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Laser-Assisted Venous Thrombectomy for Treatment of Recurrent In-Stent Restenosis and Superior Vena Cava Syndrome
Volume 27
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Number 4
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April
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2016
can induce periurethral prostate necrosis with desquamation, fragmentation, and passage into the urethra.
REFERENCES 1. Pisco JM, Rio Tinto H, Campos Pinheiro L, et al. Embolisation of prostatic arteries as treatment of moderate to severe lower urinary symptoms (LUTS) secondary to benign hyperplasia: results of short- and mid-term follow-up. Eur Radiol 2013; 23:2561–2572. 2. Camara-Lopes G, Mattedi R, Antunes AA, et al. The histology of prostate tissue following prostatic artery embolization for the treatment of benign prostatic hyperplasia. Int Braz J Urol 2013; 39: 222–227. 3. Bilhim T, Pisco JM, Rio Tinto H, et al. Prostatic arterial supply: anatomic and imaging findings relevant for selective arterial embolization. J Vasc Interv Radiol 2012; 23:1403–1415.
Laser-Assisted Venous Thrombectomy for Treatment of Recurrent In-Stent Restenosis and Superior Vena Cava Syndrome From: Osman Ahmed, MD William T. Kuo, MD Department of Radiology, Division of Interventional Radiology Stanford Hospital and Clinics 300 Pasteur Drive, Room H3630, MC: 5642 Stanford, CA 94305-5642
Editor: We report a new technique using laser-assisted venous thrombectomy to treat severe in-stent restenosis (ISR) in a patient with recurrent central venous occlusion and superior vena cava (SVC) syndrome. The patient was prospectively enrolled in a study approved by the institutional review board. The patient was a 39-yearold woman with a history of end-stage renal disease and left brachiobasilic arteriovenous fistula who presented with recurrent head and neck swelling and prominent chest wall veins. She developed central venous occlusion several years earlier after multiple dialysis catheter placements and was treated with SVC and bilateral brachiocephalic vein (BCV) stent placement at an outside hospital. Over the next 4 years, she underwent five additional procedures, including repeat left BCV stent placement and angioplasty of ISR to treat the remaining central venous stents. The most recent procedure was performed 1 month before her referral. At the time of presentation, a computed tomography (CT) venogram revealed high-grade ISR of the right BCV and SVC stents. Given her extensive history and recent intervention for ISR only 1 month before, an alternative method for treatment was sought. Neither of the authors has identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.12.015
603
Using a right internal jugular vein approach, a 9-F PINNACLE sheath (Terumo, Tokyo, Japan) was placed into the SVC. A central venogram was obtained, demonstrating high-grade stenosis along the right BCV and SVC stents (Fig 1a). Using a right femoral approach, an 11-F PINNACLE sheath (Terumo) was placed, and through-and-through access was obtained after a snare was used to capture the guide wire. A 10MHz intravascular ultrasound (IVUS) catheter (Volcano Corporation, San Diego, California) was used to scan the right BCV and SVC stents, confirming severe ISR with a minimum lumen diameter of 3 mm. A parallel wire was inserted through the jugular access, and the neck sheath was exchanged for a 9-F curved-tip Flexor sheath (Cook, Inc, Bloomington, Indiana). Through this sheath, a 2.5 mm 112 cm Turbo-Elite laser ablation catheter (Spectranetics Corporation, Colorado Springs, Colorado) was inserted. The wire through the ablation catheter was retracted to allow catheter tip deflection using the curved sheath. Under IVUS guidance from the femoral sheath, tissue ablation was carefully performed by rotating the curved-tip jugular sheath to torque and direct the laser catheter tip against the stenotic areas (Fig 2). Subsequently, from the femoral access, an 8 mm 4 cm CONQUEST balloon (Bard Peripheral Vascular, Inc, Tempe, Arizona) was inflated parallel to the laser catheter to increase apposition of the laser tip against deeper tissue within the stent (Fig 3), and further rotational thrombectomy was performed. Subsequent IVUS confirmed effective circumferential tissue ablation with only residual nonocclusive synechiae. A 12 mm 6 cm ATLAS balloon (Bard Peripheral Vascular, Inc) was inflated to disrupt the residual synechiae. A final venogram showed restoration of patency through the stents (Fig 1b). No complication was observed. The patient was discharged the same day after reinitiating warfarin (Coumadin) therapy for anticoagulation. At the 2-week clinical follow-up examination, her SVC symptoms had completely resolved. A follow-up CT venogram obtained at 6 months demonstrated stent patency compared with the CT venogram obtained before the procedure (Fig 4a, b), and a follow-up clinic visit at 15 months revealed no signs of recurrence with respect to head and neck swelling or chest wall collateral veins. At the present time, the standard treatment options for patients who develop severe ISR include repeat balloon angioplasty or additional stent placement (1). However, despite repeated interventions, restenosis may still occur, as observed in the present case. Additionally, repeat stent placement after failed angioplasty or failed primary stent placement does not remove the occlusive tissue, potentially limiting the ability to achieve optimal vessel diameter. Furthermore, extension of an existing stent with a new stent still predisposes the vessel to recurrent edge stenosis (2).
604
’
Letters to the Editor
Ahmed and Kuo
’
JVIR
Figure 1. (a) Initial digital subtraction venogram of the right BCV and SVC demonstrates high-grade ISR of the BCV (solid arrows) and SVC (dashed arrows) stents. (b) After thrombectomy, repeat venogram shows improved stent patency with approximately 50% increase in luminal caliber of BCV (solid arrows) and SVC (dashed arrows) stents.
Although laser-assisted thrombectomy is well described in the arterial circulation (3), its use in venous-based interventions has not been reported. The use of the excimer laser recently gained US Food and Drug Administration and European CE Mark approval for treating ISR in arterial stents (4), but no labeled indication or data exist for treating restenosis in venous stents. Because the Turbo-Elite catheter is currently designed for relatively smaller arterial vessel diam-
eters, a combination of parallel balloon inflation and a curved sheath introducer was used in the present study to maximize contact of the laser catheter tip against stenotic areas within the large venous stents. We believe these maneuvers allowed better circumferential ablation within the stent. It was also observed that IVUS could help guide the laser catheter for effective ablation and to confirm treatment of these regions in real time. The lack of major complications was attributed
Volume 27
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Number 4
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April
’
2016
Figure 2. Spot fluoroscopic image shows laser-assisted thrombectomy within the BCV stent with simultaneous IVUS guidance. Rotation of a transjugular curved sheath (top arrow) containing the laser catheter allows steering of the catheter tip (middle arrow) toward the stenotic lesions. A transfemoral IVUS probe (bottom arrow) is placed parallel to the laser catheter tip to allow direct visualization and monitoring during tissue ablation.
605
Figure 3. Spot fluoroscopic image demonstrates placement and inflation of a parallel 8-mm balloon (asterisk) to increase apposition of the laser catheter tip (arrow) against deeper, chronic tissue along the stent.
Figure 4. Axial CT venograms obtained before (a) and 6 months after (b) laser-assisted venous thrombectomy. (a) Before intervention, there is high-grade stenosis within the BCV stent (arrow). (b) At 6 months after intervention, the stent remains widely patent (arrow).
606
’
Letters to the Editor
to keeping the catheter within the stent margins during laser activation, as the metal stent protected against vessel perforation. In conclusion, laser-assisted venous thrombectomy appears to be a useful technique for treating ISR, particularly in patients who are refractory to standard endovascular treatment.
REFERENCES 1. Kundu S. Review of central venous disease in hemodialysis patients. J Vasc Interv Radiol 2010; 21:963–968. 2. Van Tricht I, De Wachter D, Tordoir J, Verdonck P. Hemodynamics and complications encountered with arteriovenous fistulas and grafts as vascular access for hemodialysis: a review. Ann Biomed Eng 2005; 33: 1142–1157. 3. Schmidt A, Zeller T, Sievert H, et al. Photoablation using the turbobooster and excimer laser for in-stent restenosis treatment: twelve-month results from the PATENT study. J Endovasc Ther 2014; 21:52–60. 4. Dippel EJ, Makam P, Kovach, et al; EXCITE ISR Investigators.Randomized controlled study of excimer laser atherectomy for treatment of femoropopliteal in-stent restenosis: initial results from the EXCITE ISR trial (EXCImer Laser Randomized Controlled Study for Treatment of FemoropopliTEal In-Stent Restenosis). JACC Cardiovasc Interv 2015; 8:92–101.
Intraprocedural Foot Embolization during In-Stent Restenosis Superficial Femoral Artery Recanalization: Plantar to Pedal Loop Aspiration Thrombectomy Technique Using the Penumbra MAX Catheter From: Roberto Gandini, PhD Stefano Merolla, MD Fabrizio Chegai, MD Giovanni Pratesi, PhD Sergio Abrignani, MD Giorgio Loreni, MD Chiara A. Pistolese, MD Enrico Pampana, MD Department of Diagnostic Imaging, Interventional Radiology, Radiotherapy and Nuclear Medicine (R.G., S.M., F.C., S.A., G.L., C.A.P., E.P.) and Department of Biomedicine and Prevention, Unit of Vascular Surgery (G.P.) IRCCS Fondazione Policlinico di Tor Vergata Rome 00133, Italy
Editor: We report results of successful thromboaspiration of distal foot embolization that occurred as a result of a recanalization procedure of a superficial femoral artery occlusion from in-stent restenosis despite the use of an embolic protection device. An 84-year-old man with a history of cardiovascular disease, hyperlipidemia, and R.G. and E.P. are paid consultants for Penumbra, Inc (Alameda, California). None of the other authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.12.020
Gandini et al
’
JVIR
hypertension presented with a 4-week history of gradually increasing severe claudication and nocturnal rest pain. Computed tomography angiography demonstrated occlusion of a stent that had been implanted 5 years before in the right superficial femoral artery and popliteal artery segments P1 and P2, with patent distal runoff. In accordance with local institutional guidelines, institutional review board approval was not required for this report. The patient was treated with dual antiplatelet therapy (acetylsalicylic acid 100 mg/d and clopidogrel 75 mg/d) for 3 days before the intervention, and an adequate amount of intravenous heparin was administered during the procedure to maintain an activated clotting time 4 250 seconds. Initial angiography confirmed occlusion of the superficial femoral artery and P1 and P2 segments with a patent P3 segment and visualization of foot circulation. Given the uncertain age and composition of the occlusion and to protect downstream circulation, a 6-mm SpiderFX Embolic Protection Device (ev3 Inc, Plymouth, Minnesota) was deployed in the distal popliteal artery. Afterward the lesion was traversed and sequentially dilated with 4-mm (Amphirion Deep; Medtronic Invatec, Frauenfeld, Switzerland) and 6-mm (Mustang Balloon Dilatation Catheter; Boston Scientific, Marlborough, Massachusetts) balloons. On removal, the filter had organized clots and thrombotic debris trapped inside. Further control angiography showed recanalization of the occluded stent, patency of the peroneal artery up to its middle third, and occlusion of both posterior and anterior tibial arteries (Fig a), but without visualization of foot circulation, which was previously present. To quickly restore blood flow in at least one belowthe-knee vessel, the posterior tibial artery and the anterior tibial artery up to their distal third were immediately catheterized with a 6-F 401 90-cm-long guide catheter (Mach 1 Guide Catheter; Boston Scientific). Using the guide catheter, a manual aspiration thrombectomy was also performed up to the ankle (Fig b, arrow). However, injection of contrast medium directly into the anterior tibial artery showed the presence of an occluding calcified clot in the dorsalis pedis (Fig c, arrow). Because the guide catheters and other available aspiration devices were too large and stiff to access the distal vessels in the foot, we elected to use the Penumbra 3 MAX neurovascular aspiration catheter (Penumbra, Inc, Alameda, California). The Penumbra 3 MAX aspiration catheter was introduced over the guide wire to the dorsalis pedis artery with a plantar to pedal loop technique and advanced past the clot. When the aspiration catheter engaged the thrombus, the guide wire was removed, and the Penumbra aspiration pump system, which was connected directly to the hub of the Penumbra aspiration catheter, was turned on (Fig d). Recanalization of both tibial arteries was obtained after only one pass, without the use of a Penumbra separator or adjunctive catheter-directed thrombolysis.
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Number 4
’
April
’
2016
can induce periurethral prostate necrosis with desquamation, fragmentation, and passage into the urethra.
REFERENCES 1. Pisco JM, Rio Tinto H, Campos Pinheiro L, et al. Embolisation of prostatic arteries as treatment of moderate to severe lower urinary symptoms (LUTS) secondary to benign hyperplasia: results of short- and mid-term follow-up. Eur Radiol 2013; 23:2561–2572. 2. Camara-Lopes G, Mattedi R, Antunes AA, et al. The histology of prostate tissue following prostatic artery embolization for the treatment of benign prostatic hyperplasia. Int Braz J Urol 2013; 39: 222–227. 3. Bilhim T, Pisco JM, Rio Tinto H, et al. Prostatic arterial supply: anatomic and imaging findings relevant for selective arterial embolization. J Vasc Interv Radiol 2012; 23:1403–1415.
Laser-Assisted Venous Thrombectomy for Treatment of Recurrent In-Stent Restenosis and Superior Vena Cava Syndrome From: Osman Ahmed, MD William T. Kuo, MD Department of Radiology, Division of Interventional Radiology Stanford Hospital and Clinics 300 Pasteur Drive, Room H3630, MC: 5642 Stanford, CA 94305-5642
Editor: We report a new technique using laser-assisted venous thrombectomy to treat severe in-stent restenosis (ISR) in a patient with recurrent central venous occlusion and superior vena cava (SVC) syndrome. The patient was prospectively enrolled in a study approved by the institutional review board. The patient was a 39-yearold woman with a history of end-stage renal disease and left brachiobasilic arteriovenous fistula who presented with recurrent head and neck swelling and prominent chest wall veins. She developed central venous occlusion several years earlier after multiple dialysis catheter placements and was treated with SVC and bilateral brachiocephalic vein (BCV) stent placement at an outside hospital. Over the next 4 years, she underwent five additional procedures, including repeat left BCV stent placement and angioplasty of ISR to treat the remaining central venous stents. The most recent procedure was performed 1 month before her referral. At the time of presentation, a computed tomography (CT) venogram revealed high-grade ISR of the right BCV and SVC stents. Given her extensive history and recent intervention for ISR only 1 month before, an alternative method for treatment was sought. Neither of the authors has identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.12.015
603
Using a right internal jugular vein approach, a 9-F PINNACLE sheath (Terumo, Tokyo, Japan) was placed into the SVC. A central venogram was obtained, demonstrating high-grade stenosis along the right BCV and SVC stents (Fig 1a). Using a right femoral approach, an 11-F PINNACLE sheath (Terumo) was placed, and through-and-through access was obtained after a snare was used to capture the guide wire. A 10MHz intravascular ultrasound (IVUS) catheter (Volcano Corporation, San Diego, California) was used to scan the right BCV and SVC stents, confirming severe ISR with a minimum lumen diameter of 3 mm. A parallel wire was inserted through the jugular access, and the neck sheath was exchanged for a 9-F curved-tip Flexor sheath (Cook, Inc, Bloomington, Indiana). Through this sheath, a 2.5 mm 112 cm Turbo-Elite laser ablation catheter (Spectranetics Corporation, Colorado Springs, Colorado) was inserted. The wire through the ablation catheter was retracted to allow catheter tip deflection using the curved sheath. Under IVUS guidance from the femoral sheath, tissue ablation was carefully performed by rotating the curved-tip jugular sheath to torque and direct the laser catheter tip against the stenotic areas (Fig 2). Subsequently, from the femoral access, an 8 mm 4 cm CONQUEST balloon (Bard Peripheral Vascular, Inc, Tempe, Arizona) was inflated parallel to the laser catheter to increase apposition of the laser tip against deeper tissue within the stent (Fig 3), and further rotational thrombectomy was performed. Subsequent IVUS confirmed effective circumferential tissue ablation with only residual nonocclusive synechiae. A 12 mm 6 cm ATLAS balloon (Bard Peripheral Vascular, Inc) was inflated to disrupt the residual synechiae. A final venogram showed restoration of patency through the stents (Fig 1b). No complication was observed. The patient was discharged the same day after reinitiating warfarin (Coumadin) therapy for anticoagulation. At the 2-week clinical follow-up examination, her SVC symptoms had completely resolved. A follow-up CT venogram obtained at 6 months demonstrated stent patency compared with the CT venogram obtained before the procedure (Fig 4a, b), and a follow-up clinic visit at 15 months revealed no signs of recurrence with respect to head and neck swelling or chest wall collateral veins. At the present time, the standard treatment options for patients who develop severe ISR include repeat balloon angioplasty or additional stent placement (1). However, despite repeated interventions, restenosis may still occur, as observed in the present case. Additionally, repeat stent placement after failed angioplasty or failed primary stent placement does not remove the occlusive tissue, potentially limiting the ability to achieve optimal vessel diameter. Furthermore, extension of an existing stent with a new stent still predisposes the vessel to recurrent edge stenosis (2).
604
’
Letters to the Editor
Ahmed and Kuo
’
JVIR
Figure 1. (a) Initial digital subtraction venogram of the right BCV and SVC demonstrates high-grade ISR of the BCV (solid arrows) and SVC (dashed arrows) stents. (b) After thrombectomy, repeat venogram shows improved stent patency with approximately 50% increase in luminal caliber of BCV (solid arrows) and SVC (dashed arrows) stents.
Although laser-assisted thrombectomy is well described in the arterial circulation (3), its use in venous-based interventions has not been reported. The use of the excimer laser recently gained US Food and Drug Administration and European CE Mark approval for treating ISR in arterial stents (4), but no labeled indication or data exist for treating restenosis in venous stents. Because the Turbo-Elite catheter is currently designed for relatively smaller arterial vessel diam-
eters, a combination of parallel balloon inflation and a curved sheath introducer was used in the present study to maximize contact of the laser catheter tip against stenotic areas within the large venous stents. We believe these maneuvers allowed better circumferential ablation within the stent. It was also observed that IVUS could help guide the laser catheter for effective ablation and to confirm treatment of these regions in real time. The lack of major complications was attributed
Volume 27
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Number 4
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April
’
2016
Figure 2. Spot fluoroscopic image shows laser-assisted thrombectomy within the BCV stent with simultaneous IVUS guidance. Rotation of a transjugular curved sheath (top arrow) containing the laser catheter allows steering of the catheter tip (middle arrow) toward the stenotic lesions. A transfemoral IVUS probe (bottom arrow) is placed parallel to the laser catheter tip to allow direct visualization and monitoring during tissue ablation.
605
Figure 3. Spot fluoroscopic image demonstrates placement and inflation of a parallel 8-mm balloon (asterisk) to increase apposition of the laser catheter tip (arrow) against deeper, chronic tissue along the stent.
Figure 4. Axial CT venograms obtained before (a) and 6 months after (b) laser-assisted venous thrombectomy. (a) Before intervention, there is high-grade stenosis within the BCV stent (arrow). (b) At 6 months after intervention, the stent remains widely patent (arrow).
606
’
Letters to the Editor
to keeping the catheter within the stent margins during laser activation, as the metal stent protected against vessel perforation. In conclusion, laser-assisted venous thrombectomy appears to be a useful technique for treating ISR, particularly in patients who are refractory to standard endovascular treatment.
REFERENCES 1. Kundu S. Review of central venous disease in hemodialysis patients. J Vasc Interv Radiol 2010; 21:963–968. 2. Van Tricht I, De Wachter D, Tordoir J, Verdonck P. Hemodynamics and complications encountered with arteriovenous fistulas and grafts as vascular access for hemodialysis: a review. Ann Biomed Eng 2005; 33: 1142–1157. 3. Schmidt A, Zeller T, Sievert H, et al. Photoablation using the turbobooster and excimer laser for in-stent restenosis treatment: twelve-month results from the PATENT study. J Endovasc Ther 2014; 21:52–60. 4. Dippel EJ, Makam P, Kovach, et al; EXCITE ISR Investigators.Randomized controlled study of excimer laser atherectomy for treatment of femoropopliteal in-stent restenosis: initial results from the EXCITE ISR trial (EXCImer Laser Randomized Controlled Study for Treatment of FemoropopliTEal In-Stent Restenosis). JACC Cardiovasc Interv 2015; 8:92–101.
Intraprocedural Foot Embolization during In-Stent Restenosis Superficial Femoral Artery Recanalization: Plantar to Pedal Loop Aspiration Thrombectomy Technique Using the Penumbra MAX Catheter From: Roberto Gandini, PhD Stefano Merolla, MD Fabrizio Chegai, MD Giovanni Pratesi, PhD Sergio Abrignani, MD Giorgio Loreni, MD Chiara A. Pistolese, MD Enrico Pampana, MD Department of Diagnostic Imaging, Interventional Radiology, Radiotherapy and Nuclear Medicine (R.G., S.M., F.C., S.A., G.L., C.A.P., E.P.) and Department of Biomedicine and Prevention, Unit of Vascular Surgery (G.P.) IRCCS Fondazione Policlinico di Tor Vergata Rome 00133, Italy
Editor: We report results of successful thromboaspiration of distal foot embolization that occurred as a result of a recanalization procedure of a superficial femoral artery occlusion from in-stent restenosis despite the use of an embolic protection device. An 84-year-old man with a history of cardiovascular disease, hyperlipidemia, and R.G. and E.P. are paid consultants for Penumbra, Inc (Alameda, California). None of the other authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.12.020
Gandini et al
’
JVIR
hypertension presented with a 4-week history of gradually increasing severe claudication and nocturnal rest pain. Computed tomography angiography demonstrated occlusion of a stent that had been implanted 5 years before in the right superficial femoral artery and popliteal artery segments P1 and P2, with patent distal runoff. In accordance with local institutional guidelines, institutional review board approval was not required for this report. The patient was treated with dual antiplatelet therapy (acetylsalicylic acid 100 mg/d and clopidogrel 75 mg/d) for 3 days before the intervention, and an adequate amount of intravenous heparin was administered during the procedure to maintain an activated clotting time 4 250 seconds. Initial angiography confirmed occlusion of the superficial femoral artery and P1 and P2 segments with a patent P3 segment and visualization of foot circulation. Given the uncertain age and composition of the occlusion and to protect downstream circulation, a 6-mm SpiderFX Embolic Protection Device (ev3 Inc, Plymouth, Minnesota) was deployed in the distal popliteal artery. Afterward the lesion was traversed and sequentially dilated with 4-mm (Amphirion Deep; Medtronic Invatec, Frauenfeld, Switzerland) and 6-mm (Mustang Balloon Dilatation Catheter; Boston Scientific, Marlborough, Massachusetts) balloons. On removal, the filter had organized clots and thrombotic debris trapped inside. Further control angiography showed recanalization of the occluded stent, patency of the peroneal artery up to its middle third, and occlusion of both posterior and anterior tibial arteries (Fig a), but without visualization of foot circulation, which was previously present. To quickly restore blood flow in at least one belowthe-knee vessel, the posterior tibial artery and the anterior tibial artery up to their distal third were immediately catheterized with a 6-F 401 90-cm-long guide catheter (Mach 1 Guide Catheter; Boston Scientific). Using the guide catheter, a manual aspiration thrombectomy was also performed up to the ankle (Fig b, arrow). However, injection of contrast medium directly into the anterior tibial artery showed the presence of an occluding calcified clot in the dorsalis pedis (Fig c, arrow). Because the guide catheters and other available aspiration devices were too large and stiff to access the distal vessels in the foot, we elected to use the Penumbra 3 MAX neurovascular aspiration catheter (Penumbra, Inc, Alameda, California). The Penumbra 3 MAX aspiration catheter was introduced over the guide wire to the dorsalis pedis artery with a plantar to pedal loop technique and advanced past the clot. When the aspiration catheter engaged the thrombus, the guide wire was removed, and the Penumbra aspiration pump system, which was connected directly to the hub of the Penumbra aspiration catheter, was turned on (Fig d). Recanalization of both tibial arteries was obtained after only one pass, without the use of a Penumbra separator or adjunctive catheter-directed thrombolysis.