Adjunctive techniques in percutaneous mechanical thrombectomy*,**

https://doi.org/10.1053/tvir.2003.36437Get rights and content

Abstract

Percutaneous mechanical thrombectomy is an established method in interventional radiology and refers to the removal of acute embolic or thrombotic occlusive material in arteries, veins, or vascular grafts using percutaneous transluminal methods. However, initial complete removal of occlusive material can be achieved only in a minority of patients. The amount of removed material varies with the age and composition of the occlusive material. To achieve sufficient revascularization, adjunctive use of a variety of percutaneous endovascular recanalization techniques is necessitated. Additional treatment with local intra-arterial fibrinolysis, balloon angioplasty, stent implantation, endoluminal atherectomy, and other measures results in primary technical success rates of 70% to 100% for revascularization of acutely occluded vessels. The above-mentioned different techniques should not be viewed as competitive treatment modalities, rather a synergistic approach should be offered. The aim of this report is to review different adjunctive techniques in percutaneous mechanical thrombectomy with emphasis on techniques, mechanisms of action, experimental and clinical results, potential complications, and their potential role in view of clinical pathways to treat acute limb ischemia. © 2003 Elsevier Inc. All rights reserved.

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

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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.

    **

    1089-2516/03/0601-0003$30.00/0

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