2

Age Travel Immobilization History of DVT Malignancy Surgery Trauma

Hypercoagulable States

Pregnancy Oral

Contraceptives Central venous

catheters SLE

Pulmonary Embolism (PE). Post Thrombotic Syndrome (PTS).

Anatomic Criteria- Proximal Thombus› Caval› Iliac vein› Femoral

vein

Clinically Symptomatic Active/functional patients. Patients with massive

swelling venous gangrene. Tolerate anticoagulation. Optimal outcome with

acute DVT (2 weeks).

Improve quality of life. Preserve valve function and decrease

post thrombotic syndrome (PTS)

Anticoagulation (Gold Standard).

Inferior vena cava filter (Greenfield Filter)

Interventional treatment.

…does prevent clot propagation1.…does reduce risk of pulmonary embolism.But, it typically……does NOT resolve clot.16

…does NOT rapidly resolve symptoms.16

…does NOT prevent PTS (Post Thrombotic Syndrome

ANTICOAGULATION ALONE IS NOT ENOUGH

Catheter directed lytics. EKOS catheter. Angiojet. Trellis Pharmaco-mechanical

thrombectomy.

Isolated Pharmacomechanical Thrombolysis Treatments (Isolated PMT)•Thrombus isolated between occluding balloons•Lytic isolated between occluding balloons•Reduction in thrombolytic dosing• Aspiration of thrombus and lytic•Single setting thrombus removal•No reported major bleeding• Reduces/eliminates ICU time

Pharmacomechanical Thrombolysis Treatments (PMT)•Thrombolytic infusion with mechanical energy• Dissolves and macerates thrombus • Reduces the thrombolytic dose & time

1. Proximal and distal balloons, with balloon

2. inflation syringes, a thrombolysis infusion port, the thrombus

3. aspiration syringe, and a drive unit for mechanical dispersion

4. of the thrombolytic agent

Potential Advantages of Local Thrombolysis and Mechanical Thrombectomy

• Local delivery of thrombolytic agent• Smaller doses of thrombolytic agent • Shorter duration of thrombolysis• Avoid risks of systemic effects of thrombolytic agents- Can be used in patients with relative contraindicationsto thrombolysis- Decreases bleeding complications• Less costly

The Trellis thrombectomy system (Covidien)

Done in a Cardiovascular cathlab. Prone position (Popliteal vein

approach). Percutaneous via 8 French Sheath. General vs. local with sedation (patient

preference).

Thrombus isolated & targeted

delivery of thrombolytic

drug

Single-setting treatment in 83% of cases*

Isolated Pharmacomechanical Thrombolysis using the Trellis Peripheral Infusion System As presented at VEITH 11/2008 ~ 1,304 Venous Patients Commercial Registry

Catheter delivered over

guidewire

54 year old male with recent resection of brain tumor presents to ER with massive right leg swelling that had been present for 24 hours. Denied chest pain or SOB.

Venous US-extensive acute occlusive venous thrombus from ankle up to common femoral vein.

Initiated on anti-coagulant(Heparin(LMW),Thienopyridine,tPATissue

Plasminogen activators ) in ER. Venogram Trellis Mechanical Thrombectomy Planned.

Can be done as an outpatient. Bedrest for 2-4 hours. Thigh high ACE wrap for 3 days, then

compression stocking. Still need anticoagulation!!

The restoration of rapid inline venous flow was 100%, 50%-82% lysis was achieved in 82% of cases, mean tPA dose was 13.4 mg, mean treatment time was 91 minutes, and primary patency rate was 100% at 1-month follow-up

In patients with DVT involving, the ilio-femoral and the upper-extremity vessels, The use of the Trellis device was associated with a high technical

success rate as well as a satisfactory 12-month patency rate.

Reduced lytic dose shorter treatment time and hospital stay, No bleeding complications ( major bleeding, access-site

pseudoaneurysms, distal embolism, or arteriovenous fistula formation.)

REFERENCES`)Total preservation of patency and valve function after percutaneous pharmacomechanical thrombolysis using the Trellis®-8 system for an acute, extensive deep venous thrombosis.Wormald JR, Lane TR, Herbert PE, Ellis M, Burfitt NJ, Franklin IJ.2)Ann R Coll Surg Engl. 2012 Mar;94(2):e103-5. doi: 10.1308/003588412X13171221589496 3)http://www.ncbi.nlm.nih.gov/pubmed/17538133 Pharmacomechanical thrombectomy of acute deep vein thrombosis with the Trellis-8 isolated thrombolysis catheter.O'Sullivan GJ1, Lohan DG, Gough N, Cronin CG, Kee ST.