Introduction

Percutaneous thrombectomy was introduced over

10 years ago and refers to the removal of acute throm-
bus using non-surgical methods [1, 2]. Thrombectomy is
achieved by thrombus dissolution, thrombus fragmen-
tation, aspiration of thrombus or a combination of these
methods. Percutaneous thrombectomy techniques can
be broadly divided into percutaneous aspiration
thombectomy (PAT) in which thrombus is aspirated
through catheters, and mechanical thrombectomy (MT)
procedures, which involve maceration of thrombus or
fragmentation and removal of thrombus. Mechanical
thrombectomy usually involves specialized devices,
whereas aspiration thrombectomy can be achieved with
catheters and guidewires available in most interven-
tional radiology suites.
Percutaneous thrombectomy can be a primary
procedure in which the operator sets out to clear
the occluded vessel by percutaneous thrombectomy
alone, or in combination with transcatheter throm-
bolysis.
Percutaneous thrombectomy can be used to remove
thrombus from arteries, veins or vascular grafts. Similar
to thrombolysis, thrombectomy is relatively ineffective if
the thrombus is organized and best results are obtained
in acute occlusions of less than two weeks duration.
When the concept of mechanical thrombectomy
(MT) was first introduced, it was hoped that MT would
obviate the need for thrombolysis in many cases. While
this is undoubtedly true for some applications such as
haemodialysis fistulae, thrombolysis is still the main
method used to remove thrombus in a substantial pro-
portion of procedures. With increasing experience and
refinements in the designs of the devices themselves, the
role of MT is becoming better defined [3, 4, 5].
Indications
Arteries
The main indications for thrombectomy in the arterial
system include: (a) removal of acute emboli from the
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Eur. Radiol. (2002) 12:205217
DOI 10.1007/s003300101014
VASCULAR- INTERVENTIONAL
Robert Morgan
Anna-Maria Belli
Percutaneous thrombectomy: a review
Received: 7 May 2001
Accepted: 21 May 2001
Published online: 26 July 2001
Springer-Verlag 2001
R. Morgan (
)
) A.-M. Belli
Department of Vascular Radiology,
St. George's Hospital, Blackshaw Road,
London SW17 0QT, UK
E-mail: robert.morgan@stgeorges.nhs.uk
Phone: +44-20-87251076
Fax: +44-20-87252936
Abstract Percutaneous thrombec-
tomy (PT) is an established tech-
nique for the removal of acute
thrombus in occluded arteries, veins
and vascular grafts. Percutaneous
thrombectomy can be used as an
adjunctive treatment to other meth-
ods of thrombus removal such as
thrombolysis or as sole therapy. The
two main methods are percutaneous
aspiration thrombectomy in which
thrombus is removed by suction
with the aid of wide-bore catheters,
and mechanical thrombectomy us-
ing a variety of automated devices to
fragment or remove thrombus. As-
piration thrombectomy is often used
as an adjunct to thrombolysis in
acute arterial occlusion, or as sal-
vage therapy to remove distal em-
boli following iliac or femo-
ropopliteal angioplasty. Mechanical
thrombectomy is useful for the
treatment of thrombosed dialysis
grafts and is being increasingly used
for the treatment of massive pulmo-
nary emboli and ileofemoral or
ileocaval deep venous thromboses.
Keywords Thrombectomy
Arteries Thrombosis Veins
Grafts Interventional procedure
Stenosis or thrombosis
Thrombolysis
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distal circulation following angioplasty or stent proce-
dures; (b) the removal of de novo emboli from the distal
circulation; (c) the clearance of thrombus from acutely
occluded vascular grafts; and (d) the clearance of
thrombus from acute native vessel occlusions. Percuta-
neous thrombectomy is usually performed in the lower
extremity arteries, although it can also be used in upper
extremity and visceral arteries.
Veins
The main indications for percutaneous thrombectomy
in the venous system are the treatment of: (a) acute
ileocaval thrombosis; (b) ileofemoral vein thrombosis;
(c) acute superior vena cava thrombosis; and (d) re-
moval or fragmentation of massive pulmonary emboli
(PE) in severely ill patients.
Dialysis grafts
One of the main roles of percutaneous thrombectomy in
recent years has been the treatment of acutely throm-
bosed dialysis grafts, particularly prosthetic dialysis
grafts.
Contraindications
Percutaneous thrombectomy should not generally be
performed if removal of thrombus cannot be achieved
safely. Thrombectomy should not be performed across
the aortic bifurcation from the contralateral femoral ar-
tery, because of the risk of passing embolic material into
the ipsilateral normal circulation.
Equipment
Aspiration thrombectomy
The equipment required for this technique is relatively
simple and consists of a thin-walled guiding catheter
(e.g. Britetip, Cordis, Ascot, Berkshire, UK), a vascu-
lar sheath with a removable hemostatic valve (William
Cook, Europe, Bjaeverstock, Denmark), and a 50-ml
syringe with a luer lock connector. The removable
haemostatic valve is necessary to prevent retention of
aspirated thrombus within the sheath upon removal
from the artery. Aspiration catheters are available in
straight versions and with a variety of shaped-tip con-
figurations. The thin wall of the aspiration catheter
ensures the maximum internal luminal diameter for
aspiration of thrombus. Aspiration catheters are
available in sizes from 6 to 10 F, but aspiration via
4- or 5-F catheters can be performed in the tibial circu-
lation.
Mechanical thrombectomy devices
In the past decade there have been many types of
thrombectomy catheter produced for use in the coro-
nary and peripheral circulations. These devices have all
been designed to achieve rapid clearance of acute oc-
clusions in arteries, bypass grafts and veins, and avoid
the morbidity and increased procedural time required
for thrombolysis. Some designs have met with clinical
success and remain on the market. Many others have
been withdrawn because of poor performance. The de-
vices most commonly used in current practice are de-
scribed below.
The MT devices can be broadly divided into two
categories:
1. Hydrodynamic recirculation devices. The method of
action of these devices is dependent on the Venturi
effect produced by retrogradely directed high-speed
saline jets. Local thrombus is sucked into the aper-
ture of the device and macerated by the high local
shear forces. Removal of the products of fragmenta-
tion is usually accomplished by an exhaust lumen in
the device. Examples include the Hydrolyser device
and the Oasis system.
2. Rotational recirculation devices. These devices pro-
duce clot fragmentation by production of a hydrody-
namic vortex, which is created by a high-speed rotat-
ing impeller or basket. Examples include the Am-
platz thrombectomy device and the Arrow-Trerotola
PTD.
There are many devices available and new ones are un-
der development. The most commonly used devices are
described below. Devices which utilize saline injection
are usually powered by standard angiographic pump in-
jectors. Purely mechanical devices are usually supplied
with a motor.
Hydrolyser system
The Hydrolyser system (Cordis, Johnson and Johnson,
Miami, Fla.) is a hydrodynamic mechanical thrombec-
tomy device and has been in clinical use since 1993. It
consists of a 6- or 7-F double-lumen, 65-cm-long cathe-
ter with a 6-mm oval side hole 4 mm from the distal tip.
The smaller-injection lumen ends in a hairpin loop at
the device tip. Heparinized saline is injected through the
injection lumen by an angiographic pump at a rate of
3 mls/s at 750 psi and is directed by the hairpin loop
retrogradely into the exhaust lumen. At the site of the
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oval side window this saline jet creates a local reduction
in pressure (Venturi effect) which sucks adjacent
thrombus into the hole and disrupts it. The thrombus
fragments are carried away in the exhaust lumen by the
reversed saline flow and collected in a vacuum bag. The
system can be used over a 0.025-in. guidewire and in-
troduced through a 7-F sheath.
Oasis thrombectomy system
The Oasis thrombectomy system (Boston Scientific,
Galway, Ireland) is similar to the Hydrolyser catheter
and is available in 6-, 8- and 10-F sizes, and 65- and
100-cm lengths, and accepts an 0.018-in. guidewire. The
device consists of two lumens in addition to the guide-
wire lumen. A jet of heparinized saline is directed in a
reverse direction into a larger exhaust lumen from a
shepherd's hook catheter at the tip of the device. This
jet creates a pressure reduction at the site of the Venturi
effect which solubilizes the thrombus and propels the
microfragments into the outflow lumen (Fig. 1). The
device is designed for clearing peripheral arterial occlu-
sions and dialysis grafts.
Angiojet rheolytic thrombectomy catheter
The Angiojet rheolytic thrombectomy catheter (RTC;
Possis Medical, Minneapolis, Minn.) is a hydrodynamic
recirculation device that is also similar in action to the
Hydrolyser device. It consists of a 5-F double-lumen
catheter which accepts an 0.018 in. guidewire. High-
speed saline jets are injected through the smaller cathe-
ter lumen and are directed retrogradely into the exhaust
lumen producing a Venturi effect. In addition, there are
three low-speed jets which emerge from the catheter tip
in a radial fashion and enhance the recirculation cur-
rent. Thrombus is fragmented by the Venturi and recir-
culation vortices and is carried away in the exhaust lu-
men.
Amplatz thrombectomy device
The Amplatz thrombectomy device (ATD; Microvena
technologies, White Bear Lake, Minn.) is a recirculation
thrombectomy device which has undergone several re-
finements over the years. It consists of an 8-F 120-cm-
long catheter with a 1-cm-long metallic capsule mount-
ed in its distal end (Fig. 2). Within the protective capsule
is a sharp rotating blade or impeller, which is rotated at
speeds of up to 150,000 rpm by a compressed air tur-
bine. The high rotation speed of the impeller creates a
strong recirculation vortex. Adjacent thrombus be-
comes attracted by the vortex into the end hole of the
capsule and becomes macerated by the rapidly rotating
impeller blades before passing out of the capsule
through three large side holes. A second channel within
the device allows injection of contrast medium, saline or
thrombolytic agents. One of the main drawbacks of the
ATD is that it is not an over-the-wire device and cannot
be steered. The device should be used with an angled-tip
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Fig. 1a, b The Oasis thrombectomy system. a The Oasis throm-
bectomy catheter and close-up view of the catheter tip. b Mecha-
nism of action of the catheter tip. A jet of heparinized saline cre-
ates a Venturi effect at the distal tip of the catheter. This rapidly
fragments the thrombus and the microfragments are propelled into
the outflow lumen
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9
guiding catheter which can direct the catheter around
curves. If a guiding catheter is not used, care should be
taken when advancing the device because of the risk of
vessel trauma.
Arrow-Trerotola percutaneous thrombolytic device
The Arrow-Trerotola percutaneous thrombolytic device
(PTD; Arrow International, Reading, Pa.) was devel-
oped specifically for the clearance of thrombosed dialy-
sis grafts. The device consists of a rotating nitinol bas-
ket, which is driven at 3000 rpm by a hand-held motor.
The basket is contained in a 5-F catheter, which can be
introduced through a 5.5-F sheath. The rotating basket
disrupts the thrombus into small pieces less than 3 mm
in diameter, the majority being smaller than 1 mm di-
ameter. The resulting fragments can be aspirated
through the side-arm of the introducer sheath. The main
advantages of the PTD are its simplicity and low manu-
facturing costs compared with other devices; however,
the PTD causes substantial endovascular denudation
when it is used in native veins and as a result its use
should be confined to PTFE grafts [6].
Applications of percutaneous thrombectomy
Arterial occlusions
Percutaneous aspiration thromboembolectomy
Percutaneous aspiration thromboembolectomy (PAT)
was first described by Starck et al. [1] and Sniderman
et al. [2] and is currently mainly used for acute arterial
and graft occlusions below the inguinal ligament. Per-
cutaneous aspiration thromboembolectomy can also be
used to treat acute occlusion in the iliac arteries and su-
prainguinal grafts; however, total clearance of thrombus
from these areas is seldom achieved because of the
larger calibre of iliac arteries and grafts with regard to
the size of the catheters. There is also a potential risk of
dislodging thrombus into the infrainguinal circulation.
Although embolism into the infrainguinal circulation
arising from PATof iliac thrombus could also be cleared
by thrombectomy, this would necessitate an additional
arterial puncture in the reverse (i.e. antegrade direc-
tion). Percutaneous aspiration thromboembolectomy is
not generally used for venous occlusions because of the
larger calibre of the occluded veins relative to the size of
the catheters.
Technique
Ideally, the largest-calibre catheter available (i.e. 9 or
10 F) should be used for PAT of femoral or popliteal
occlusions. In practice, the largest catheters often used
are 8 F. Some operators consider 8 F to be too large for
routine PAT through an antegrade femoral puncture,
and initially attempt PAT with 6-F catheters and work
up to larger catheters if PAT is unsuccessful. Smaller
catheters should be used in the infrapopliteal vessels.
Tibioperoneal trunk occlusions can be treated with 6-F
catheters. Although thin-walled catheters are not avail-
able for the treatment of thrombi in the tibial arteries, it
is possible to remove thrombi from these vessels using
standard 4- or 5-F catheters (Fig. 3). Percutaneous aspi-
ration thromboembolectomy in the popliteal and tibial
arteries should be accompanied with bolus intra-arterial
injections of a vasodilator (e.g. Glyceryl trinitrate,
150600 mcg) to prevent arterial spasm induced by the
repeated passage of large-aspiration catheters.
In the case of native vessel occlusion, the catheter is
advanced under fluoroscopic guidance through the
sheath over a guidewire into the distal part of the
thrombotic occlusion. The guidewire is removed and
suction is applied to the syringe by an assistant. If graft
thrombectomy is performed, and the sheath tip has been
advanced into the graft (either via a common femoral
artery access or a direct graft puncture technique), the
catheter can be advanced into the graft thrombus with-
out a guidewire. Under continuous suction, the catheter
is moved slowly back and forth through the thrombus
until blood ceases to pass into the syringe indicating oc-
clusion of the catheter by thrombus. Taking care to
maintain suction to avoid dislodgement of the captured
material, the catheter is withdrawn proximally. Just be-
fore the catheter tip enters the end of the sheath, the
sheath valve is disconnected and the catheter and sheath
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Fig. 2 The Amplatz thrombectomy device
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valve are withdrawn simultaneously until the catheter
has been removed completely from the patient. The as-
sistant should stop the flow of blood from the detached
sheath by digital pressure while the operator discon-
nects the valve from the catheter, flushes it to remove
any retained debris and replaces it onto the sheath. The
contents of the catheter are expelled by injection of sa-
line into a basin draped with gauze, which separates the
aspirated material from the blood. The progress of
thrombus aspiration is monitored by contrast injections
through the side arm of the sheath (Fig. 4).
The procedure can be repeated several times as re-
quired. Sometimes, the sheath lumen itself becomes
obstructed by a large piece of thrombus (this even hap-
pens with removable hub sheaths). In this situation it is
necessary to insert a guidewire into the vessel and ex-
change the sheath for a new one.
Percutaneous aspiration thromboembolectomy
alone is often effective at clearing short occlusions and
small amounts of thrombus. Although it is possible to
clear longer occlusions (e.g. total femoropopliteal graft
occlusions) with PAT, adjunctive thrombolysis is often
required to achieve complete clearance. The main ad-
vantage of PAT is that thrombus is rapidly removed and
flow restored, which enables the procedure to be com-
pleted in a single session if PAT is successful alone.
Results of PAT
Despite the widespread use of this technique, data on
the clinical use of PAT are surprisingly limited [7, 8, 9].
Most papers involve heterogeneous groups and contain
patients with both acute de novo emboli and patients
with emboli arising from complications of endovascular
interventions. One exception is the series reported by
Wagner and Starck who achieved technical success fol-
lowing PATin 87.3% of 102 patients with acute de novo
lower extremity embolic occlusions; however, adjunc-
tive methods were required in 60% of cases. These
methods included disruption of the thrombus with bas-
kets and balloon dilation, and local thrombolysis with
bolus injection of 100,000 units of Urokinase. Presum-
ably the technical success for PAT alone in the treat-
ment of acute emboli is therefore somewhat less than
the 87.3% reported [7].
The use of PAT for the treatment of embolic com-
plications of angioplasty seems to be higher than for de
novo emboli. This is probably linked to the smaller vol-
ume of embolic material in these situations. Cleveland
et al. reported technical success for PAT in 87% of
15 patients with acute emboli complicating angioplasty
or atherectomy (1 patient). The reported success rates
for PAT of residual thrombus following local thrombol-
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Fig. 3a, b Percutaneous aspi-
ration thombectomy of embolic
occlusion of the tibial vessels.
a This patient had just under-
gone a successful right iliac an-
gioplasty. Angiography of the
run-off vessels after angioplasty
showed occlusion of previously
patent anterior and posterior
tibial arteries. This was consis-
tent with acute embolization as
a complication of the iliac an-
gioplasty procedure. b Aspira-
tion thromboembolectomy was
performed using a 4-F Cobra
catheter. After several passes of
the catheter into both occluded
tibial vessels, the angiogram
showed successful removal of
the embolic material and reso-
lution of patency to the run-off
vessels
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ysis are also high with success rates of 100% reported by
Cleveland in 6 patients [9].
Complications of PAT
Serious complications are uncommon. Material may
embolise more distally, although it is usually possible to
also remove this by further aspiration. Dissection of the
arterial wall may occur due to blind passage of catheters
through the occluded vessel. If the dissection is flow-
limiting, it can be treated by prolonged low-pressure
balloon inflation, stenting or atherectomy.
If PAT is used as a primary treatment for acute oc-
clusions and is not completely successful, residual
thrombus is usually treated by a thrombolysis infusion.
In this situation, the risk of hemorrhage around the in-
troducer sheath may be increased if a large access
sheath has been required for the PAT procedure.
Finally, it is possible to remove large volumes of
blood during PAT. If successive passes of the aspiration
catheter only yield full 50-cc syringes of blood with very
small volumes of thrombus, it is likely that further pass-
es of the catheter will not produce further improve-
ments and that PATshould be discontinued.
Mechanical thrombectomy
Mechanical thrombectomy may be used as an adjunct to
thrombolysis or instead of thrombolysis. In common
with thrombolysis, MT is less successful with increasing
age of thrombus and should probably be limited to oc-
clusions less than 14 days old [10, 11], although some
newer devices are being developed to address subacute
thrombus.
Technique
The method of thrombectomy is broadly similar for all
of the devices. None of the devices are suitable for use
distal to the popliteal arteries because of their size. The
Hydrolyser is relatively flexible and can be used across
the aortic bifurcation through a Balkin sheath (Cook
Europe, Bjaeverstock, Denmark). The ATD is relative-
ly inflexible and is not suitable for use from the con-
tralateral side. Over-the-wire devices (Oasis, Hydroly-
ser and the Angiojet) are generally easier to use than
devices without guidewires because they can be manip-
ulated around corners. Devices without guidewire lu-
mens, such as the ATD, should optimally be used with
guiding catheters. Some authors have advocated placing
a blood pressure cuff around the limb below the throm-
bus and inflating it above arterial pressure to prevent
distal embolization [12].
After vascular access has been achieved and a
sheath of appropriate size has been inserted, a catheter
and guidewire are advanced if possible into the oc-
cluded segment. The device is advanced into the
thrombus and the power activated. The device is ad-
vanced back and forth within the thrombus and fre-
quent check angiograms are performed through the
sheath to assess the progress of the procedure. Small
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Fig. 4ac Percutaneous aspiration thrombectomy of acute embol-
ic occlusion of the distal popliteal artery. a A 77-year-old male pa-
tient with an acute embolic occlusion of the right popliteal artery.
b This patient was treated by aspiration thromboembolectomy us-
ing a 7-F aspiration catheter. This image was obtained after re-
moval of the embolus and shows a patent distal popliteal artery,
tibioperoneal trunk, and peroneal and posterior tibial arteries. c
This image shows the embolus obtained by PAT presented on a
gauze swab. The tip of the aspiration catheter is shown alongside
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residual distal thrombi or emboli can be removed by
adjunctive PAT. If significant thrombus persists despite
the best efforts of MT or PAT, local thrombolysis
should be instituted (Fig. 5).
If it is not possible to pass a guidewire into the
thrombus, the thrombus may be organised and resistant
to thrombectomy [10, 13]; however, it is still worthwhile
attempting thrombectomy in these cases by activating
the device above the thrombus and advancing the de-
vice tip into the thrombus.
Results
The data from some of the largest series of mechanical
thrombectomy in the lower extremity are presented in
Table 1. Although each device has its own particular
advantages and disadvantages, the results are broadly
similar and no single device seems to be better than the
others. There seems to be no significant difference in
the results of MT for native artery occlusions or bypass
graft occlusions. The reported success rates for MT in
the lower extremities range from 66 to 90% [10, 11, 12,
13, 14, 15]; however, adjunctive thrombolysis (usually
overnight) is required in 2042% of patients [10, 11, 12,
13, 14]. Adjunctive PAT and balloon angioplasty are
also usually required in addition to MTin most series, to
address the underlying cause for occlusion.
The thrombus clearance rates of MT alone are sub-
stantially less than the combination of MT and throm-
bolysis together. Rousseau et al. reported success rates
for MT alone in 61% of cases, which increased to 83%
when MT was followed by thrombolysis [11]. On the
other hand, mechanical thrombectomy combined with
PAT achieves successful clearance of acutely throm-
bosed arteries and grafts in 5880% of cases. Both MT
and PAT are rapid procedures which enable vessel
clearance to be completed in a single procedure obviat-
ing the expense, time and complications of thromboly-
sis.
Complications
Distal embolization during thrombectomy is reported in
up to 28% of series; however, these emboli can be
cleared in almost every case by further MT, PAT or
thrombolysis. Reekers et al. reported one patient with
resistant distal emboli who went on to have a below-
knee amputation [10]. Puncture-site haematomas occur
with similar frequency to other endoluminal interven-
tions using large sheaths. Vessel dissection occasionally
occurs due to manipulation of the device but is usually
mild and self-limiting [13].
Ileofemoral and ileocaval thrombosis
Rapid clearance of thrombus with early resolution of
venous patency in patients with lower-limb deep venous
thrombosis (DVT) is theoretically desirable because it
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Fig. 5ac Clearance of acutely occluded superficial femoral and
profunda femoris arteries with the Hydrolyser device. a Antegrade
puncture of the left common femoral artery was performed and a
catheter introduced into the occluded superior femoral artery
(SFA). b After three passes of the Hydrolyser device, flow was re-
stored to the SFA and the proximal profunda was cleared. c The
profunda was almost completely cleared by further passes of the
Hydrolyser device
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lowers the risk of acute complications of DVT such as
PE. Moreover, late sequelae of DVT, such as venous
oedema secondary to valvular incompetence caused by
venous thrombosis, can be avoided. For these reasons,
treatment of patients with extensive ileofemoral DVT
with catheter-directed thrombolysis is being advocated,
although there is as yet no good evidence for the clinical
efficacy of the procedure [16].
The main disadvantage of venous thrombolysis is
that it is more time-consuming than arterial thromboly-
sis and the doses of thrombolytic agent required are
very large which makes the procedure very expensive.
The average dose reported by the United States DVT
registry in 1999 was 7.8 million units of Urokinase at a
mean procedural time of 53 h [17]. The use of mechani-
cal thrombectomy devices in these patients should result
in reduced procedural times and therefore reduced
doses of thrombolytic agent even if clot removal is in-
complete with MTalone.
The ideal thrombectomy catheter would be able to
clear a large amount of thrombus, be atraumatic to ve-
nous valves and be associated with a low risk of PE
[18]. In theory, larger-calibre devices are required
compared with arterial MT, because the already large
veins are usually distended by thrombus. This is one of
the main reasons that PAT is of limited efficacy in ve-
nous occlusions. Over-the-wire devices are preferable
because of the ability to steer them around bends.
Thrombectomy should be performed only in the acute
phase of thrombosis. After a week or so, synechiae
form between the vein wall and the clot, which reduces
substantially the effectiveness of thrombectomy and
thrombolysis.
Results from several animal studies evaluating the
Hydrolyser, Oasis, Amplatz and Arrow-Trerotola de-
vices have been reported with favourable success rates
and low incidence of PE [19, 20, 21, 22]; however, clini-
cal experience is as yet limited to a few case reports [12,
23, 24, 25, 26, 27]. Uflacker used the ATD in three pa-
tients with iliac and/or caval thrombosis with complete
success in one patient and partial success in the other
two patients [23]. Reekers and Blank reported complete
clearance of an acute ileocaval thrombosis using the
Hydrolyser device [27]. Evidence from work in animals
suggests that damage to venous valves, while not inevi-
table, does occur following the use of thrombectomy
devices [18].
On the basis of current evidence, complete success
using thrombectomy devices alone can be expected in a
small proportion of patients, whereas the majority re-
quire some form of adjunctive therapy such as throm-
bolysis or stents. Evidence from larger series is required
to properly assess the success rates of these devices in
the treatment of ileofemoral and ileocaval thrombosis.
If complete or partial clearance of thrombus can be
achieved, the high cost of the devices can be offset by
the savings gained by reduced amounts of thrombolytic
agent required; however, we still do not know whether
invasive and costly treatments in the form of thrombec-
tomy or thrombolysis should be recommended for the
treatment of DVTof the lower extremities.
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Table 1 Mechanical thrombectomy in lower extremity arteries and bypass grafts
Reference Patients Device Success Adjunctive treatment Complications
[14] 40 patients ATD Complete success 75% Lysis 20% None
all native arteries Partial success 20%
32 emboli
8 in situ thrombosis
[12] 12 patients ATD Success 66% Lysis 33% 28%
10 grafts Two embolizations
2 native cleared
all in situ
[10] 28 patients Hydrolyser Success 82% Lysis 42% 25% embolization
11 native Native: 73% 6 of 7 aspirated/lysed
17 grafts Grafts: 88% 1 patient, amputation
all in situ
[15] 36 patients Hydrolyser Success: 81% 3% embolization,
15 native Native: 87% aspirated
14 grafts Grafts: 79%
[11] 29 patients Hydrolyser Success: 83% Lysis 34% 14% embolization,
15 native Native: 87% aspirated
14 grafts Grafts: 79%
[13] 50 patients Anjiojet Success 90% Lysis 30% 2% embolization,
39 native aspirated
11 grafts 4% mild dissections
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Superior vena caval and upper extremity venous
thrombosis
Thrombosis of the SVC and upper extremity veins is
usually due to long-term indwelling venous catheters,
effort-thrombosis of the subclavian vein due to com-
pression at the thoracic inlet (Paget-Schroetter syn-
drome) and to malignant disease. Malignant SVC ob-
struction is usually treated by radiotherapy, metallic
stenting and/or thrombolysis. Thrombectomy has a lim-
ited role because of the presence of neoplastic tissue. If
thrombosis occurs in the absence of a significant ob-
structing lesion, the use of MT devices may achieve
clearance of thrombus more rapidly than standard
thrombolytic regimes.
Successful treatment of acute obstruction of the su-
perior vena cava using the ATD, Hydrolyser, Angiojet
and TEC catheter have been reported [15, 23, 28, 29].
Pulmonary embolism
Most PE do not cause significant haemodynamic dis-
turbance and are treated by systemic heparinization.
Patients with massive emboli with acute right heart
failure require more active therapy to break up the em-
boli. Administration of a thrombolytic agent either via a
peripheral vein or delivered directly into the thrombus
is used by many clinicians to achieve clot lysis and im-
prove the patient's cardiovascular status; however,
thrombolysis takes time to take effect, and may be inef-
fective or contraindicated in some patients. Mechanical
thrombectomy may be used as an alternative to surgical
thrombectomy to achieve rapid clot dissolution in se-
verely ill patients.
Aspiration thrombectomy
Lang et al. [30] used PAT to treat massive PE in three
patients with the aid of a 14-F aspiration catheter intro-
duced into the pulmonary artery coaxially over a 6-F
multipurpose guiding catheter. After removing the 6-F
catheter, aspiration thrombectomy was performed
through the 14-F catheter. Ninety percent of the clot
burden was removed in three patients [30].
Catheter fragmentation
Large central PE can be broken into smaller pieces us-
ing standard angiographic catheters. These fragmenta-
tion techniques produce a rapid improvement in the
patient's clinical status as a result of reduced pulmonary
arterial pressure and right heart strain. Fragmentation
should be performed using a pigtail or multipurpose
catheter. The 8-F Grollman pulmonary pigtail catheter
is particularly well suited to this technique (Cordis,
Johnson and Johnson, N. J.). After a diagnostic angio-
gram has been performed, a guidewire is advanced
through the embolus followed by the catheter. The
guidewire is removed enabling the catheter tip to as-
sume its natural configuration. The pigtail is withdrawn
through the clot and the procedure is repeated in one or
more vessels until there is improvement in pulmonary
arterial blood flow. The treatment may be combined
with local or peripheral thrombolysis.
Fava et al. [31] treated 16 cases of massive PE with a
combination of catheter fragmentation and direct local
thrombolysis. In 8 patients mechanical fragmentation
was performed before thrombolysis and the mean pul-
monary artery pressure dropped from 57 to 39.5 mmHg.
Overall success with complete clinical recovery oc-
curred in 14 patients (87.5%) and one patient died dur-
ing the treatment due to cardiovascular collapse [31].
Brady et al. reported successful fragmentation of em-
boli in three patients with significant improvement in
systemic and pulmonary arterial pressures [32].
Although there is limited reported experience, the
evidence suggests that embolus fragmentation can pro-
duce rapid improvement in right heart function. More-
over, the equipment for this technique is inexpensive
and available in every interventional department.
Mechanical thrombectomy devices
The Greenfield transvenous embolectomy catheter
(Boston, Galway, Ireland) was the first device used to
treat PE [33]. In a series of 46 patients, all of whom re-
quired inotropic support or mechanical ventilation,
successful clot extraction was achieved in 76% of
46 patients with a 30-day survival rate of 76% [33];
however, the bulkiness of the catheter (12 F) and diffi-
culties in manipulation through the heart has limited its
use to a few centres.
There are a few reports of the use of different types
of thrombectomy devices in the pulmonary arteries.
Uflacker et al. [34] achieved clinical improvement in
dyspnoea, chest pain and hypotension in four of five
patients with massive PE using the ATD device. Only
one of these patients received lytic therapy. Complica-
tions included massive self-limiting haemoptysis at the
end of the procedure in one patient and cardiac arrest
and death in another patient [34].
Clinical experience using the Hydrolyser in the
treatment of acute massive PE was reported by Fava et
al in 11 patients [35]. Four patients were treated with
local thrombolysis after thrombectomy. Eight to 12
passes were made through the pulmonary artery with
the Hydrolyser catheter. Clinical success occurred in
10 patients (90.9%). One patient died during the pro-
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cedure and one patient had a self-limiting haemoptysis
immediately after thrombectomy. Henry et al. also used
the Hydrolyser successfully in two patients [36]. There
are also case reports of successful use of the Arrow-
Trerotola thrombolytic device in two patients [37] and
the Anjiojet RTC catheter in one patient with massive
PEs [38].
In summary, all three techniques are relatively suc-
cessful in producing a reduction in the volume of ob-
structing embolus in the central pulmonary arteries with
a consequent improvement in the cardiorespiratory sta-
tus of patients with massive PE. The simplest technique
seems to be fragmentation with a standard angiographic
catheter. Finally, the results of mechanical thrombecto-
my may be improved if thrombectomy is followed by
intrapulmonary thrombolytic infusion [39].
Occluded dialysis grafts
One of the most common indications for mechanical
thrombectomy is the treatment of occluded dialysis ac-
cess grafts (ODAG), particularly in the United States.
Treatment options for ODAG include surgical throm-
bectomy, catheter thrombolysis and mechanical throm-
bectomy. In the early 1990s thrombolysis became widely
used, and in many centres it superceded surgery as the
primary treatment method; however, thrombolysis is
time-consuming and expensive in terms of the costs of
the lytic agent and manpower required for the treat-
ment. Interventional radiologists investigated other
methods to reopen blocked grafts which were quicker
and less expensive, particularly mechanical thrombec-
tomy.
There are several techniques for the restoration of
flow to dialysis grafts using mechanical thrombectomy,
which include thromboaspiration, pull-back thrombec-
tomy using balloon catheters, and mechanical throm-
bectomy using automated thrombectomy devices. Most
techniques can be used alone, in combination with other
methods of mechanical thrombectomy or with throm-
bolysis. Mechanical thrombectomy, either alone or with
adjunctive thrombolysis, has largely replaced throm-
bolysis using pulse-spray or infusion techniques for the
treatment of ODAG. A brief overview is provided be-
low. Although some native fistula occlusions can also be
treated by the following methods, mechanical throm-
bectomy is mainly used to treat prosthetic dialysis
grafts, which are usually placed in a loop configuration
in the lower or upper arm.
Pull-back thrombectomy
Pull-back thrombectomy involves moving the thrombus
out of the graft into the draining vein and further on into
the pulmonary circulation. This is achieved by placing
two overlapping vascular sheaths into the graft, one to-
ward the venous anastomosis and the other toward the
arterial anastomosis. A balloon catheter is advanced
across the arterial anastomosis into the native artery,
inflated and pulled back to the level of the sheath tip.
The balloon is deflated, withdrawn through the sheath,
and reinserted through the other sheath. The balloon is
reinflated, and is pushed over a guidewire as far as the
right atrium. It is usually necessary to treat any under-
lying venous outflow stenoses by angioplasty before the
thrombus can be pushed into the central veins.
In Trerotola's original report using this technique in
34 clotted grafts in 24 patients, successful graft clear-
ance was achieved in 94% of grafts with a mean time to
achieve lysis of 62 min and an overall mean procedure
time of 116 min [40]. In a randomized prospective study
comparing pull-back thrombectomy with pulsed-spray
thrombolysis, the technical and clinical success rates
were similar, although the mean procedure time was
significantly lower in the MT group (2.2 h) compared
with the thrombolysis group (3.5 h) [41]. Zaetta et al.
[42] described a slightly different approach in which
they performed pull-back thrombectomy using a bal-
loon catheter introduced into the dialysis graft from the
internal jugular vein. The advantages of this procedure
are the single venous access, the reduced radiation dose
to the interventionalist (a problem with virtually all
other methods of percutaneous treatment of ODAG)
and the avoidance of the risk of graft infection arising
from dual sheath insertion into the graft. Successful
declotting was achieved in 81% of 31 patients [42].
The main risks of this procedure as with most me-
chanical techniques is embolization into the native ar-
tery caused by displacement of thrombus across the ar-
terial anastomosis and clinically significant pulmonary
emboli. Both complications are surprisingly uncommon.
Arterial emboli can be avoided by clearing most of the
thrombus from the body of the graft before the arterial
anastomosis is crossed. Clinically significant PE do oc-
cur but again are uncommon. Mechanical thrombecto-
my should probably not be performed frequently (i.e.
within 1 month of a previous treatment), in patients
with respiratory disease or in patients with a history of
PE.
Thromboaspiration
Thromboaspiration involves removal of thrombus from
the graft and venous outflow by suction through crossed
7- or 8-F thin-walled aspiration catheters. Turmel-Ro-
drigues reported 100% success using this method in 43
grafts with primary patency rates of 85, 33 and 24% at 1,
6 and 12 months, respectively [43]. Thromboaspiration
can be used in association with a balloon catheter.
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Thrombus is moved by pull-back thrombectomy from
the arterial limb into the venous limb. This thrombus is
aspirated through an aspiration catheter placed into the
venous limb. This method avoids manipulation of an
aspiration catheter at the arterial anastomosis and re-
duces the risk of arterial embolization. Technical suc-
cess rates of over 90% have been reported [44, 45]. The
main advantage of thromboaspiration is the removal of
a substantial proportion of the thrombus volume, which
obviates embolization into the lungs. Care should be
taken to avoid aspiration of large volumes of blood,
which may result in reduction of the haemoglobin in al-
ready anaemic patients. Aspirated blood can be sieved
through gauze and reinjected to avoid haemodepletion.
Mechanical thrombectomy devices
Most of the thrombectomy devices described in the
previous sections can be used to treat dialysis access
grafts. Trerotola developed the Arrow-Trerotola percu-
taneous thrombolytic device (A-TPTD) specifically for
use in dialysis grafts. In a randomized, prospective study
comparing pulse-spray thrombolysis with the A-TPTD
in 122 patients, the technical success and 3-month pa-
tency rates were identical and the median procedure
time was significantly shorter in the MT group (75 vs
85 min; p < 0.04) [45].
Results of the Anjiojet catheter were reported in a
multicentre prospective randomized trial involving
153 patients, which compared the Anjiojet rheolytic
catheter with surgical thombectomy. The technical suc-
cess rates were 73% for the Anjiojet and 79% for sur-
gery. The technical success and patency rates were not
statistically different between the two treatment meth-
ods. The complication rates were also similar, although
surgery had more major complications [46]. In another
randomized prospective study which compared surgical
thrombectomy with mechanical thrombectomy, 37 pa-
tients were assigned to either surgery or MT with the
Amplatz thrombectomy device. Similar to the previous
study, the technical success rates were similar and no
significant difference was observed in the primary or
secondary patency rates [47].
Experience with the Hydrolyser catheter has been
reported by Overbosch et al. [48] and Vorwerk et al.
[49]. In a Dutch multicentre trial, 65 occluded dialysis
shunts (which included 24 native fistulas) were treated
with the Hydrolyser device with a technical success rate
of 89% [48]. Vorwerk et al. reported restoration of flow
in 86% of 51 grafts using the Hydrolyser device intro-
duced through a single vascular sheath in the venous
limb and a pull-back balloon technique similar to that
described previously [49].
Finally, van Ha and Kim [50] recently reported the
results of a prospective study comparing the Oasis
thrombectomy device with pulse-spray thrombolysis in
55 patients. The technical success rates and mean pro-
cedure times were similar; however, this group reported
two severe complications in the Oasis group, one arte-
rial rupture and one venous rupture both of which re-
quired metallic stenting. In addition, the patency rates
for thrombolysis were higher than in the Oasis group
[50].
In summary, there are many different techniques of
mechanical thrombectomy for the treatment of occlud-
ed dialysis grafts. All of these methods have high success
rates and produce patency rates similar to those of
thrombolysis and conventional surgical thrombectomy.
In the majority of studies involving MT, the procedural
time is reduced compared with thrombolysis. Costs are
reduced for the more simple techniques using balloons
and aspiration catheters, although costs rise substan-
tially with the use of the automated devices. There is at
the present time no evidence that use of automated de-
vices is justified on the basis of technical success, re-
duction in complications or improvement in patency
rates.
Conclusion
Percutaneous aspiration thrombectomy has become an
established part of the interventional radiologist's ar-
mamentarium and is most useful for the aspiration of
embolic complications of angioplasty and as an adjunct,
rather than as an alternative, to thrombolysis. Mechan-
ical thrombectomy devices are useful for the treatment
of thrombosed dialysis grafts and can be used as sole
therapy. They are less effective for the treatment of
acute peripheral arterial ischaemia and the treatment of
venous thrombosis.
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