloon angioplasty are also usually required in addition to MTin most series, to address the underlying cause for occlusion. The thrombus clearance rates of MT alone are sub- stantially less than the combination of MT and throm- bolysis together. Rousseau et al. reported success rates for MT alone in 61% of cases, which increased to 83% when MT was followed by thrombolysis [11]. On the other hand, mechanical thrombectomy combined with PAT achieves successful clearance of acutely throm- bosed arteries and grafts in 5880% of cases. Both MT and PAT are rapid procedures which enable vessel clearance to be completed in a single procedure obviat- ing the expense, time and complications of thromboly- sis. Complications Distal embolization during thrombectomy is reported in up to 28% of series; however, these emboli can be cleared in almost every case by further MT, PAT or thrombolysis. Reekers et al. reported one patient with resistant distal emboli who went on to have a below- knee amputation [10]. Puncture-site haematomas occur with similar frequency to other endoluminal interven- tions using large sheaths. Vessel dissection occasionally occurs due to manipulation of the device but is usually mild and self-limiting [13]. Ileofemoral and ileocaval thrombosis Rapid clearance of thrombus with early resolution of venous patency in patients with lower-limb deep venous thrombosis (DVT) is theoretically desirable because it 211 EUR 10.10.01 10:40 Seite 7 CYAN MAGENTA YELLOW BLACK FIRMENGRUPPE APPL FIRMENGRUPPE APPL Fig. 5ac Clearance of acutely occluded superficial femoral and profunda femoris arteries with the Hydrolyser device. a Antegrade puncture of the left common femoral artery was performed and a catheter introduced into the occluded superior femoral artery (SFA). b After three passes of the Hydrolyser device, flow was re- stored to the SFA and the proximal profunda was cleared. c The profunda was almost completely cleared by further passes of the Hydrolyser device D o k u m e n t : e u r - 1 0 1 4 . 1 V d o c ; S e i t e : 1 0 ; A u s z u g : V o l l f a r b e ; D a t u m : 2 1 . 1 2 . 1 0 1 ; U h r z e i t : 1 2 : 0 6 : 2 3 lowers the risk of acute complications of DVT such as PE. Moreover, late sequelae of DVT, such as venous oedema secondary to valvular incompetence caused by venous thrombosis, can be avoided. For these reasons, treatment of patients with extensive ileofemoral DVT with catheter-directed thrombolysis is being advocated, although there is as yet no good evidence for the clinical efficacy of the procedure [16]. The main disadvantage of venous thrombolysis is that it is more time-consuming than arterial thromboly- sis and the doses of thrombolytic agent required are very large which makes the procedure very expensive. The average dose reported by the United States DVT registry in 1999 was 7.8 million units of Urokinase at a mean procedural time of 53 h [17]. The use of mechani- cal thrombectomy devices in these patients should result in reduced procedural times and therefore reduced doses of thrombolytic agent even if clot removal is in- complete with MTalone. The ideal thrombectomy catheter would be able to clear a large amount of thrombus, be atraumatic to ve- nous valves and be associated with a low risk of PE [18]. In theory, larger-calibre devices are required compared with arterial MT, because the already large veins are usually distended by thrombus. This is one of the main reasons that PAT is of limited efficacy in ve- nous occlusions. Over-the-wire devices are preferable because of the ability to steer them around bends. Thrombectomy should be performed only in the acute phase of thrombosis. After a week or so, synechiae form between the vein wall and the clot, which reduces substantially the effectiveness of thrombectomy and thrombolysis. Results from several animal studies evaluating the Hydrolyser, Oasis, Amplatz and Arrow-Trerotola de- vices have been reported with favourable success rates and low incidence of PE [19, 20, 21, 22]; however, clini- cal experience is as yet limited to a few case reports [12, 23, 24, 25, 26, 27]. Uflacker used the ATD in three pa- tients with iliac and/or caval thrombosis with complete success in one patient and partial success in the other two patients [23]. Reekers and Blank reported complete clearance of an acute ileocaval thrombosis using the Hydrolyser device [27]. Evidence from work in animals suggests that damage to venous valves, while not inevi- table, does occur following the use of thrombectomy devices [18]. On the basis of current evidence, complete success using thrombectomy devices alone can be expected in a small proportion of patients, whereas the majority re- quire some form of adjunctive therapy such as throm- bolysis or stents. Evidence from larger series is required to properly assess the success rates of these devices in the treatment of ileofemoral and ileocaval thrombosis. If complete or partial clearance of thrombus can be achieved, the high cost of the devices can be offset by the savings gained by reduced amounts of thrombolytic agent required; however, we still do not know whether invasive and costly treatments in the form of thrombec- tomy or thrombolysis should be recommended for the treatment of DVTof the lower extremities. 212 EUR 10.10.01 10:41 Seite 8 CYAN MAGENTA YELLOW BLACK FIRMENGRUPPE APPL FIRMENGRUPPE APPL Table 1 Mechanical thrombectomy in lower extremity arteries and bypass grafts Reference Patients Device Success Adjunctive treatment Complications [14] 40 patients ATD Complete success 75% Lysis 20% None all native arteries Partial success 20% 32 emboli 8 in situ thrombosis [12] 12 patients ATD Success 66% Lysis 33% 28% 10 grafts Two embolizations 2 native cleared all in situ [10] 28 patients Hydrolyser Success 82% Lysis 42% 25% embolization 11 native Native: 73% 6 of 7 aspirated/lysed 17 grafts Grafts: 88% 1 patient, amputation all in situ [15] 36 patients Hydrolyser Success: 81% 3% embolization, 15 native Native: 87% aspirated 14 grafts Grafts: 79% [11] 29 patients Hydrolyser Success: 83% Lysis 34% 14% embolization, 15 native Native: 87% aspirated 14 grafts Grafts: 79% [13] 50 patients Anjiojet Success 90% Lysis 30% 2% embolization, 39 native aspirated 11 grafts 4% mild dissections D o k u m e n t : e u r - 1 0 1 4 . 1 V d o c ; S e i t e : 1 1 ; A u s z u g : V o l l f a r b e ; D a t u m : 2 1 . 1 2 . 1 0 1 ; U h r z e i t : 1 2 : 0 6 : 2 4 Superior vena caval and upper extremity venous thrombosis Thrombosis of the SVC and upper extremity veins is usually due to long-term indwelling venous catheters, effort-thrombosis of the subclavian vein due to com- pression at the thoracic inlet (Paget-Schroetter syn- drome) and to malignant disease. Malignant SVC ob- struction is usually treated by radiotherapy, metallic stenting and/or thrombolysis. Thrombectomy has a lim- ited role because of the presence of neoplastic tissue. If thrombosis occurs in the absence of a significant ob- structing lesion, the use of MT devices may achieve clearance of thrombus more rapidly than standard thrombolytic regimes. Successful treatment of acute obstruction of the su- perior vena cava using the ATD, Hydrolyser, Angiojet and TEC catheter have been reported [15, 23, 28, 29]. Pulmonary embolism Most PE do not cause significant haemodynamic dis- turbance and are treated by systemic heparinization. Patients with massive emboli with acute right heart failure require more active therapy to break up the em- boli. Administration of a thrombolytic agent either via a peripheral vein or delivered directly into the thrombus is used by many clinicians to achieve clot lysis and im- prove the patient's cardiovascular status; however, thrombolysis takes time to take effect, and may be inef- fective or contraindicated in some patients. Mechanical thrombectomy may be used as an alternative to surgical thrombectomy to achieve rapid clot dissolution in se- verely ill patients. Aspiration thrombectomy Lang et al. [30] used PAT to treat massive PE in three patients with the aid of a 14-F aspiration catheter intro- duced into the pulmonary artery coaxially over a 6-F multipurpose guiding catheter. After removing the 6-F catheter, aspiration thrombectomy was performed through the 14-F catheter. Ninety percent of the clot burden was removed in three patients [30]. Catheter fragmentation Large central PE can be broken into smaller pieces us- ing standard angiographic catheters. These fragmenta- tion techniques produce a rapid improvement in the patient's clinical status as a result of reduced pulmonary arterial pressure and right heart strain. Fragmentation should be performed using a pigtail or multipurpose catheter. The 8-F Grollman pulmonary pigtail catheter is particularly well suited to this technique (Cordis, Johnson and Johnson, N. J.). After a diagnostic angio- gram has been performed, a guidewire is advanced through the embolus followed by the catheter. The guidewire is removed enabling the catheter tip to as- sume its natural configuration. The pigtail is withdrawn through the clot and the procedure is repeated in one or more vessels until there is improvement in pulmonary arterial blood flow. The treatment may be combined with local or peripheral thrombolysis. Fava et al. [31] treated 16 cases of massive PE with a combination of catheter fragmentation and direct local thrombolysis. In 8 patients mechanical fragmentation was performed before thrombolysis and the mean pul- monary artery pressure dropped from 57 to 39.5 mmHg. Overall success with complete clinical recovery oc- curred in 14 patients (87.5%) and one patient died dur- ing the treatment due to cardiovascular collapse [31]. Brady et al. reported successful fragmentation of em- boli in three patients with significant improvement in systemic and pulmonary arterial pressures [32]. Although there is limited reported experience, the evidence suggests that embolus fragmentation can pro- duce rapid improvement in right heart function. More- over, the equipment for this technique is inexpensive and available in every interventional department. Mechanical thrombectomy devices The Greenfield transvenous embolectomy catheter (Boston, Galway, Ireland) was the first device used to treat PE [33]. In a series of 46 patients, all of whom re- quired inotropic support or mechanical ventilation, successful clot extraction was achieved in 76% of 46 patients with a 30-day survival rate of 76% [33]; however, the bulkiness of the catheter (12 F) and diffi- culties in manipulation through the heart has limited its use to a few centres. There are a few reports of the use of different types of thrombectomy devices in the pulmonary arteries. Uflacker et al. [34] achieved clinical improvement in dyspnoea, chest pain and hypotension in four of five patients with massive PE using the ATD device. Only one of these patients received lytic therapy. Complica- tions included massive self-limiting haemoptysis at the end of the procedure in one patient and cardiac arrest and death in another patient [34]. Clinical experience using the Hydrolyser in the treatment of acute massive PE was reported by Fava et al in 11 patients [35]. Four patients were treated with local thrombolysis after thrombectomy. Eight to 12 passes were made through the pulmonary artery with the Hydrolyser catheter. Clinical success occurred in 10 patients (90.9%). One patient died during the pro- 213 EUR 10.10.01 10:41 Seite 9 CYAN MAGENTA YELLOW BLACK FIRMENGRUPPE APPL FIRMENGRUPPE APPL D o k u m e n t : e u r - 1 0 1 4 . 1 V d o c ; S e i t e : 1 2 ; A u s z u g : V o l l f a r b e ; D a t u m : 2 1 . 1 2 . 1 0 1 ; U h r z e i t : 1 2 : 0 6 : 2 5 cedure and one patient had a self-limiting haemoptysis immediately after thrombectomy. Henry et al. also used the Hydrolyser successfully in two patients [36]. There are also case reports of successful use of the Arrow- Trerotola thrombolytic device in two patients [37] and the Anjiojet RTC catheter in one patient with massive PEs [38]. In summary, all three techniques are relatively suc- cessful in producing a reduction in the volume of ob- structing embolus in the central pulmonary arteries with a consequent improvement in the cardiorespiratory sta- tus of patients with massive PE. The simplest technique seems to be fragmentation with a standard angiographic catheter. Finally, the results of mechanical thrombecto- my may be improved if thrombectomy is followed by intrapulmonary thrombolytic infusion [39]. Occluded dialysis grafts One of the most common indications for mechanical thrombectomy is the treatment of occluded dialysis ac- cess grafts (ODAG), particularly in the United States. Treatment options for ODAG include surgical throm- bectomy, catheter thrombolysis and mechanical throm- bectomy. In the early 1990s thrombolysis became widely used, and in many centres it superceded surgery as the primary treatment method; however, thrombolysis is time-consuming and expensive in terms of the costs of the lytic agent and manpower required for the treat- ment. Interventional radiologists investigated other methods to reopen blocked grafts which were quicker and less expensive, particularly mechanical thrombec- tomy. There are several techniques for the restoration of flow to dialysis grafts using mechanical thrombectomy, which include thromboaspiration, pull-back thrombec- tomy using balloon catheters, and mechanical throm- bectomy using automated thrombectomy devices. Most techniques can be used alone, in combination with other methods of mechanical thrombectomy or with throm- bolysis. Mechanical thrombectomy, either alone or with adjunctive thrombolysis, has largely replaced throm- bolysis using pulse-spray or infusion techniques for the treatment of ODAG. A brief overview is provided be- low. Although some native fistula occlusions can also be treated by the following methods, mechanical throm- bectomy is mainly used to treat prosthetic dialysis grafts, which are usually placed in a loop configuration in the lower or upper arm. Pull-back thrombectomy Pull-back thrombectomy involves moving the thrombus out of the graft into the draining vein and further on into the pulmonary circulation. This is achieved by placing two overlapping vascular sheaths into the graft, one to- ward the venous anastomosis and the other toward the arterial anastomosis. A balloon catheter is advanced across the arterial anastomosis into the native artery, inflated and pulled back to the level of the sheath tip. The balloon is deflated, withdrawn through the sheath, and reinserted through the other sheath. The balloon is reinflated, and is pushed over a guidewire as far as the right atrium. It is usually necessary to treat any under- lying venous outflow stenoses by angioplasty before the thrombus can be pushed into the central veins. In Trerotola's original report using this technique in 34 clotted grafts in 24 patients, successful graft clear- ance was achieved in 94% of grafts with a mean time to achieve lysis of 62 min and an overall mean procedure time of 116 min [40]. In a randomized prospective study comparing pull-back thrombectomy with pulsed-spray thrombolysis, the technical and clinical success rates were similar, although the mean procedure time was significantly lower in the MT group (2.2 h) compared with the thrombolysis group (3.5 h) [41]. Zaetta et al. [42] described a slightly different approach in which they performed pull-back thrombectomy using a bal- loon catheter introduced into the dialysis graft from the internal jugular vein. The advantages of this procedure are the single venous access, the reduced radiation dose to the interventionalist (a problem with virtually all other methods of percutaneous treatment of ODAG) and the avoidance of the risk of graft infection arising from dual sheath insertion into the graft. Successful declotting was achieved in 81% of 31 patients [42]. The main risks of this procedure as with most me- chanical techniques is embolization into the native ar- tery caused by displacement of thrombus across the ar- terial anastomosis and clinically significant pulmonary emboli. Both complications are surprisingly uncommon. Arterial emboli can be avoided by clearing most of the thrombus from the body of the graft before the arterial anastomosis is crossed. Clinically significant PE do oc- cur but again are uncommon. Mechanical thrombecto- my should probably not be performed frequently (i.e. within 1 month of a previous treatment), in patients with respiratory disease or in patients with a history of PE. Thromboaspiration Thromboaspiration involves removal of thrombus from the graft and venous outflow by suction through crossed 7- or 8-F thin-walled aspiration catheters. Turmel-Ro- drigues reported 100% success using this method in 43 grafts with primary patency rates of 85, 33 and 24% at 1, 6 and 12 months, respectively [43]. Thromboaspiration can be used in association with a balloon catheter. 214 EUR 10.10.01 10:41 Seite 10 CYAN MAGENTA YELLOW BLACK FIRMENGRUPPE APPL FIRMENGRUPPE APPL D o k u m e n t : e u r - 1 0 1 4 . 1 V d o c ; S e i t e : 1 3 ; A u s z u g : V o l l f a r b e ; D a t u m : 2 1 . 1 2 . 1 0 1 ; U h r z e i t : 1 2 : 0 6 : 2 5 Thrombus is moved by pull-back thrombectomy from the arterial limb into the venous limb. This thrombus is aspirated through an aspiration catheter placed into the venous limb. This method avoids manipulation of an aspiration catheter at the arterial anastomosis and re- duces the risk of arterial embolization. Technical suc- cess rates of over 90% have been reported [44, 45]. The main advantage of thromboaspiration is the removal of a substantial proportion of the thrombus volume, which obviates embolization into the lungs. Care should be taken to avoid aspiration of large volumes of blood, which may result in reduction of the haemoglobin in al- ready anaemic patients. Aspirated blood can be sieved through gauze and reinjected to avoid haemodepletion. Mechanical thrombectomy devices Most of the thrombectomy devices described in the previous sections can be used to treat dialysis access grafts. Trerotola developed the Arrow-Trerotola percu- taneous thrombolytic device (A-TPTD) specifically for use in dialysis grafts. In a randomized, prospective study comparing pulse-spray thrombolysis with the A-TPTD in 122 patients, the technical success and 3-month pa- tency rates were identical and the median procedure time was significantly shorter in the MT group (75 vs 85 min; p < 0.04) [45]. Results of the Anjiojet catheter were reported in a multicentre prospective randomized trial involving 153 patients, which compared the Anjiojet rheolytic catheter with surgical thombectomy. The technical suc- cess rates were 73% for the Anjiojet and 79% for sur- gery. The technical success and patency rates were not statistically different between the two treatment meth- ods. The complication rates were also similar, although surgery had more major complications [46]. In another randomized prospective study which compared surgical thrombectomy with mechanical thrombectomy, 37 pa- tients were assigned to either surgery or MT with the Amplatz thrombectomy device. Similar to the previous study, the technical success rates were similar and no significant difference was observed in the primary or secondary patency rates [47]. Experience with the Hydrolyser catheter has been reported by Overbosch et al. [48] and Vorwerk et al. [49]. In a Dutch multicentre trial, 65 occluded dialysis shunts (which included 24 native fistulas) were treated with the Hydrolyser device with a technical success rate of 89% [48]. Vorwerk et al. reported restoration of flow in 86% of 51 grafts using the Hydrolyser device intro- duced through a single vascular sheath in the venous limb and a pull-back balloon technique similar to that described previously [49]. Finally, van Ha and Kim [50] recently reported the results of a prospective study comparing the Oasis thrombectomy device with pulse-spray thrombolysis in 55 patients. The technical success rates and mean pro- cedure times were similar; however, this group reported two severe complications in the Oasis group, one arte- rial rupture and one venous rupture both of which re- quired metallic stenting. In addition, the patency rates for thrombolysis were higher than in the Oasis group [50]. In summary, there are many different techniques of mechanical thrombectomy for the treatment of occlud- ed dialysis grafts. All of these methods have high success rates and produce patency rates similar to those of thrombolysis and conventional surgical thrombectomy. In the majority of studies involving MT, the procedural time is reduced compared with thrombolysis. Costs are reduced for the more simple techniques using balloons and aspiration catheters, although costs rise substan- tially with the use of the automated devices. There is at the present time no evidence that use of automated de- vices is justified on the basis of technical success, re- duction in complications or improvement in patency rates. Conclusion Percutaneous aspiration thrombectomy has become an established part of the interventional radiologist's ar- mamentarium and is most useful for the aspiration of embolic complications of angioplasty and as an adjunct, rather than as an alternative, to thrombolysis. Mechan- ical thrombectomy devices are useful for the treatment of thrombosed dialysis grafts and can be used as sole therapy. They are less effective for the treatment of acute peripheral arterial ischaemia and the treatment of venous thrombosis. 215 EUR 10.10.01 10:41 Seite 11 CYAN MAGENTA YELLOW BLACK FIRMENGRUPPE APPL FIRMENGRUPPE APPL References 1. Starck EE, McDermott JC, Crummy AB, Turnipseed WD et al. (1985) Per- cutaneous aspiration thrombectomy. Radiology 156: 6166 2. 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