Thrombolysis, thromboaspiration, ultrasound thrombectomy: adjuncts techniques for aorto-iliac recanalization.

Transcription

1 Thrombolysis, thromboaspiration, ultrasound thrombectomy: adjuncts techniques for aorto-iliac recanalization. Dr. S. Schepers Dr. F. Van Elst Sint-Trudo Hospital Sint-Truiden Belgium

2 Chronic aorto-iliac occlusions Thrombolysis thrombectomy Laser Acute aorto-iliac occlusions Thrombolysis Aspiration thrombectomy Mechanical thrombectomy Ultrasoun thrombectomy

3 Chronic aorto-iliac occlusive disease

4 Chronic aorto-iliac occlusive disease Treatment evolved from surgical endarterectomy to surgical bypass grafting to endovascular treatment TASC A TASC D PTA Treatment decision: life expectancy age classification surgery co-morbidity previous procedures

5 Chronic aorto-iliac occlusive disease

6 Chronic aorto-iliac occlusive disease

7 Chronic aorto-iliac occlusive disease Thrombolysis and thrombectomy recent occlusion simplify occlusion by conversion into stenosis Laser chronic thrombus plaque dominant lesions definitive therapy! (PTA and/or surgery)

8 Chronic aorto-iliac occlusive 1. Thrombolysis disease dissolve the occluding thrombus restore perfusion identify underlying cause of arterial/graft occlusion convert major reconstruction to limited procedure lyse thrombi in distal arteries, restoring patency to outflow

9 2. Laser Chronic aorto-iliac occlusive disease pulse-light to minimize thermal injury slow progression continuous saline infusion to limit dissection

10 2. Laser Chronic oarto-iliac occlusive disease Percutaneous laser-assisted recanalization of long chronic iliac artery occlusions: primary and mid-term results. (Balzer et al Eur Radiol 2006 Feb) 46 chronic iliac occlusion (average lenght 57.1mm) laser and PTA results: primary technical success rate was 95.3%, with a major complication rate of 6.9% overall primary patency rate was 86.1% follow-up 4 year

11 Chronic aorto-iliac occlusive disease

12 Chronic aorto-iliac occlusive disease

13 Chronic aorto-iliac occlusive disease

14 Acute aorto-iliac occlusion

15 Acute aorto-iliac occlusion Risk of morbidity and mortality following open surgical intervention remains high (5 20%) Why? old patients high rate of cardiac and other co-morbidities

16 Acute aorto-iliac occlusion Need for less invasive intervention: Thrombolytic therapy Aspiration thrombectomy Mechanical thrombectomy (Ultrasound thrombectomy) +/- PTA and/or surgery!

17 Acute aorto-iliac occlusion Thrombolytic therapy Followed by definitive therapy to address the underlying lesion that caused the occlusion. If not: high risk early rethrombosis 3 clinical trials of thrombolytic therapy versus surgery - Rochester series -Surgery or Thrombolysis for the Ischemic Lower Extremity (STILE) trial -Thrombolysis Or Peripheral Arterial Surgery (TOPAS) trial

18 ROCHESTER series single center, 114 pt urokinase vs. surgery identical amputation rate different mortality rate due to perioperative cardiopulmonary complications

19 STILE trial 393 pt in 3 groups: rt-pa, urokinase or surgery finally 2 thrombolytic groups combined endpoints of amputation and death equivalent

20 STILE trial 2 subgroup analysis: native artery vs. bypass graft occlusion results: rate major amputation higher in native artery occlusions treated with thrombolysis (10% vs 0% after 1 year) lower amputation rate in bypass graft occlusions treated with thrombolysis Conclusion: thrombolysis may be of greatest benefit in patients with acute bypass occlusions of less than 14d

21 TOPAS trial 544 patients randomized to recombinant urokinase or surgery similar rate of amputationfree survival after 1 year conclusion: acute leg ischemia could be managed with thrombolysis achieving similar amputation and mortality rates but avoiding open surgical procedure

22 Acute aorto-iliac occlusion Thrombolysis: how to do it? contralateral approach infusion catheter several centimeters into thrombus (single end hole 3F or 4F) low-dose infusion - Urokinase concomitant heparine to prevent pericatheter thrombosis control angiogram at least every 12h patient monitoring hematologic control definitive therapy

23 Acute aorto-iliac occlusion Complications of thrombolysis bleeding (up to 10%) stroke (2%) distal embolisation (10%) National Audit of Thrombolysis for Acute Leg Ischemia (NATALI) database. (Br J Surgery 2003;90) > 1000 procedures results: amputation free survival rates of 75% at 30 days mortality rate of 12,5% amputation with survival rate of 12,5% high risk for amputation: female, diabetic, neurologic deficit, ischemic heart disease

24 Acute aorto-iliac occlusion Aspiration thrombectomy = removing small fragments of clot percutaneously - 6 to 8F catheter passed into the occlusion; 50ml syringe attached to the end of the catheter and aspirated at the time it is withdrawn through the occlusion - good result in selected patients with small emboli - acute occlusions in distal peripheral arteries, not in larger arterial branches like iliac vessels

25 Acute aorto-iliac occlusion Mechanical thrombectomy = breaking up thrombus within the vessel and aspirating it - expensive single-use equipment - only occlusions < 14 days - no comparative trials with surgery or thrombolysis - arterial damage, hematoma (large puncture wounds)

26 Acute aorto-iliac occlusion Mechanical thrombectomy 1. Amplatz thrombectomy device: - rotational forces to break up thrombus into tiny fragments that simply disperse within the circulation. - clinical significant embolization is rare

27 Acute aorto-iliac occlusion Mechanical thrombectomy 2. High-pressure saline jet device: - high-pressure saline jets to create a vortex at the catheter tip, so that thrombus is aspirated into a maceration chamber and then removed through a separate channel - AngioJet, Hydrolyser, Oasis - hazard that a great volume of blood can be lost during aspiration!

28 AngioJet Acute aorto-iliac occlusion

29 Acute aorto-iliac occlusion

30 Acute aorto-iliac occlusion

31 Acute aorto-iliac occlusion

32 Authors n Conduit, no (%) No (%), success Adjunctive lysis, no(%) Complications (%) Primary Patency (%) Müller- Hülsbeck et al 112 Native, 99 (86) Graft, 16 (14) 80 (71) 20 (18) Embolization (9.8) Dissection (8) Perforation (3.6) Amputation (1.8) Mortality (7) 6 mo (68) 2 yr (60) 3 yr (58) Silva et al 22 Native, 13 (59) Graft, 9 (41) 21 (95) None Hemorrhage (10) Embolism (9) Dissection (5) Occlusion (18) Amputation (5) Mortality (14) Not applicable Wagner et al 50 Native, 39 (78) Graft, 11 (22) 36 (52) 15 (30) Hemorrhage (6) Emboli (6) Dissection (6) Perforation (4) Amputation (8) 1 yr (69) Mortality (0) Kasirajan et al 86 Native, 52 (63) Graft, 31 (37) 70 (84) 50 (58) Hemorrhage (3.5) Embolism (2.3) Dissection (3.5) Perforation (2.3) Amputation (11.6) 6 mo (79)

33 Acute aorto-iliac occlusion Trellis system = mechanically assisted pharmacologic thrombolysis - drug dispersion and thrombectomy catheter - 2 balloons to isolate treatment zone and maintain thrombolytic agent locally - after inflation change guidewire for dispersion wire - aspirate thrombus after 15min - vessels 4 to 12mm

34 Acute aorto-iliac occlusion

35 Acute aort-iliac occlusions Trellis system: Sarac TP et al: Clinical and economic evaluation of the Trellis thrombectomy device for arterial occlusions: preliminary analysis. J Vasc Surg 2004; 39(3): patients treated results: 58% acute and 42% chronic occlusion 73% infra-inguinal and 27 supra-inguinal technical succes 92% 30-day amputation-free survival rate 96% no difference acute/chronic, infra/supra-inguinal conclusion: Early results suggests that it is as effective as traditional catheter-directed thrombolysis. Furthermore, there were no bleeding complications, likely the result of the Trellis device requiring shorter procedure and infusion times.

36 CONCLUSION (1) The practical management of aorto-iliac occlusions remains a challenge, as it involves one of the most complex decision pathways in vascular surgery. Thrombolysis and thrombectomy offers a less invasive approach to thrombotic occlusions, with the opportunity to address the unmasked, causative lesions directly. Correction of these lesions can often be accomplished through an endovascular approach such as PTA(S).

37 CONCLUSION (2) Even when after thrombolysis and/or thombectomy a bypass graft must be placed, the procedure can frequently be performed in an elective setting after adequate patient preparation. A successfull outcome depends upon an experienced team with access to the full range of available techniques, and the ability to use them appropriately in individually selected patients.