Spontaneous rupture of the left common iliac vein associated with May Thurner syndrome: successful management with surgery and placement of an endovascular stent

We report a case of spontaneous rupture of the left common iliac vein diagnosed pre-operatively with CT and successfully treated with surgery and placement of a stent. A 60-year-old woman was referred to our emergency room because of a sudden left lower abdominal pain and swelling of the left lower extremity. CT revealed a huge retroperitoneal haematoma and extrinsic compression of the left common iliac vein with acute thrombosis of deep veins of the left lower extremity. Venous patch angioplasty was performed at the site of spontaneous rupture. After thrombectomy with use of a Forgaty catheter, a stent was placed at the occluded segment of the left common iliac vein under the C-arm fluroscopic guidance. Follow-up CT 10 days and 8 months after initial examination demonstrated a venous stent with preserved luminal patency and striking resolution of deep vein thrombosis of the left lower extremity.     

Ovine Iliac Vein Model for Endovascular Thrombectomy of Acute Deep Venous Thrombosis

An ovine iliac vein thrombosis model was devised to test a wall-contacting rotational thrombectomy device. Thrombosis was successfully induced in 9 sheep with an average clot length of 31 mm ± 12 and >60% vessel occlusion on angiography. The thrombus was subsequently removed, maintaining normal intraoperative pulmonary arterial pressure (5.9 mm Hg ± 3.6) and complete distal reperfusion after thrombectomy. Additionally, the sheep were without signs of vascular trauma or embolic complications on gross necropsy and histopathologic analysis. The findings from this study support the use of an ovine iliac deep vein thrombosis model for testing of a lower extremity thrombectomy device.     

Catheter direct thrombolysis: Role of actilyse in treatment of acute deep venous thrombosis

Purpose

To evaluate the short and long term efficiency of catheter directed thrombolysis using recombinant tissue type plasminogin activator (r-TPA; Actilyse), in treating acute deep venous thrombosis of the lower limb.

Material and methods

Twenty-eight patients with acute lower limb deep venous thrombosis underwent treatment by direct intra clot injection of thrombolytic therapy; Actilyse.

Result

Thrombus lysis was completed in 23 (82.2%) of 28 patients, partial in 4 (14.3%) patients and not achieved in one (3.5%) patient. There was no major complication. There was no rethrombosis or post thrombotic syndrome in any of the treated 23 patients over the follow up period of one year.

Conclusion

The treatment of acute lower limb deep venous thrombosis using recombinant tissue type plasminogin activator (r-TPA; Actilyse), is safe, effective and achieves significantly better short and long term clinical outcome for patients.     

Mechanical Thrombectomy of Iliac Vein Thrombosis in a Pig Model Using the Rotarex and Aspirex Catheters

Purpose

To investigate the efficacy and safety of mechanical thrombectomy for iliac vein thrombosis using Rotarex and Aspirex catheters in a pig model.

Materials and Methods

Iliac vein thrombosis was induced in six pigs by means of an occlusion-balloon catheter and thrombin injection. The presence of thrombi was verified by digital subtraction angiography (DSA) and computed tomography (CT). Thrombectomy was performed using 6F and 8F Rotarex and 6F, 8F, and 10F Aspirex catheters (Straub Medical AG, Wangs, Switzerland). After intervention, DSA and CT were repeated to evaluate the efficacy of mechanical thrombectomy and to exclude local complications. In addition, pulmonary CT was performed to rule out pulmonary embolism. Finally, all pigs were killed, and iliac veins were dissected to perform macroscopic and histological examination.

Results

Thrombus induction was successfully achieved in all animals as verified by DSA and CT. Subsequent thrombectomy lead to incomplete recanalization of the iliac veins with residual thrombi in all cases. However, the use of the 6F and 8F Rotarex catheters caused vessel perforation and retroperitoneal hemorrhage in all cases. Application of the Aspirex device caused one small transmural perforation in a vessel treated with a 10F Aspirex catheter, and this was only seen microscopically. Pulmonary embolism was detected in one animal treated with the Rotarex catheters, whereas no pulmonary emboli were seen in animals treated with the Aspirex catheters.

Conclusion

The Aspirex catheter allowed subtotal and safe recanalization of iliac vein thrombosis. In contrast, the use of the Rotarex catheter caused macroscopically obvious vessel perforations in all cases.     

Noninvasive extracorporeal thrombolysis using electrical discharge-induced shock waves: in vitro experiments

RATIONALE AND OBJECTIVES: Many thrombectomy approaches have been developed for the treatment of venous thrombosis; however, no reference standard exists at this time. The aim of this study was to evaluate the efficacy of the transcutaneous application of electrical discharge-induced shock waves for thrombolysis in an in vitro model. METHODS: Shock waves were applied on a thrombus positioned in a plasma-containing silicon tube using 2 different energy flux densities (0.53 and 2.26 mJ/mm). Depending upon the specific experiment, the thrombus was slightly moved to mimic pulsatory motions or/and additional Actilyse was added. Plasma samples were taken to determine the d-dimers before and after the application of shock waves. RESULTS: Energy of 0.53 mJ/mm was insufficient for thrombolysis whereas the energy of 2.26 mJ/mm yielded a removal rate of up to 76.4% when the thrombus was slightly moved during the procedure. The amount of d-dimers correlated well with the addition of Actilyse. However, this did not affect the removal rate significantly. CONCLUSION: The results demonstrate the potential of electrical discharge-induced shock waves for thrombolysis.     

Fogarty catheter complication treated with angiographic techniques: New use for balloon occlusion catheter

Fogarty catheter embolectomy is occasionally associated with complications, including intimal dissection and thrombosis. We report a case of this complication in the iliac artery treated angiographically by thrombectomy with a balloon occlusion catheter.     

Percutaneous ilio-caval thrombectomy with the Amplatz device: preliminary results

The Amplatz Thrombectomy Device (ATD) is a percutaneous, rotational thrombectomy catheter, capable of recirculating and homogenizing the thrombus in order to obtain mechanical clot dissolution. The authors present their experience with mechanical thrombectomy with the ATD in eight cases of ilio-caval thrombosis. Under temporary caval filter protection, the ATD was introduced through the right transjugular approach (in one patient this was used in combination with the right femoral approach) and activated for a time ranging from 90 to 180 s. Complete clearing of thrombotic material in the treated venous segments was achieved in six cases (75 %), partial success was obtained in one case (12.5 %) and failure occurred in one patient (12.5 %). One patient developed a recurrence of venous iliac thrombosis 1 week after the procedure and postphlebitic syndrome 6 months after the first episode of deep venous thrombosis, and one patient died from acute myocardial infarction, unrelated to thrombectomy session, after 3 days. A negative clinical and radiological follow-up at 3, 6, 12 and 24 months was obtained in the remaining six patients. If a fresh free-floating ilio-caval clot must be removed immediately, the ATD can be effective under temporary filter protection. Received: 5 May 1998; Revision received: 8 June 1998; Accepted: 16 September 1998     

Prototype percutaneous thrombolytic device: preclinical testing in subacute inferior vena caval thrombosis in a pig model.

PURPOSE: To develop an animal model of subacute inferior vena caval (IVC) thrombosis and apply this model in evaluating the safety and efficacy of a prototype percutaneous thrombolytic device for restoring patency. MATERIALS AND METHODS: In 11 pigs, a stent with a ligature in the middle was placed in the IVC. Thrombin was injected to induce thrombosis. Hemostasis was achieved by using an occlusion balloon. The stent was ligated to prevent thrombus migration. Five to 8 days after thrombus induction, the ligature was broken and the stent fully deployed. In 10 animals, thrombectomy was performed by using the percutaneous thrombolytic device. A vena caval filter was inserted at the beginning of each declotting procedure. Thrombus removal percentage was estimated and pulmonary angiograms obtained to detect embolism before and after thrombectomy. The IVC was analyzed histologically. To determine thrombus composition, one animal was sacrificed without thrombectomy. Concerning procedural safety, failure of the stent delivery system, stent migration, and venous perforation due to balloon inflation and the stent placement or thrombectomy procedure were evaluated. RESULTS: Thrombus creation was successful in all animals. Fragmentation led to 75%--100% thrombus removal with flow restoration in all cases. There were no episodes of stent delivery failure, stent migration, or venous perforation. No significant pulmonary embolism was observed. In one case, a vessel dissection was identified at histologic examination. CONCLUSION: In this animal model of IVC thrombosis, the percutaneous thrombolytic device is effective and safe for clot removal.     

Thrombolysis of occluded femoropopliteal grafts

In a series of 44 occluded femoropopliteal grafts, streptokinase was used for thrombolytic therapy in 22 cases and urokinase in 22 cases. In most cases, thrombolytic agents were administered via an indwelling arterial catheter directly into the proximal thrombus. The catheter tip was advanced as thrombolysis occurred. Compared with streptokinase infusions, urokinase bolus injection followed by infusion had better results (77% vs 41%) and fewer complications (23% vs 50%). During thrombolytic infusion, concomitant heparin infusion was usually used to reduce the frequency of thrombus formation on the infusion catheter or recurrent thrombosis of the graft, once the tip of the infusion catheter was advanced distally. Follow-up in 23 of 26 successful cases showed that 11 of the grafts remained open at an average follow-up of 12 months or until the patient died. The 12 grafts that reoccluded remained open an average of 3 months. In none of the 18 failures was simple surgical thrombectomy or thrombectomy with graft revision effective in revascularizing the distal limb. The advantages of thrombolysis compared with thrombectomy are less trauma to the graft, which is especially important in vein grafts, and improved distal runoff due to lysis of infrapopliteal thrombus. Even among cases considered failures in this series, the surgical approach was often simplified because of partial thrombolysis. Thrombolysis requires a considerable amount of time, effort, and expense, but in certain patients where thrombectomy is indicated for the treatment of occluded femoropopliteal grafts this technique offers important advantages.     

Intravascular ultrasound angioplasty in peripheral arterial occlusion. Preliminary experience

Purpose: To determine if ultrasound angioplasty in a percutaneous approach was capable of recanalizing occluded arteries in acute and subacute peripheral arterial occlusions.Material and Methods: We applied an ultrasound angioplasty device in a percutaneous approach in 9 patients with peripheral arterial occlusions. All patients suffered from severe leg ischemia due to subacute thrombotic occlusions.Results: The ultrasound transmitter easily created a channel within the occlusive material. To further reduce the mass of the occlusive material, an aspiration thrombectomy was performed in all cases, leading to a complete recanalization in 7 cases. In 2 cases, a remaining stenosis was successfully dilated.Conclusion: Intravascular ultrasonic devices can be useful for recanalization of occluded peripheral arteries. In particular, if thrombolytic therapy of longer peripheral arterial occlusions fails or is contraindicated, ultrasound angioplasty may be a new approach for recanalization.     

Percutaneous mechanical thrombectomy for thrombosed vessels with a hydrolyser (hydrodynamic thrombectomy catheter): clinical experience

A hydrodynamic thrombectomy catheter was prospectively evaluated for the treatment of thrombosed vessels. Seven patients (7 males: age range from 56 to 82 years; mean age: 79 years) presenting with acute or chronic occlusion of peripheral native arteries (n = 6) and dialysis shunt (n = 1) were treated with the hydrolyser (Cordis, Johnson and Johnson, Japan). Mean occlusion time was 135 days (range: 2-300 days), and mean thrombus length 16 cm (range: 5-20 cm). Removal of the thrombus was successful in five patients (71%), regardless of the length of the thrombus. Mean procedure time was 20 minutes (range: 15-30 minutes). No major complications occurred. Adjunctive thrombolysis was required for persistence of the residual thrombosed distal vessel in one patient. Adjunctive balloon angioplasty was performed in two patients (one native vessel and one dialysis shunt), and stent placement was performed in one patient (dialysis shunt). In two unsuccessful cases, the hydrolyser could not be advanced to the distal side because of the solid thrombus. Therefore, thrombolytic therapy was chosen. However, this therapy failed because the guidewire did not pass within the thrombus. Surgery was performed in these two patients. We conclude from this clinical experience that percutaneous thrombectomy with a hydrolyser is a promising technique for the treatment of thrombosed vessels. Especially in the acute stage of thrombosed occlusion, percutaneous thrombectomy with a hydrolyser is superior to thrombectomy with a Fogarty balloon catheter because of its shorter procedure time and fewer complications.     

Rheolytic hydrodynamic thrombectomy for percutaneous treatment of acutely occluded infra-aortic native arteries and bypass grafts: midterm follow-up results

RATIONALE AND OBJECTIVES: To evaluate the efficacy of a rheolytic thrombectomy catheter (RTC) for treatment of acutely occluded infra-aortic native arteries and bypass grafts and to determine midterm primary patency, death, and amputation-free survival rates. METHODS: From March 1995 to September 1997, 112 patients with occluded arteries or bypass grafts were primarily treated with RTC at two centers. Thrombus removal was evaluated by two angiographers. RESULTS: More than 75% of the thromboembolic material could be removed with RTC alone. Mean activation time of RTC was 280 +/- 163 seconds. Residual mural or organized thrombi (29%) required adjunctive fibrinolytic therapy or aspiration thrombectomy. Remaining stenoses were treated with percutaneous transluminal angioplasty and additional stent implantation. For acute reocclusions, surgical intervention was required. Technical success after the entire procedure was 88.4%. RTC-associated complications included distal embolization, dissection, vessel perforation, and technical failure of RTC. Mean follow-up time was 14.8 months +/- 11.5, rates of primary patency, secondary patency, death, and amputation-free survival were 60%, 84%, 16%, and 75% after 2 years, respectively. CONCLUSIONS: RTC is a rapid and efficient technique for mechanical thrombectomy of acutely thrombosed native leg arteries and bypass grafts. Midterm results are comparable to the results of alternative treatment modalities such as Fogarty balloon thromboembolectomy or local fibrinolysis.     

Experimental treatment of early chronic iliac vein thrombosis with a modified hydrodynamic thrombectomy catheter: preliminary animal experience

PURPOSE: To evaluate the efficacy and safety of a new hydrodynamic catheter for removal of chronic iliac vein thrombus. METHODS: Unilateral iliac vein thrombosis was induced in seven pigs by combining permanent coil and temporary balloon occlusion. Thrombectomy was performed with a new hydrodynamic catheter (10 F S.E.T.) 3 days after thrombus induction. After thrombectomy, the animals were killed and the iliac veins were examined histologically. RESULTS: Complete thrombectomy (100% thrombus removal) was achieved in three of seven animals, 75% removal in three of seven animals, and only 30% removal in one animal. The average thrombus removal was 75%. Successful re-establishment of flow was achieved in five of seven cases. Histologically, the thrombi were partially organized, meeting the histologic criteria for early chronic venous thrombosis. Minor venous wall damage caused by the thrombectomy procedure without acute hemodynamic consequences was observed in four of seven cases. CONCLUSION: The 10-F S.E.T. catheter was reasonably effective in removing chronic iliac vein thrombus with no hemodynamically significant complications.     

Direct percutaneous embolization of a postembolectomy pseudoaneurysm

A case of direct percutaneous embolization of a large pseudoaneurysm of the posterior tibial artery is presented. The pseudoaneurysm developed following thrombectomy of an occluded femoropopliteal bypass graft with a Fogarty balloon catheter. Two needles were used: a 19 gauge needle to perform embolization and a 22 gauge needle for contrast injection. The two needle technique allowed rapid, safe embolization with precise angiographic control of the embolization procedure.     

经动脉序贯静脉置管溶栓治疗急性混合型下肢深静脉血栓26例的初步临床疗效观察

目的评价经动脉序贯静脉置管溶栓治疗急性混合型下肢深静脉血栓（lower extremity deep vein thrombosis,LEDVT）的安全性和有效性。 方法回顾性分析26例急性混合型LEDVT患者的临床资料。患者术前置入下腔静脉滤器,穿刺左侧肱动脉于患侧髂动脉置管溶栓,2～3 d后复查造影并穿刺患侧腘静脉行球囊扩张（percutaneous transluminal angioplasty,PTA）+手动抽栓（percutaneous mechanical thrombectomy,PMT）+置管溶栓（catheter directed thrombolysis,CDT）。观察血栓清除情况、患侧下肢周径变化情况及溶栓并发症等。 结果26例患者经动脉置管溶栓后24例（92.31%）腘静脉及膝下段深静脉血栓大部分溶解;之后行PTA+PMT+CDT操作1次者17例（65.39%）,操作2次者7例（26.92%）,操作3次后置入髂静脉支架者2例（7.69%）。血栓清除率Ⅲ级者22例（84.62%）,Ⅱ级者2例（7.69%）,I级者2例（7.69%）。治疗前膝上周径与健侧差值为（5.02±2.29）cm,治疗后差值为（0.74±0.18）cm,两者比较具有显著的统计学差异（t=7.601,P<0.001）。26例溶栓治疗无严重并发症。 结论经髂动脉置管溶栓序贯腘静脉PTA+PMT+CDT对于急性混合型LEDVT治疗安全有效。     

机械性血栓清除术联合同期髂静脉支架植入治疗合并左髂静脉受压综合征的急性下肢深静脉血栓形成

目的：评价经皮机械性血栓清除术联合同期髂静脉支架植入治疗合并左髂静脉受压综合征的急性下肢深静脉血栓（DVT）形成的可行性、安全性及有效性。 方法：选取2015年4月-2017年6月收治左髂静脉受压综合征伴急性下肢DVT的患者33例,发病时间6 h-14 d,平均年龄（57.97±14.44）岁。所有患者均在滤器保护下进行治疗。AngioJet血栓清除术、球囊扩张和髂静脉支架植入均在同期完成,术后保留鞘管予以溶栓治疗,每天复查造影,若血栓完全溶解,取出下腔静脉滤器并结束溶栓。术后第1、3、6、12个月进行门诊随访,行彩色超声和（或）下肢静脉造影检查了解下肢深静脉及髂支架内血流通畅情况。 结果：33例患者均同期完成手术,技术成功率100%,AngioJet抽吸时间为（224.70±72.78）s,溶栓时间（34.00±15.37）h,尿激酶用量（112.58±49.92）万U。33例患者同期植入髂静脉支架33枚。血栓清除率Ⅲ级患者29例,血栓清除率Ⅱ级患者4例。无出血、症状性肺栓等严重并发症发生。术后随访1例患者术后两月血栓复发,32例患者术后随访超声和（或）下肢静脉造影检查提示下肢深静脉及髂静脉支架内血流通畅。 结论：机械性血栓清除术联合同期髂静脉支架植入治疗合并左髂静脉受压综合征的急性下肢深静脉血栓形成是一种安全有效的方法。     

A new use of the Simpson percutaneous atherectomy catheter: Resection of retained valve cusps of an in-situ vein graft

Anin-situ saphenous vein graft occluded because of retained valve cusps. After aspiration thrombectomy, percutaneous transluminal balloon angioplasty was performed, but reocclusion occurred 11 months later. Following a second aspiration thrombectomy, the restenosed retained cusps were resected using the Simpson percutaneous atherectomy catheter. The graft remained patent until the patient’s death from unrelated causes 6 months later.     

机械性血栓清除装置治疗深静脉血栓的临床研究现状

相对于传统溶栓治疗,机械性血栓清除术具有即刻恢复血流、缩短溶栓时间、减少溶栓剂剂量等优势,是治疗深静脉血栓最有前景的方案。本文就目前临床常用于深静脉血栓治疗的机械性血栓清除装置进行综述如下。     

深静脉血栓的血管内溶栓治疗

通过对深静脉血栓的血管内溶栓治疗分析，提供一种有效的治疗静脉血栓的新方法。本组７例，左髂总静脉血栓４例，左髂外静脉２例，右髂外静脉１例，７例均先插管逆，顺行静脉造影确定血栓长度及病变程度。     

Therapeutic ultrasound for the recanalization of peripheral vascular occlusions]

Since the development of percutaneous transluminal angioplasty several techniques such as laser or atherectomy devices have been developed for recanalization of peripheral arterial occlusions. In a first clinical study we investigated if also the application of intravascular ultrasound can be useful for recanalization of occluded peripheral arteries. We applied an ultrasound angioplasty device (ACOLYSIS, ANGIOSONICS, USA) in a percutaneous approach in 8 patients with peripheral arterial occlusions (7 femoro-popliteal segments, 1 external iliac artery-occlusion). All patients suffered from severe leg ischemia due to subacute thrombotic occlusions. The ultrasound transmitter was introduced and advanced under fluoroscopic guidance to the site of the lesion. After activation the ultrasound transmitter was slowly advanced into the occlusion easily creating a channel within the occlusive material. Depending on the length of the occlusion (5-16 cm) treatment times ranged from 120-480 s. To further reduce the mass of the occlusive material an aspiration thrombectomy was performed in all cases leading to a complete recanalization in 6 cases. In 2 cases a remaining stenosis was successfully dilated. Intra-vascular ultrasonic devices can be useful for recanalization of occluded peripheral arteries. With the use of high-energy ultrasound a selective injury of the occlusive material can be induced without damaging the surrounding arterial wall. This selectivity is based on the differences in elasticity between the atherosclerotic plaque and the media layers. Especially if thrombolytic therapy of longer peripheral arterial occlusions fails or is contraindicated ultrasound angioplasty may be a new approach for recanalization.