Percutaneous thrombectomy: a review

Percutaneous thrombectomy (PT) is an established technique for the removal of acute thrombus in occluded arteries, veins and vascular grafts. Percutaneous thrombectomy can be used as an adjunctive treatment to other methods 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 using a variety of automated devices to fragment or remove thrombus. Aspiration thrombectomy is often used as an adjunct to thrombolysis in acute arterial occlusion, or as salvage therapy to remove distal emboli following iliac or femoropopliteal angioplasty. Mechanical thrombectomy is useful for the treatment of thrombosed dialysis grafts and is being increasingly used for the treatment of massive pulmonary emboli and ileofemoral or ileocaval deep venous thromboses.     

Amplatz血栓消融器治疗下肢深静脉血栓(附18例分析)

目的：报告Amplatz血栓消融器治疗下肢深静脉血栓的应用情况。方法：回顾2001～2002年18例下肢深静脉血栓，腔髂静脉(n=2)，髂静脉(n=6)，髂股静脉(n=9)，股静脉(n=1)，在临时性／永久性下腔静脉滤器的保护下，经患侧腘静脉(n=10)和健侧股静脉(n=8)为入路行ATD血栓消融术。结果：13例经ATD血栓消融术后，血栓即时清除成功，占72．2％，ATD启动平均时间79．2s，血栓清除率在20％～99％，平均70．3％，17例患者需辅助治疗，占94．4％(17／18)，12例行Stent置入术，13例行经皮血管成形术，2例行经导管血栓抽吸术，9例行血栓药物溶解术，平均随访6个月均未复发DVT。结论：在下腔静脉滤器保护下，ATD是治疗下肢深静脉血栓的有效方法。     

Amplatz血栓消融器在急性肺动脉栓塞中的临床应用

急性肺动脉栓塞（pulmonary embolism,PE）起病急,病情进展快,未经治疗病死率可高达20％～30％。我院自2001年6月始,采用Amplatz Thrombectomy Device（ATD）成功抢救了5例危重的大面积PE病例。现报道如下。     

Implanted central venous catheter-related acute superior vena cava syndrome: management by metallic stent and endovascular repositioning of the catheter tip

We describe a case of a 49-year-old woman with stage-IIIB lung adenocarcinoma who experienced an acute superior vena cava syndrome related to an implanted central venous catheter without associated venous thrombosis. The catheter was surgically implanted for chemotherapy. Superior vena cava syndrome appeared after the procedure and was due to insertion of the catheter through a subclinical stenosis of the superior vena cava. Complete resolution of the patient's symptoms was obtained using stent placement and endovascular repositioning of the catheter tip. Received: 24 April 1999; Revised: 8 February 2000; Accepted: 9 February 2000     

经皮血栓碎吸联合血管成形治疗髂静脉压迫综合征并深静脉血栓形成

目的探讨经皮血栓碎吸联合血管成形治疗髂静脉压迫综合征并下肢深静脉血栓形成的临床效果。资料与方法回顾性分析184例髂静脉压迫综合征并下肢深静脉血栓形成的病例资料。经皮穿刺患侧股静脉,在导丝引导下采用12～14 F鞘管抽吸髂、股静脉内血栓;对于股、腘静脉血栓,利用Fogarty球囊导管将血栓碎解、拖拉至髂静脉内,再行机械性血栓抽吸术。对髂静脉严重狭窄或闭塞者,行经皮腔内血管成形术或支架置入治疗。结果本组血栓清除率Ⅲ级80.98%,Ⅱ级19.02%;出院时患肢膝上、下15 cm 周径为（43.9±4.7） cm、（31.5±4.1） cm,与入院时相比其间差异有统计学意义（t=6.43,t=5.79,均P=0.000）。随访6～24个月,治疗有效率为97.75%;178例支架置入病人术后6、12、24个月彩色多普勒超声或 DSA 复查,支架通畅率为97.19%、94.94%、92.13%。结论血栓碎吸联合血管成形治疗髂静脉压迫综合征并下肢深静脉血栓形成,其近、中期疗效显著,住院时间短,是一种安全有效的介入治疗方法。     

Percutaneous transluminal angioplasty in segmental obstruction of the hepatic inferior vena cava: Long-term results

Percutaneous transluminal angioplasty (PTA) was performed in 8 patients with segmental obstruction of the hepatic inferior vena cava. Using Grüntzig balloon catheters, canalization and dilatation were initially successful in all 8 patients without any complications. In long-term observation of 12–48 months, recurrence of obstruction was confirmed in 5 patients. These were recanalized easily by repeat PTA. Long-term patency was obtained in 3 patients in whom the lumen was opened to 13 mm or more in diameter as seen in lateral views of the vena cavogram.     

Percutaneous Venous Thrombectomy Using the Arrow-Trerotola Percutaneous Thrombolytic Device (PTD) with Temporary Caval Filtration: In Vitro Investigations

Purpose To evaluate the size and quantity of downstream emboli after thrombectomy using the Arrow-Trerotola Percutaneous Thrombolytic Device (PTD) with or without temporary filtration for extensive iliofemoral and iliocaval thrombi in an in vitro flow model.Methods Iliocaval thrombi were simulated by clotted bovine blood in a flow model (semilucent silicone tubings, diameter 12–16 mm). Five experimental set-ups were performed 10 times each; thrombus particles and distribution were measured in the effluent. First, after retrograde insertion, mechanical thrombectomy was performed using the PTD alone. Then a modified self-expanding tulip-shaped temporary vena cava stent filter was inserted additionally at the beginning of each declotting procedure and removed immediately after the intervention without any manipulation within or at the filter itself. In a third step, the filter was filled with thrombus only. Here, two experiments were performed: Careful closure within the flow circuit without any additional fragmentation procedure and running the PTD within the filter lumen, respectively. In the final set-up, mechanical thrombectomy was performed within the thrombus-filled tubing as well as in the filter lumen. The latter was closed at the end of the procedure and both devices were removed from the flow circuit.Results Running the PTD in the flow circuit without filter protection led to a fragmentation of 67.9% (±7.14%) of the clot into particles 500 m; restoration of flow was established in all cases. Additional placement of the filter safely allowed maceration of 82.9% (±5.59%) of the thrombus. Controlled closure of the thrombus-filled filter within the flow circuit without additional mechanical treatment broke up 75.2% (±10.49%), while additional mechanical thrombectomy by running the PTD within the occluded filter led to dissolution of 90.4% (±3.99%) of the initial clot. In the final set-up, an overall fragmentation rate of 99.6% (±0.44%) was achieved.Conclusions The combined use of the Arrow-Trerotola PTD and a temporary vena cava stent filter proved to be effective for even large clot removal in this experimental set-up.     

下腔静脉滤器置入后大剂量尿激酶溶栓治疗下肢深静脉血栓形成

目的　探讨下腔静脉滤器置入后大剂量尿激酶溶栓治疗下肢深静脉血栓形成的可行性。方法　 1 3例经造影证实为左下肢深静脉血栓患者 ,先于下腔静脉内放置滤器 ,后在监护下经患者足背静脉加压推注尿激酶进行持续溶栓治疗 ,尿激酶 (UK)用量 90 0万U～ 1 60 0万U。疗效判断标准 :痊愈 :患者无症状 ,下肢造影示深静脉通畅 ;显效 :患者症状明显缓解 ,下肢造影示深静脉回流畅 ,但壁不光滑 ,血管内径 >70 % ;有效 :症状有所缓解 ,造影示血栓残留 ,血管内径 <70 % ;无效 :症状及下肢造影均无改善。结果　 1 3只下腔静脉滤器均展开良好 ,无移位。其中 :痊愈 2例 ,显效 9例 ,有效 2例 ,无效 0例 ,溶栓过程中未出现肺动脉栓塞症状及出血现象。结论　下腔静脉滤器置入后经患肢浅静脉大剂量尿激酶溶栓治疗下肢深静脉血栓形成是安全、有效的     

Predicting the Safety and Effectiveness of Inferior Vena Cava Filters (PRESERVE): Outcomes at 12 months

ObjectiveTo determine the safety and effectiveness of vena cava filters (VCFs).MethodsA total of 1429 participants (62.7 ± 14.7 years old; 762 [53.3% male]) consented to enroll in this prospective, nonrandomized study at 54 sites in the United States between October 10, 2015, and March 31, 2019. They were evaluated at baseline and at 3, 6, 12, 18, and 24 months following VCF implantation. Participants whose VCFs were removed were followed for 1 month after retrieval. Follow-up was performed at 3, 12, and 24 months. Predetermined composite primary safety (freedom from perioperative serious adverse events [AEs] and from clinically significant perforation, VCF embolization, caval thrombotic occlusion, and/or new deep vein thrombosis [DVT] within 12-months) and effectiveness (composite comprising procedural and technical success and freedom from new symptomatic pulmonary embolism [PE] confirmed by imaging at 12-months in situ or 1 month postretrieval) end points were assessed.ResultsVCFs were implanted in 1421 patients. Of these, 1019 (71.7%) had current DVT and/or PE. Anticoagulation therapy was contraindicated or had failed in 1159 (81.6%). One hundred twenty-six (8.9%) VCFs were prophylactic. Mean and median follow-up for the entire population and for those whose VCFs were not removed was 243.5 ± 243.3 days and 138 days and 332.6 ± 290 days and 235 days, respectively. VCFs were removed from 632 (44.5%) patients at a mean of 101.5 ± 72.2 days and median 86.3 days following implantation. The primary safety end point and primary effectiveness end point were both achieved. Procedural AEs were uncommon and usually minor, but one patient died during attempted VCF removal. Excluding strut perforation greater than 5 mm, which was demonstrated on 31 of 201 (15.4%) patients’ computed tomography scans available to the core laboratory, and of which only 3 (0.2%) were deemed clinically significant by the site investigators, VCF-related AEs were rare (7 of 1421, 0.5%). Postfilter, venous thromboembolic events (none fatal) occurred in 93 patients (6.5%), including DVT (80 events in 74 patients [5.2%]), PE (23 events in 23 patients [1.6%]), and/or caval thrombotic occlusions (15 events in 15 patients [1.1%]). No PE occurred in patients following prophylactic placement.ConclusionsImplantation of VCFs in patients with venous thromboembolism was associated with few AEs and with a low incidence of clinically significant PEs.     

Iliocaval thrombosis: percutaneous treatment with hydrodynamic thrombectomy

Mechanical thrombectomy is of growing importance for the treatment of thrombus. Although there are numerous reports about dialysis fistulae and arterial thrombosis, venous applications are currently not well known. We report that an extensive venous thrombotic occlusion can be treated with mechanical thrombectomy, without additional local lysis. This report deals with the indication and technique of venous mechanical thrombectomy and discusses the possible applications. Received: 22 February 1999; Revised: 20 May 1999; Accepted: 29 July 1999     

Gianturco self-expanding stents: Clinical experience in the vena cava and large veins

Twenty-five patients with stenosis of the vena cava (21) and other large veins (4) have been treated with self-expanding Gianturco metallic stents. Eighteen patients had superior vena cava syndrome. In 17, the stricture was due to malignant superior vena cava compression recurrent after maximum tolerance radiotherapy and/or chemotherapy. In 16 of these patients there was early symptomatic relief. In 1 patient with a benign posttraumatic superior vena cava stricture, the stenosis was not relieved, and occlusion occurred after 1 month. Stenoses associated with dialysis shunts were relieved in 2 other patients. Two malignant and one benign inferior vena cava stenoses were relieved either until death, or in the benign case, for 30 months. One malignant subclavian vein obstruction occluded after 24 h due to stent misplacement and another with extrinsic mediastinal compression remained patent until death, extensive thrombus having been lysed prior to stent placement. The results of this short series suggest that the Gianturco self-expanding stent in the vena cava and large veins is easy and safe to place, and in most cases produces almost immediate palliation of the distressing effects of venous obstruction, often in a preterminal and inoperable patient.     

Endovascular treatment of superior vena cava obstruction in patients with malignancies

The aim of this study was to report our experience on the management of superior vena cava obstruction (SVCO) secondary to malignant disease, using endovascular procedures. Twenty-six patients with SVCO due to primary or secondary tumors of the lung or the mediastinum, or catheter inserted for treatment of an extra-thoracic neoplasm, had an endovascular therapy which consisted of stenting, angioplasty, thrombo-aspiration or local fibrinolysis. Immediately after the procedure, rapid relief of symptoms occurred in 24 (90 %) of the patients. The mean Kishi's score decreased from 5.5 to 0.96. Immediate complications included one death related to pericarditis bleeding following fibrinolysis. Three patients relapsed after 20 days, 4 months and 6 months, and needed a second stenting. At 6 months the primary patency rate was 83 % and the secondary patency rate was 89 %. Endovascular treatment of SVCOs is a simple and safe procedure to restore the patency of the superior vena cava in malignant SVCO. It should be indicated in most cases as first-line treatment and performed as early as possible. Received: 8 May 1998; Revision received: 10 August 1998; Accepted: 18 August 1998     

In vitro evaluation of a new temporary venous filter: The spring filter

Purpose To evaluate in vitro the functional efficacy of a new variable-sized, temporary venous filter, the Spring filter (SF).Methods The SF was tested in a flow phantom, using flexible, thin-walled polyethylene tubes 12, 14, and 16 mm in diameter to simulate veins. Clots of three sizes were used: 6 × 10 mm, 6 × 20 mm, 9 × 20 mm. Filter deployment was performed, ensuring that its functional diameter after placement was a predetermined multiple of the radius r of the tube: 3.0r, 2.8r, 2.6r, 2.4r. The terminal coil was visually examined for changes in configuration. Clot retention by the filter for a period of 3 min was recorded as a success. The baseline intraluminal pressure and the maximum pressure reached after clot introduction were recorded. The trapping ability was calculated from the results for 10 clots. The effect of the following parameters on filter function were studied: size of embolus, caliber of simulated vein, and functional diameter of filter.Results The filter configuration was stable. Not a single instance of axial tilting occurred on deployment. Functional diameter was the major determinant of filter function. One hundred percent of clots were trapped irrespective of clot size and tube caliber when the functional diameter was 3.0r. Only 73% (95% confidence interval (CI): 57%–88%) and 77% (95% CI: 61%–92%) of small emboli were held up by the filter when the functional diameters were 2.6r and 2.4r, respectively (p = 0.0001). A significant reduction in clot trapping was encountered even with medium clots when the functional diameter was 2.4r (p = 0.02).Conclusion Against the background of available data on retrievable vena caval filters, the current model of SF warrants further investigation.     

Evaluation of Retrievability of the Gunther Tulip Vena Cava Filter

Purpose To evaluate the feasibility and safety of withdrawal of a Gunther tulip retrievable vena cava filter (GTF). Methods Between June 2001 and December 2005, at our institution 86 GTFs were implanted for temporary caval filtration in 59 patients (37 women, 22 men; mean age 59.3 years, range 18–87 years). For GTFs retrieved thereafter, we retrospectively reviewed the following parameters: rate of success in retrieval, degree of trapped thrombus in the filter, and complications during retrieval. Results Worsening of or new development of pulmonary embolism after filter implantation did not occur in any patient. Of the 86 GTFs implanted, retrieval of 80 was attempted. Among those 80 filters, 77 (96%) were successfully retrieved (with the standard method, n = 72; with the modified method, n = 5) without any complication. The period of implantation of the retrieved filters was 13.4 ± 4.2 days. In the 5 filters that were filled to a height of ≥ 1/4 with trapped thrombus, retrieval was performed after attempts were made to decrease trapped thrombi. In addition, a temporary filter or another GTF was temporarily placed at the cephalad level of the GTF during this removal procedure. Conclusion GTFs can be retrieved in the majority of cases. Even when encountering situations in which the filter could not be removed using the standard method, withdrawal was possible in a high frequency of cases through various trials using modified methods.     

Gunther Tulip Inferior Vena Cava Filter Placement During Treatment for Deep Venous Thrombosis of the Lower Extremity

Purpose To evaluate the efficacy and safety of Gunther tulip retrievable vena cava filter (GTF) implantation to prevent pulmonary embolism during intravenously administered thrombolytic and anticoagulation therapy and interventional radiological therapy for occlusive or nonocclusive deep venous thrombosis (DVT) of the lower extremity.Methods We evaluated placement of 55 GTFs in 42 patients with lower extremity DVT who had undergone various treatments including those utilizing techniques of interventional radiology.Results Worsening of pulmonary embolism in patients with existing pulmonary embolism or in those without pulmonary embolism at the time of GTF insertion was avoided in all patients. All attempts at implantation of the GTF were safely accomplished. Perforation and migration experienced by one patient was the only complication. Mean period of treatment for DVT under protection from pulmonary embolism by the GTF was 12.7 ± 8.3 days (mean ± SD, range 4–37 days). We attempted retrieval of GTFs in 18 patients in whom the venous thrombus had disappeared after therapy, and retrieval in one of these 18 cases failed. GTFs were left in the vena cava in 24 patients for permanent use when the DVT was refractory to treatment.Conclusion The ability of the GTF to protect against pulmonary embolism during treatment of DVT was demonstrated. Safety in both placement and retrieval was clarified. Because replacement with a permanent filter was not required, use of the GTF was convenient when further protection from complicated pulmonary embolism was necessary.     

国产ZQL型可回收式腔静脉滤器的初步临床应用与观察

目的　探讨自行开发的可回收式腔静脉滤器 (国产ZQL型可回收式腔静脉滤器 ,以下简称滤器 )预防肺动脉栓塞的临床应用价值。方法　对 2 4例下肢深静脉血栓形成 (deepveinthrombosis,DVT)和 (或 )肺动脉栓塞 (pulmonaryembolism ,PE)的患者经右侧颈内静脉或经健侧股静脉置入滤器 ,并同时行肺动脉造影。术后第 3和第 7天摄腹部平片。术后 3、6、12、18个月摄腹部平片及行下腔静脉、肺动脉造影。如果在 2周内下肢深静脉血栓完全清除 ,则取出滤器 ,取出前摄腹部平片及行下腔静脉、肺动脉造影 ;如果在 2周内下肢深静脉血栓未能完全清除则将滤器长期留置于下腔静脉内。如果随访期间出现病情变化 ,则需随时复查。所有影像资料经 2位主任医师采用盲法进行评价。结果　 2 4例患者的下腔静脉滤器均成功置入预定部位 ,其中肾静脉水平以下 2 3例 ,肾静脉水平以上1例 ,2例患者置于肾静脉水平以下的滤器分别于术后第 7天和第 9天顺利取出。中位随访期为 6个月。未发生滤器展开不良、滤器移位 (>10mm)、滤器倾斜 (>10°)、滤器断裂或滤器穿透静脉壁造成血肿等。除 1例腔静脉滤器捕获栓子外 ,未发生滤器血栓形成 ,无下腔静脉闭塞发生 ,随访期内全部患者未再发生肺动脉栓塞。结论　国产滤器置入操作简便、定位准确、稳定性     

Entrapment of J-Tip guidewires by venatech and stainless-steel greenfield vena cava filters during central venous catheter placement: Percutaneous management in four patients

We present four patients in whom beside placement of a central venous catheter was complicated by entrapment of a J-tip guidewire by a previously placed vena cava (VC) filter. Two Venatech filters were fragmented and displaced into the superior VC or brachiocephalic vein during attempted withdrawal of the entrapped wire. Two stainless-steel Greenfield filters remained in place and intact. Fluoroscopically guided extraction of both wires entrapped by Greenfield filters was successfully performed in the angiography suite.     

Balloon Dilation of the Superior Vena Cava (SVC) Resulting in SVC Rupture and Pericardial Tamponade: A Case Report and Brief Review

Stent placement is an accepted primary treatment for SVC syndrome. Balloon dilation is frequently performed prior to stent placement. Although various stent-related hemorrhagic complications have been reported, as well as reports of iatrogenic catheter and guidewire perforations, there has been only one previous report of balloon dilation–related SVC rupture. We report a second case, including the clinical scenario, in the hope that should this complication occur, it might be recognized quickly and treated successfully.     

Percutaneous mechanical thrombectomy combined with catheter-directed thrombolysis in the treatment of symptomatic lower extremity deep venous thrombosis

Purpose

To evaluate the efficacy of percutaneous mechanical thrombectomy (PMT) combined with catheter-directed thrombolysis (CDT) in the treatment of massive symptomatic lower limb deep venous thrombosis (DVT).

Materials and methods

One hundred and three clinically confirmed DVT patients were discharged from our institution. Sixteen patients with massive lower limb DVT were included in this retrospective study. After prophylactic placement of inferior vena cava filters (IVCFs), percutaneous mechanical thrombectomy (ATD, n = 10; Straub, n = 6) and catheter-directed thrombolysis were performed in all patients. Complementary therapy included percutaneous transluminal venous angioplasty (PTA, n = 3) and stent placement (n = 1). The doses of thrombolytic agents, length of hospital stay, peri-procedure complications and discharge status were reviewed. Oral anticoagulation was continued for at least 6 months during follow-up.

Results

The average hospital stay was 7 days. The technical success rate (complete and partial lysis of clot) was 89%, the other 11% patients only achieved less than 50% clot lysis. The mean dose of urokinase was 3.3 million IU. There were no significant differences of clinical outcome between the ATD and Straub catheter group. The only major complication was an elderly male who experienced a fatal intracranial hemorrhage while still in the hospital (0.97%, 1/103). Minor complications consisted of three instances of subcutaneous bleeding. No transfusions were required. Vascular patency was achieved in 12 limbs during follow-up. No pulmonary emboli occurred. There is one recurrent DVT 4.5 months after the treatment.

Conclusions

Percutaneous mechanical thrombectomy combined with catheter-directed thrombolysis is an effective and safe method for the treatment of symptomatic DVT. A randomized prospective study is warranted.