Iliofemoral mechanical thrombolysis with AngioJetTM

Chung Sim Lim, Stephen Black

Guy’s and St Thomas’ NHS Foundation Trust

London, UK

Thrombolysis of iliofemoral DVT

• Iliofemoral deep venous thrombosis (DVT) is a significant risk factor for developing post-thrombotic syndrome (PTS)

• Several clinical studies have reported that early removal of thrombus is likely to reduce the risk of developing / severity of PTS

• Mechanical thrombectomy

• Often use in combination with chemical thrombolysis (pharmacomechanical thrombolysis)

• Potential advantages in comparison with catheter-directed thrombolysis (CDT)

• Reduction in the amount of lytic agent used, hence decrease risk of bleeding

• Reduction of duration of treatment, angio suite use, hospital stay (hence likely to reduce cost and improve patient satisfaction)

• Improvement in efficiency of thrombus removal

• Reduction of venography and check lysis, hence decrease in radiation to patient and clinician

Garcia et al. J Vasc Interv Radiol 2015;26:777-785

Lin et al. Am J Surg 2006;192:782-788

Kim et al. 2006;29:1003-1007

AngioJet rheolytic thrombolysis

AngioJet rheolytic thrombolysis

• The AngioJet catheter uses the Bernoulli principle for thrombus removal

• Velocity increases – pressure decreases

Jet Tube

AngioJet rheolytic thrombolysis

• Mechanical +/- pharmacological thrombolysis

• Arterial, venous and AV fistula thrombolysis

• Several catheters with various specifications and indications • Solent PROXI/OMNI/DISTA• AVX• ZelanteDVT

AngioJet ZelanteDVT catheter

• For iliofemoral DVT – ZelanteDVTcatheter

• Modalities:• Rheolytic thrombectomy

• Rapid lysis

• Power pulse delivery

Specifications ZelanteDVT

Vessel Diameter > 6mm

Working Length 105cm

Shaft Diameter 8F *

OTW 0.035”

Double Marker Band 15 mm

Maximum run time 8 min

Max run time with blood flow: 4 min

Flow Rate 60 ml/min

Power Pulse delivery 0.6ml per stroke

Introducer Sheath 8F*

Number of Main Jets 5

Catalogue Number 114610

GTIN: 08714729904731

Shelf Life 2 Years

AngioJet ZelanteDVT catheter

Power pulse delivery

• Power pulse delivery• Deliver a dose of lytic agent to thrombus

(e.g. 5-20 mg tPA)

• Await 20 minutes for lytic agent to act

• AngioJet thrombectomy

AngioJet ZelanteDVT catheter

Several strategies including• Rheolytic (mechanical) thrombolysis only (without lytic agent) (RT)

• Pharmacomechanical catheter-directed thrombolysis (PCDT)

• A combination of PCDT/RT + CDT

• No one strategy is better than another; case selection is important

• 32 sites in USA and Europe (329 cases)

• Overall freedom from rethrombosis rate:

• 94% (3 months)

• 87% (6 months)

• 83% (12 months)

• Major bleeding event 3.6% (“none related to AngioJet”)

• Conclusion: Safe and effective; potentially reduce the need for concomitant CDT and intensive care

Strategy Percentage of cases (%)

Median procedure time (hours)

RT only 4 1.4

PCDT 35 2

PCDT + CDT 52 22

RT + CDT 9 41

J Vasc Interv Radiol 2015;26:777-785

• Retrospective analysis

• Comparing direct (n=46) versus staged (n=45) iliofemoral stenting following AngioJet rheolytic thrombectomy

Conclusion: Both direct and staged stenting are effective treatment modalities for patients with acute

proximal DVT. Compared with staged stenting, direct stenting provides similar treatment success and

a significant reduction in the length of hospital stay; however, it has lower thrombolysis efficacy, and

the risk of PTS at 1 year is greater with direct stenting.

AngioJet ZelanteDVT catheter

• Some of our common practices

• We use a combination of strategies (CDT / PCDT / PCDT + CDT / mechanical alone)

• Routinely use intravascular ultrasound (IVUS) • Help to target areas of thrombus that need more

thrombolysis

AngioJet ZelanteDVT catheter

• Cautions• Bradycardia and hypotension during thrombolysis

• Likely due to haemolysis• Cardiac monitor (with anaesthetist)• Pause temporarily – self limiting

• Renal impairment / haematuria• Likely due to haemolysis• Well hydration pre-, peri- and post-procedure• Monitor renal function post procedure

• Follow IFU – maximum run-time with blood = 240 seconds

• We DO NOT routinely (and DO NOT recommend) use IVC filter

Case study

• 40 year old woman

• Known Factor V Leiden; no previous DVT; otherwise fit and well

• Presented with few days history of left leg pain and swelling

• Duplex ultrasonography and magnetic resonance venography confirmed left iliofemoral DVT

• Started treatment dose low molecular weight heparin, compression and analgesia

Day 1

Venography via left popliteal vein puncture

Multi-lumen infusion catheter across thrombus

Started CDT – 0.5mg/hour of tPA

Monitored in high dependency unit

Day 2

12 – 24 hours post CDT

Under general anaesthetics

Day 2

Intravascular ultrasound

Inferior vena cava (IVC)

Day 2

Intravascular ultrasound

Common iliac vein

Day 2

Intravascular ultrasound

External iliac vein

Day 2

Intravascular ultrasound

Common and profunda femoral vein

Day 2

AngioJet rheolytic (mechanical) thrombolysis

Day 2

Post AngioJet rheolytic (mechanical) thrombolysis

Day 2

Balloon venoplasty (16 mm diameter Atlas Gold)

Day 2

Iliac vein stent

Veniti 16 mm x 120 mm

Post stent venoplasty

Day 2

• Final venography

Conclusions

• AngioJet rheolytic thrombolysis is safe and effective for treatment of iliofemoral DVT

• AngioJet potentially reduces lytic agent dosage (hence less bleeding risk), venography, and hospital stay (hence possibly radiation dose and cost)

• Various strategies can be used (RT only; PCDT; a combination of RT/PCDT + CDT). Case selection is important

• However, longer term data is still needed; and further studies to optimisethe strategies of AngioJet, as well as comparing various mechanical thrombolysis methods are needed