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Chapter 143 Mechanical Interventions in Arterial and Venous Thrombosis 2115

A B C

Fig. 143.2 A 35-YEAR-OLD MAN PRESENTS WITH A 3-DAY HISTORY OF SEVERE LEFT LOWER
EXTREMITY PAIN AND SWELLING. (A) Digital subtraction venogram from a left popliteal vein approach
shows patency of the lower part of the femoral vein with a short segment of duplication; a normal variant.
(B) The left common femoral and iliac veins have large globular filling defects, consistent with acute iliofemoral
deep vein thrombosis. (C) The Trellis device was used to deliver and disperse 10 mg of recombinant tissue
plasminogen activator into the thrombus. After balloon maceration of the thrombus and subsequent placement
of two 12-mm stents to treat stenosis of the left common iliac vein, the left common femoral vein and iliac
vein are seen to be widely patent. The pain and swelling resolved within a few days.

cava [IVC] or right atrium in patients with contraindications to use aspiration. With the Powerpulse PCDT technique, the AngioJet is
of fibrinolytic drugs). first used to deliver a thrombolytic drug into the thrombus via a
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powerful pulse-spray injection. After a 20–30-minute dwell time,
Variations on a Theme: Pharmacomechanical the AngioJet is then used to aspirate and remove the softened throm-
bus. The Isolated Thrombolysis technique refers to the use of the
Catheter-Directed Thrombolysis Trellis Peripheral Infusion System (Bacchus Vascular, CA, USA) to
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provide single-session PCDT (Fig. 143.2). The Trellis device is
Pharmacomechanical catheter-directed thrombolysis (PCDT) refers composed of a multilumen catheter with two balloons that, when
to thrombus dissolution via the combined use of CDT and PMT inflated, effectively isolate a thrombus-containing treatment zone
devices. The rationale for utilizing both modalities is twofold: (1) from the remainder of the venous circulation. After the device is
fibrinolytic drugs given via CDT soften the thrombus, rendering it advanced across the venous thrombus, the occluding balloons are
more susceptible to mechanical fragmentation and removal with inflated and a thrombolytic drug is injected into the thrombus via
PMT, while also dissolving thrombus fragments that may otherwise side holes in the catheter. A sinusoidal wire within the catheter
embolize; and (2) PMT devices macerate the thrombus, enhance oscillates to disperse the drug within the thrombus, after which lique-
dispersion of the fibrinolytic drug, and accelerate pharmacologic fied thrombotic debris can be aspirated through a port in the catheter.
thrombolysis. Although a broad range of PCDT techniques have Both single-session PCDT techniques feature rapid intrathrombus
been used, they largely fall into two general categories. First, “first- drug dispersion that promotes faster thrombolysis, thereby reduced
generation” PCDT techniques incorporate PMT devices to assist patient exposure to the fibrinolytic drug. Because the mechanical
traditional CDT; either a PMT device is initially used to de-bulk manipulation can induce thrombus fragmentation and embolization,
thrombus before starting the CDT infusion, or a PMT device is used these methods are best suited for venous applications.
after CDT to aspirate and/or macerate residual thrombus. Second,
“single-session” PCDT techniques utilize PMT devices that can
rapidly disperse the thrombolytic drug within the thrombus to enable Mechanical Interventions in Peripheral
the entire clot-removal treatment to be completed in a single on-table Arterial Occlusion
procedure session, thereby obviating the need for an overnight
thrombolytic infusion with the required monitoring in an intensive- Acute peripheral arterial occlusion (PAO) is associated with high rates
care unit. of morbidity and mortality. It is usually caused by atherosclerotic
Single-session PCDT techniques have attracted considerable disease but can also arise from other etiologies (i.e., dissection, intimal
interest. Two devices can be used for single-session PCDT. The hyperplasia, in situ thrombosis secondary to a hypercoagulable state,
AngioJet Rheolytic Thrombectomy System (Possis Medical, MN, trauma, vasculitis, or aneurysm thrombosis). Up to 15%–20% of
USA) uses high-velocity saline jets to fracture the thrombus through patients with chronic peripheral artery disease will develop acute
a combination of rapid fluid streaming and hydrodynamic forces. exacerbation of symptoms (acute limb ischemia), usually due to
Based on the Bernoulli principle of low pressure, these jets create a thrombosis of the involved artery, and are at high risk of limb loss.
localized negative-pressure zone at the catheter tip, enabling clot Even with treatment, the 30-day mortality rate of acute arterial