Rheolytic thrombectomy in patients with massive pulmonary embolism: A report of two cases and review of literature

We present two cases of massive pulmonary embolism with persistent systolic hypotension but both have contraindications for thrombolysis. Therefore, rheolytic thrombectomy using AngioJet was performed and immediate haemodynamic improvement was achieved including blood pressure and symptoms. According to guidelines, catheter embolectomy or fragmentation may be considered as alternative to surgical treatment in massive pulmonary embolism patients when thrombolysis is absolutely contraindicated or has failed. Percutaneous catheter-based interventional techniques include thrombus fragmentation, rheolytic thrombectomy, suction thrombectomy and rotational thrombectomy. With the existing literature review and our case, rheolytic thrombectomy for treatment of massive pulmonary embolism using AngioJet achieves a high procedural success rate (approximately 90%) n terms of improvement of haemodynamics, pulmonary perfusion and angiographic result but low complication rate.     

Percutaneous thrombectomy for pulmonary embolism

The current treatment of massive pulmonary embolism (PE) has been either thrombolysis or surgical embolectomy. Percutaneous rheolytic thrombectomy, however, has emerged as an alternative treatment in patients with contraindications to thrombolysis. This case illustrates the usefulness of the AngioJet(R) thrombectomy catheter in patients with contraindications to thrombolytics. Three-dimensional computed tomography imaging demonstrated the effectiveness of treatment in this patient with massive PE.     

A case of massive pulmonary embolism treated with angiojet thrombectomy system]

Pulmonary embolism is a common disease process associated with a high mortality rate. In patients with massive pulmonary embolism, systemic thrombolysis is considered to be the treatment of choice, but surgical or catheter thrombectomy may be alternative emergency treatments. A 36-year-old woman with massive pulmonary embolism and contraindications to thrombolytic therapy was treated with catheter thrombectomy using the Angiojet thrombectomy system. The procedure was successfully performed with an excellent immediate angiographic result at the site of the rheolytic thrombectomy. The clinical improvement was maintained while in-hospital and during a 4-month follow-up period, with a decrease to a normal level of the peak systolic pulmonary pressure. Our case report indicates that in patients with contraindications to systemic thrombolysis, catheter thrombectomy for massive pulmonary embolism may constitute a life-saving intervention.     

Percutaneous rheolytic thrombectomy for large pulmonary embolism: a promising treatment option.

BACKGROUND: Pulmonary embolism (PE) is a common cardiovascular disease with significant mortality. Some patients with large PE are not eligible for current treatment options such as thrombolysis or surgical embolectomy. We report our experience of percutaneous rheolytic thrombectomy (PRT) using the AngioJet system combined with adjunctive local thrombolytic therapy and inferior vena cava (IVC) filter placement to treat massive or submassive PE in patients ineligible for current treatment options. METHODS AND RESULTS: Of the 14 consecutive patients ineligible for thrombolysis or embolectomy treated with PRT, 10 patients had massive PE (6 patients were hypotensive and 4 patients had intractable hypoxemia) and 4 patients had submassive PE. Adjunctive local thrombolysis was performed in 5 patients. An IVC filter was placed in 11 patients. Angiographic success based on Miller score was achieved in 13 patients (92.9%). Procedure success was obtained in 12 patients (85.7%). Procedural mortality occurred in one patient who presented in cardiogenic shock (7.1%) and non-fatal hemoptysis occurred in 1 patient (7.1%). Total in-hospital mortality occurred in 3 patients (21.4%). On a mean follow-up of 9 months, all 11 survivors had noted significant improvement in symptoms without recurrence. CONCLUSIONS: Percutaneous rheolytic thrombectomy using the AngioJet may be a treatment option for patients with massive or submassive PE who may not be eligible for thrombolytic therapy or surgical embolectomy.     

Successful management of acute massive pulmonary embolism using Angiovac suction catheter technique in a hemodynamically unstable patient

Massive pulmonary embolism with hemodynamic instability is a life-threatening condition requiring immediate treatment. Urgent thrombectomy or thrombolysis is commonly used for the treatment of this condition. However, surgery is associated with high mortality rate and many patients have contraindications to thrombolytic therapy and are at high risk for bleeding. Cather-based intervention has gained increasing popularity particularly in patients with contraindication to thrombolytic therapy or at high risk for surgical thrombectomy. Catheter-based thrombus removal can be achieved by many means such as suction, fragmentation, extraction or rheolytic thrombectomy. We present a case of an elderly lady who suffered from acute massive pulmonary embolism with hemodynamic compromise successfully treated with AngioVac catheter system (AngioDynamics, Albany, NY) with full recovery.     

Acute massive pulmonary embolism in a Jehovah's witness: successful treatment with catheter thrombectomy

A 71-year-old woman presented with an acute, massive pulmonary embolism. As a Jehovah's Witness, she was not willing to accept thrombolysis because of the potential risk of bleeding requiring blood transfusion. The patient was successfully treated with catheter thrombectomy, using rheolytic and fragmentation devices. (CHEST 2000; 117:594-597)     

Early and long-term clinical results of AngioJet rheolytic thrombectomy in patients with acute pulmonary embolism

Anticoagulant and thrombolytic therapies are a mainstay in the management of acute pulmonary embolism (PE), especially when hemodynamic compromise is present. However, systemic drugs cannot achieve timely and effective treatment of acute PE in all patients. In such a setting, mechanical removal of thrombus from the pulmonary circulation holds the promise of significant clinical benefits, although it remains untested. We report early and long-term outcome of patients with massive or submassive acute PE treated with rheolytic thrombectomy by means of the 6Fr Xpeedior AngioJet device at our institution. Three main groups were defined pre hoc: subjects with severe (i.e., shock), moderate, or mild hemodynamic compromise. Technical and procedural successes, obstruction, perfusion and Miller indexes, and clinical events were appraised. In total 25 patients were treated with thrombectomy (8 in severe, 12 in moderate, and 5 in mild hemodynamic compromise). Technical and procedural successes were obtained in all patients, as confirmed by the significant improvement in obstruction, perfusion and Miller indexes overall, and in each subgroup (all p values <0.001). Improvement in obstruction, perfusion, and Miller indexes at the end of the procedure could also be confirmed in patients (n = 8) treated with local fibrinolysis and in the absence of concomitant thrombolysis (n = 17, p <0.05). Four patients died in hospital, all other patients but 1 were safely discharged after an appropriate hospital stay, and all were alive at long-term follow-up (median 61 months). In conclusion, this study supports at early and long-term follow-up the effectiveness and safety of rheolytic thrombectomy for PE.     

Combined percutaneous aspiration thrombectomy and rheolytic thrombectomy in massive subacute vena cava thrombosis with IVC filter occlusion.

PURPOSE: To report the combined use of percutaneous aspiration thrombectomy and rheolytic thrombectomy in the setting of extensive inferior vena cava (IVC) thrombosis and filter occlusion. CASE REPORT: A 28-year-old paraplegic man with a vena cava filter in situ for previous deep vein thrombosis (DVT) was referred to our center for evaluation of dyspnea and right leg edema and swelling. Computed tomography excluded a pulmonary embolism and revealed severe, massive DVT of both iliac veins and the IVC, including the vena cava filter. Percutaneous aspiration thrombectomy was attempted because intravenous heparin therapy was ineffective, and moderate anemia contraindicated regional thrombolysis. Several passes of a guiding catheter proximally and distally to the filter, with suction provided by a 50-mL syringe, achieved minimal IVC recanalization. Subsequently, a 6-F AngioJet catheter was passed via the guiding catheter through the filter, the IVC, and both iliac veins, obtaining a satisfactory result. The patient was discharged after 7 days and did very well at 6-month follow-up, with no recurrent DVT. CONCLUSION: This case demonstrates the usefulness of combined percutaneous aspiration and rheolytic thrombectomy in treating extensive IVC thrombosis and occluded IVC filters, especially when thrombolytic therapy cannot be used.     

AngioJet rheolytic thrombectomy versus local intrapulmonary thrombolysis in massive pulmonary embolism: a retrospective data analysis.

PURPOSE: To compare the efficacy of full-dose local intrapulmonary thrombolysis (LIT) versus AngioJet rheolytic thrombectomy (ART) in the treatment of massive pulmonary embolism. METHODS: A retrospective review was conducted of 8 consecutive patients (5 women; mean age 66.0+/-5.9 years, range 56-74) who underwent LIT with high-dose intrapulmonary urokinase (4400 IU/kg over 10 minutes followed by a 2000-IU/kg/h infusion) and a subsequent 6 consecutive patients (4 men; mean age of 59.2+/-17.0 years, range 26-69) who underwent ART plus adjunctive low-dose urokinase infusions (100,000 IU) until hemodynamic recovery was achieved. Pre and postprocedural Miller scores were calculated, and relative Miller score improvement, total urokinase doses, and duration of therapy were compared. RESULTS: Hemodynamic stability was restored in all 8 LIT patients and in 5 (83%) of the 6 ART patients; 1 (16.7%) patient died during the ART procedure due to recurrent MPE. In the LIT group, the mean Miller score prior to intervention was 17.38+/-2.67, which was reduced to 6.13+/-1.46 after the intervention (p<0.0001) compared to scores of 18.83+/-2.86 and 6.83+/-2.79, respectively, in the ART group (p<0.0001). The mean urokinase dose was 2.07+/-0.44 million IU in the LIT group versus 0.70+/-0.36 million IU in the ART group (p<0.0001). The mean duration of therapy was 11.45+/-2.94 hours in the LIT group versus 3.37+/-1.41 hours in the ART group (p<0.0001). No significant difference in relative Miller score improvement was observed. CONCLUSION: By accelerating the fragmentation of thrombus, ART plus adjunctive low-dose urokinase seems to be more rapidly effective compared to LIT. ART achieves both rapid cardiovascular relief and reduces the dose of thrombolytic agent necessary in patients with massive pulmonary embolism.     

Rheolytic percutaneous thrombectomy for acute pulmonary embolism in a pediatric patient.

Acute massive pulmonary embolism can have significant hemodynamic effects in both adults and children. We describe the case of a 10-year-old boy who developed cardiogenic shock after suffering a massive pulmonary embolism. A significant thrombus burden was removed using a catheter-based strategy of rheolytic thrombectomy, leading to stabilization of the patient.     

Rheolytic thrombectomy in patients with massive and submassive acute pulmonary embolism

Objectives : To appraise the impact of AngioJet rheolytic thrombectomy (RT) on angiographic and clinical endpoints in patients with acute pulmonary embolism (PE). Background : The management of patients with acute PE and hemodynamic compromise, based mainly on anticoagulant and thrombolytic therapies, is challenging and still suboptimal in many patients. In such a setting, mechanical removal of thrombus from pulmonary circulation holds the promise of significant clinical benefits, albeit remains under debate. Methods : We retrospectively report on 51 patients referred to our catheterization laboratory and treated with AngioJet RT. Patients were classified according to the degree of hemodynamic compromise (shock, hypotension, and right ventricular dysfunction) to explore thoroughly the degree of angiographic pulmonary involvement (angiographic massive PE was defined as the presence of a Miller index ≥ 17) and the impact on angiographic (obstruction, perfusion, and Miller indexes) and clinical (all‐cause death, recurrence of PE, bleeding, renal failure, and severe thrombocytopenia) endpoints of AngioJet RT. Results : Angiographic massive PE was present in all patients with shock, whereas patients with right ventricular dysfunction and hypotension showed a similar substantial pulmonary vascular bed involvement. Technical success was obtained in 92.2% of patients, with a significant improvement in obstruction, perfusion and Miller indexes in each subgroup (all P < 0.0001). Four patients reported major bleedings and eight (15.7%) died in‐hospital. Laboratory experience was significantly associated to a lower rate of major bleedings. All survivors were alive at long‐term follow‐up (35.5 ± 21.7 months) except three who expired due to cancer and acute myocardial infarction. Conclusions : In experienced hands AngioJet RT can be operated safely and effectively in most patients with acute PE, either massive or submassive, and substantial involvement of pulmonary vascular bed. © 2009 Wiley‐Liss, Inc.     

Efficacy of rheolytic thrombectomy in early versus late myocardial infarction

BACKGROUND: Rheolytic thrombectomy has been used successfully to treat acutely occluded lower-limb vessels, dialysis grafts, intrahepatic portosystemic shunts, and diseased native coronary vessels and saphenous vein grafts. Few studies, however, have examined the efficacy of rheolytic thrombectomy in the acute myocardial infarction (AMI) setting. We sought to determine the efficacy of the AngioJet Rheolytic thrombectomy catheter (Possis Medical, Minneapolis, MN, USA) in patients presenting with AMI either before or after 12 hours of onset of symptoms. METHODS: Procedural and angiographic data on 61 consecutive patients (January 2003-December 2003) who presented with an AMI and had rheolytic thrombectomy with the AngioJet catheter performed were reviewed. Coronary flow was assessed with thrombolysis in myocardial infarction (TIMI) frame counts (TFCs). Of the 61 patients studied, 40 had AngioJet performed within 12 hours and 21 had it done after 12 hours from the onset of symptoms. Procedural success was measured by TFCs measured before and after the procedure and was defined as a change in the TFC of >or=50%. Statistical significance was considered at a P value of <0.05. RESULTS: Procedural success was achieved in 75% of the patients in the early presentation group (within 12 hours) and 0% of the patients in the late presentation group (after 12 hours). TFC values were statistically different (P<0.001) in the early group, but not significant (P>0.1) in the late thrombectomy group. CONCLUSION: Rheolytic thrombectomy with the AngioJet catheter is more effective in terms of improvement in coronary blood flow as assessed by TFCs when used less than 12 hours after the onset of clinical symptoms suggestive of AMI.     

Rheolytic thrombectomy and platelet glycoprotein IIb/IIIa blockade for stent thrombosis.

Conventional transcatheter-based strategies result in good procedural success but poor clinical outcome in the treatment of intracoronary stent thrombosis. A combined approach of mechanical thrombus burden reduction using AngioJet rheolytic thrombectomy with adjunctive glycoprotein (GP) IIb/IIIa antagonists has not been studied. Between July 1998 and August 2000, 15 patients (17 procedures) underwent AngioJet thrombectomy for stent thrombosis at the Beth Israel Deaconess Medical Center. Patients were followed clinically through 6 months following the AngioJet procedure. All patients presented with signs of acute myocardial infarction at a median of 6 days following the original stenting procedure. Most vessels (88%) were occluded at presentation. A GP IIb/IIIa inhibitor was administered during 16 of the 17 procedures. Rheolytic thrombectomy resulted in complete removal of filling defects in all reviewed cases and led to significant improvement in lumen diameter and TIMI flow with reduction in the thrombotic lesion length (all P values < 0.05). Angiographic success (< 30% residual stenosis, TIMI 3 flow) was attained in all but one procedure. No patient required emergent coronary bypass grafting, repeat coronary angioplasty, or died in-hospital. At 6 months, there were no deaths and repeat revascularization was performed in four patients (29%). A combined approach of rheolytic thrombectomy with adjunctive GP IIb/IIIa blockade was highly effective in resolving stent thrombosis and was associated with favorable acute and long-term outcomes.     

Thrombectomy with AngioJet catheter in native coronary arteries for patients with acute or recent myocardial infarction

The AngioJet thrombectomy catheter removes thrombi by rheolytic fragmentation and suction. The purpose of this study was to identify the efficacy and safety of this new device. Myocardial infarction (MI) is associated with intracoronary thrombus. Intracoronary thrombus has been identified as a risk factor of unfavorable outcome after percutaneous transluminal coronary angioplasty. To what extent the AngioJet is applicable or effective for acute or recent MI in native coronary artery is not clear. Thrombectomy with the AngioJet was attempted in 31 patients with 31 native coronary arteries selected from 304 patients with acute or recent MI. Follow-up angiography was performed at 3 to 6 months. Procedure success was achieved in 29 patients (94%). Adjunctive balloon angioplasty was performed after AngioJet thrombectomy in 30 patients (97%), and in only 1 patient (3%) AngioJet thrombectomy was the sole procedure. Subsequent stenting after balloon angioplasty was attempted successfully in 12 patients (40%) without thrombotic complications. Thrombolysis In Myocardial Infarction trial flow grading increased from 0.70 +/- 0.97 before to 2.61 +/- 0.88 after AngioJet thrombectomy (p <0.0001), to 2.84 +/- 0.64 after adjunctive procedures (p = 0.070). At follow-up angiography restenosis rate was 21% but Thrombolysis In Myocardial Infarction flow 3 was present in all patients. The restenosis rate of stented patients was 8%. There were no major events during in-hospital and follow-up. The AngioJet can be used safely and successfully to remove thrombus from the native coronary artery of patients with MI. Thrombus removal makes subsequent stenting safe and uncomplicated. The restenosis rate was considered to be acceptable.     

Rheolytic thrombectomy for thromboembolic occlusion of the internal carotid artery complicating coronary intervention

Stroke associated with percutaneous coronary intervention (PCI) is an infrequent, but devastating complication. Intra-arterial thrombolysis has been used with limited success, but there are no widely accepted strategies for acute ischemic stroke during PCI. We report a case in which the AngioJet rheolytic thrombectomy device was used in an attempt to re-establish patency of an occluded internal carotid artery in the setting of an acute stroke caused by thromboembolization from the right coronary artery during PCI.     

Massive air embolus treated with rheolytic thrombectomy

The incidence of air embolism during diagnostic cardiac catheterization and percutaneous coronary intervention is reported at a rate of 0.84% and 0.24%. Although there is no optimal technique to restore blood flow after blockage by air emboli, treatment options include manual aspiration or forcefully injecting saline, with auxiliary supportive measures like 100% oxygen or an intra-aortic balloon pump. The AngioJet (Possis Medical, Inc., Minneapolis, Minnesota) device is a catheter-based device for thrombus removal in which high-velocity saline jets are used to create a localized low-pressure zone at the distal catheter tip (Bernoulli effect), resulting in the maceration and removal of thrombus through an exhaust lumen. The use of rheolytic thrombectomy has been studied in thrombus-containing native coronary arteries as well as saphenous vein graft lesions. We report a case of a massive air embolus that occurred after activation of an AngioJet catheter in a thrombus-laden right coronary artery (RCA). The AngioJet catheter was then utilized to effectively aspirate the air embolus with restoration of coronary blood flow. Use of a guiding catheter that is nonocclusive or with side holes to ensure continuous blood flow from the central aorta may help avoid entrainment of air into the coronary artery during activation of the AngioJet thrombectomy catheter. To our knowledge, this is the first reported case of such a potential complication. In the event of such a complication, the AngioJet catheter can be implemented to aspirate a coronary air embolus.     

Combined clot fragmentation and aspiration in patients with acute pulmonary embolism

BACKGROUND: Massive angiographic pulmonary embolism (PE) with right ventricular dysfunction (RVD) is associated with a high early mortality rate. The therapeutic alternatives for this condition include thrombolysis, surgical embolectomy, or percutaneous mechanical thrombectomy (PMT). We describe our experience using PMT in patients with massive PE and RVD with unsuccessful thrombolysis, increased bleeding risk, or major contraindications for thrombolytic therapy. METHODS: Clinical, hemodynamic, and angiographic parameters prior to and following PMT were evaluated. Our primary objective was to describe the incidence of in-hospital cardiovascular death, and of major and minor complications. Mid-term outcomes included analysis of occurrence of cardiovascular death, recurrent pulmonary embolism, change of New York Heart Association functional class, and hospital readmission. RESULTS: From July 2004 to May 2007, 69 patients were referred to the cardiac catheterization laboratory with a diagnosis of acute PE, 18 of whom met the criteria for massive PE and are the subject of this study. All patients underwent thrombus fragmentation using a pigtail catheter that was complemented in 13 patients with thrombus aspiration. A percutaneous thrombectomy device (Aspirex; Straub Medical; Wangs, Switzerland) was used in 11 patients. Hemodynamic, angiographic, and blood oxygenation parameters improved after the procedure. A significant increase was observed for systolic systemic BP (74.3+/-7.5 mm Hg vs 89.4+/-11.3 mm Hg, p=0.001) [mean+/-SD], as was a decrease in mean pulmonary artery pressure (37.1+/-8.5 mm Hg vs 32.3+/-10.5 mm Hg , p=0.0001). The in-hospital major complications rate was 11.1%; one patient died from refractory shock, and one patient had intracerebral hemorrhage with minor neurologic sequelae. No cardiovascular deaths or recurrent pulmonary thromboembolism were documented during clinical follow-up (12.3+/-9.4 months). CONCLUSIONS: In patients with massive PE, RVD and major contraindications to thrombolytic therapy, increased bleeding risk, failed thrombolysis, or unavailable surgical thrombectomy, PMT appears to be a useful therapeutic alternative.     

Aneurysm sac re-expansion after thrombolysis.

PURPOSE: To present a case of delayed abdominal aortic aneurysm (AAA) re-expansion after thrombolysis for endograft limb occlusion. CASE REPORT: A 68-year-old man underwent AAA exclusion with an AneuRx stent-graft in 1999. Five years later, he developed right limb thrombosis of the endograft. He underwent right limb thrombolysis and AngioJet thrombectomy. The patient experienced abdominal and back pain during the procedure, and the aneurysm sac, which had remained reduced in size for several years, acutely re-expanded. The patient was managed conservatively. The fluid that accumulated in the sac was reabsorbed, and the AAA returned to its previous dimensions at 1-month follow-up. CONCLUSION: Symptomatic re-expansion of the aneurysm sac after AngioJet rheolytic thrombectomy may occur when the graft is stripped of neointima by the "power-pulse" spray of lytic agent, allowing serum to seep into the sac. Based on this experience, we advise caution when delivering thrombolytics using the AngioJet "power-pulse" spray mode in patients with a thrombosed stent-graft.     

Successful Aspiration and Rheolytic Thrombectomy of a Renal Artery Infarct and Review of the Current Literature

The use of revascularization techniques including angioplasty, thrombectomy, and stenting in the coronary, cerebral, and peripheral arteries has revolutionized the entire field of endovascular therapeutics. In renal thromboembolism, the classic treatment has been anticoagulation with possible thrombolysis and surgical thrombectomy. The role of endovascular therapy in renal thromboembolism remains controversial. There are a few anecdotal reports about the use of aspiration and rheolytic thrombectomy in the renal arteries. We present a case of acute renal infarction resulting from systemic embolism secondary to atrial fibrillation. This was treated with revascularization, including aspiration and rheolytic thrombectomy, with excellent results.     

Effectiveness of rheolytic coronary thrombectomy with the AngioJet catheter

Thrombus-filled lesions are associated with a higher rate of acute complications and long-term restenosis following conventional coronary or saphenous vein graft (SVG) intervention. To evaluate the clinical effectiveness of rheolytic thrombectomy in a nonselected population in the glycoprotein IIb/IIIa blockade era, we reviewed clinical, angiographic, and procedural data on 119 patients who underwent 126 consecutive coronary AngioJet procedures (29% in SVGs, and 71% in native coronary arteries) from July 1998 to August 2000. Glycoprotein IIb/IIIa blockers were used in 88%. Most vessels (68% of SVGs, 74% of native coronary arteries) were occluded initially. Complete or substantial removal of filling defects was achieved in 76% of SVGs and 66% of native coronary cases. The AngioJet rheolytic thrombectomy device led to significant improvement in lumen diameter and Thrombolysis In Myocardial Infarction (TIMI) flow, with reduction in the thrombotic lesion length (p <0.05). Angiographic success (<30% residual stenosis, TIMI-3) was attained in 73% of SVGs and 87% of native coronary procedures. Distal embolization occurred in 13 cases, and was less likely to occur in patients treated with abciximab (0%) compared with patients treated with other glycoprotein IIb/IIIa blockers or heparin alone (17%, p = 0.02). A favorable response to the AngioJet (odds ratio 3.9) and freedom from embolization (odds ratio 14.6) were associated with a higher procedural success rate. In-hospital and long-term clinical outcomes were favorable. Thus, rheolytic thrombectomy resulted in significant reduction of the thrombus burden in most patients, restored TIMI-3 flow, and led to favorable short- and long-term outcomes.