Iliofemoral mechanical thrombolysis with AngioJet TM Chung Sim Lim, Stephen Black Guy’s and St Thomas’ NHS Foundation Trust London, UK
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