Adjunctive techniques in percutaneous mechanical thrombectomy*,**
Section snippets
Percutaneous aspiration thromboembolectomy (PAT)
The idea of removing embolic material by percutaneous transluminal aspiration was first described in 1969 by Greenfield and coworkers.7 The application of this technique to iatrogenic arterial emboli was mentioned by Buxton and Mueller in 1974.8 This technique was later resumed by Snidermann and coworkers in 1984,9 who removed postangioplasty emboli successfully in 5 of 6 patients. Starck and coworkers were the first to apply the novel method to acute thrombotic occlusions of native lower limb
Atherectomy
Various atheroablative devices have been designed in recent years for mechanical maceration.16 These devices can be divided in two major classes: (1) with concomitant suction, eg, transluminal extraction catheter (TEC), Trac Wright catheter (Kensey catheter) or (2) without concomitant suction, eg, Simpson atherectomy catheter, percutaneous rotational thrombectomy catheter (Rotablator), Redha-Cut atherectomy catheter.
However, clinical application of these modalities in thrombosed native arteries
Pharmacologic thrombolysis
Regional infusion of fibrinolytic drugs has been reported the first time over 20 years ago from Charles Dotter and coworkers.22 Since then, thrombolytic therapy has become an integral part of the management of patients with acute peripheral vascular occlusive disease in native arteries and bypass grafts, hemodialysis fistulas and veins. Thrombolysis can restore arterial flow by dissolving an occluding thrombus and can be followed by endovascular or open surgical procedures to correct any
Ultrasound thrombolysis
Ultrasound thrombolysis can be achieved indirectly via transmitted longitudinal vibrations of a metallic probe coupled to a high-frequency, high-power ultrasound generator. Theoretically, with use of high-energy ultrasound selective disruption of the occlusive material can be induced without damaging the surrounding arterial wall. This selectivity is based on the differences in elasticity between thromboembolic material and the different layers of the vessel wall. Thus, ultrasound angioplasty
Manual catheter fragmentation and other techniques of thrombus management
These techniques aim in the partial removal of thrombus with embolectomy, fragmentation, maceration or aspiration. Most of the currently described and used techniques do not totally eliminate the treated clots, but rather break down the thrombus into smaller fragments, which migrate peripherally. The technique of manual catheter fragmentation is mainly used in the pulmonary artery circulation, opening up the main pulmonary artery from large occlusive clots and thereby improving perfusion.
Ballon angioplasty and stent implantation
In case of acute thrombotic occlusions of native vessels, atherosclerotic plaques are the underlying substrate in nearly all cases. Additionally, embolic occlusions can hit atherosclerotic diseased arteries, especially in increasingly older patient populations. Therefore, ballon angioplasty has to be performed after the intial revascularization procedure using PMT in nearly all cases. PTA should be performed only after percutaneous thrombectomy has been completed because of a high incidence of
Discussion
Acute critical limb ischemia because of occlusions of native arteries or bypass grafts is a rationale for rapid revascularization. Catheter-directed pharmacologic thrombolytic therapy and percutaneous thrombectomy procedures can be used as the initial revascularization procedure solely as well as a combined procedure for treatment of thromboembolic disease.
Local intra-arterial thrombolysis represents one of the standard treatment modalities in acute thromboembolic occlusions. However, drawbacks
References (46)
- et al.
Current status of percutaneous mechanical thrombectomy. Part II. Devices and Mechanisms of action
J Vasc Interv Radiol
(1998) - et al.
Hydrodynamic thrombectomy of hemodialysis fistulas: First clinical results
J Vasc Interv Radiol
(1994) - et al.
Transvenous removal of pulmonary emboli by vacuum cup catheter technique
J Surg Res
(1969) - et al.
Manual catheter-directed aspiration techniques for declotting native fistulas for hemodialysis
J Vasc Interv Radiol
(2001) - et al.
Percutaneous pulmonary thrombectomy
J Vasc Interv Radiol
(1997) - et al.
Patient survival and limb prognosis after arterial embolectomy
Eur J Vasc Surg
(1987) - et al.
Transluminal atherectomy for occlusive peripheral disease
Am J Cardiol
(1988) - et al.
Thromboembolectomy with the transluminal extraction catheter (TEC) as adjunct to thrombolysis
J Vasc Interv Radiol
(1992) - et al.
A systematic review of intraarterial thrombolysis therapy for lower limb ischemia
Eur J Vasc Endovasc Surg
(2000) - et al.
Initial experience with the combination of reteplase and abiciximab for thrombolytic therapy in peripheral arterial occlusive disease: A pilot study
J Vasc Interv Radiol
(2002)
High intensity ultrasound increases distensibility of calcified atherosclerotic arteries
J Am Coll Cardiol
In vivo ultrasound arterial recanalization of atherosclerotic total occlusions
J Am Coll Cardiol
Catheter-delivered ultrasound potentiates in vitro thrombolysis
J Vasc Interv Radiol
Enhancement of fibrinolysis with ultrasound energy
J Vasc Interv Radiol
Short-term results with use of Amplatz thrombectomy device in the treatment of acute lower limb occlusions
J Vasc Interv Radiol
Acute embolic occlusions of the infrainguinal arteries: Percutaneous aspiration embolectomy in 102 patients
Radiology
Long-term results of percutaneous aspiration embolectomy
Cardiovasc Interv Radiol
Rapid thrombectomy with a hydrodynamic catheter: Results from a prospective multicenter trial
Radiology
Removal of iatrogenic clot by transcatheter embolectomy
Radiology
Percutaneous embolectomy by transcatheter aspiration. Work in Progress
Radiology
Percutaneous aspiration thrombembolectomy
Radiology
Percutaneous aspiration thromboembolectomy
Arterial embolism: A 44 year experience
Am J Surg
Cited by (16)
A Comparison of Outcomes Based on Vessel Type (Native Artery vs. Bypass Graft) and Artery Location (Below-Knee Artery vs. Non-Below-Knee Artery) Using a Combination of Multiple Endovascular Techniques for Acute Lower Limb Ischemia
2021, Annals of Vascular SurgeryCitation Excerpt :Over the past two decades, various additional endovascular techniques for treating ALLI have been described, such as mechanical thrombolysis, ultrasound-assisted thrombolysis, thrombus fragmentation, thromboaspiration, angioplasty, and covered stenting.9–13 A combination of these multiple endovascular techniques has consequently improved technical success.9,14,15 According to vessel type, ALLI can be categorized into native artery occlusion (native occlusion) and bypass graft occlusion (graft occlusion), including prosthetic and vein graft.
Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia
2020, European Journal of Vascular and Endovascular SurgeryCitation Excerpt :Several additional percutaneous techniques have been described for the treatment of ALI, including mechanical thrombolysis, ultrasound assisted thrombolysis, thrombus fragmentation, thrombo-aspiration, angioplasty, and covered stenting.135 Technical success rates, when combined with adjunctive techniques, vary from 70% to 100%.135 The potential advantage of these devices is speedy restoration of blood flow in the ischaemic limb.136
Concomitant percutaneous embolectomy and thrombolysis in the treatment of early massive pulmonary embolism secondary to abdominal trauma - A case report and a review
2011, Injury ExtraCitation Excerpt :The most recent meta-analyses showed an improvement in mortality rates when using thrombolytics instead of administrating only anticoagulants.5,18 In this case, given the high percentage of poor outcomes for mechanical thrombectomy due to peripheral embolisms and the severity of our patient, it was decided to add thrombolysis with intermediate doses of urokinase for mechanical thrombectomy.4,8,13,15,16 Our patient's outcome was good and she had no hemorrhagic complications.
Contemporary Management of Acute Limb Ischemia: Factors Associated with Amputation and In-Hospital Mortality
2009, Seminars in Vascular SurgeryCitation Excerpt :These devices are guide-wire−directed and either physically reduce thrombus burden or accelerate thrombolysis. Promising early results have been published with techniques done in native arteries, the pulmonary artery circulation, and arteriovenous (AV) prosthetic access grafts.19,20 Many of these catheter devices also allow concurrent pulse spray of the lytic agent.
New Technology for the Treatment of Peripheral Arterial and Venous Occlusions: Ultrasound Accelerated Thrombolysis
2008, Journal of Radiology NursingCitation Excerpt :Although CDT has demonstrated comparable or favorable morbidity and mortality rates to open surgery, extended duration of thrombolytic infusion and large drug dosages required to achieve recanalization of the vessel may lead to serious hemorrhagic complications. PMT devices have demonstrated efficacy in rapidly macerating and extracting thrombus, but with limited effectiveness in older occlusions and increased potential for distal embolization and residual thrombus (Grimm, Jahnke, Muhle, Heller, & Müller-Hülsbeck, 2003; Kalinowski & Wagner, 2003). For these reasons, PMT is generally used as an adjunct to CDT rather than as a stand-alone treatment.
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Address reprint requests to Hans-Joachim Wagner, MD, PhD, Department of Diagnostic Radiology, University Hospital, Philipps University, Baldingerstrasse, 35033 Marburg, Germany.
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