Chapters Transcript Video Devices – How I Choose Back to Symposium So I know we're a little behind on lunch, but I'll catch you up real quick. Concept here, and I wanted to share on, uh, thrombectomy devices and how I choose and rather than go through the exhaustive, uh, list of, of current available and, uh, coming devices to market as there are, as you've heard throughout the, the day with wires, catheters, atherectomy, um, back modification, it isn't knowing all the devices, but understanding what the right questions might be to ask when you're uh approaching thrombectomy. This is an ever growing space, uh, multiple billions of dollars globally, really, um, is what this market, uh, cap is and expected to grow in the next 10 years. So I think this is an area of considerable, um, interest, uh, and, and opportunity for our patients. So think about what are the questions you wanna ask yourselves when you're embarking on. Uh, thrombectomy and what device to use. We heard a little bit about this specifically the ALI and the arterial considerations are, are very clear. Usually it's acute limb ischemia or stroke, right, in that setting. Now there are some rare examples like mesenteric ischemia where we've done, but it's an acute setting where the patient presents, and the priority is rapid restoration and flow. You gotta do it quickly as opposed to the venous side with minimal. Distal embolization. We learned about this in this setting early on, right, in the cerebral, uh, cerebral vasculature, which most of us probably aren't in this space, but, you know, acute stroke, uh, large vessel occlusions, and rescue to get to something like this is huge to be able to pull something as small as this to get a rapid restoration and, uh, uh, restoration of function for these patients because of that resolution of, uh, the occlusion. And so, this is the key here. Can I do this? How much thrombus am I dealing with? What am I gonna be able to do? And in that setting, you have to ask yourself, because these vessels tend to be much smaller and much more delicate, particularly in the infrapopliteal setting as I'm focusing on CLTI. Peripheral vasculature, um, we tend to favor aspiration catheters or stent, stent retrievers. Then you wanna ask yourself, what's the clot age, you know, is it acute? Is it chronic? Is this an embolus, or is this something that was, uh, acute on chronic or de novo as a lesion that has now acutely thrombosed? You may need a combination of thrombectomy or atherectomy. So a mechanical rotational type system might be more relevant in that setting. And then finally, look at the anatomy. Usually have pre uh preoperative imaging. Certainly they have that in the cerebral vasculature, and there's a lot of torturous and, uh, delicate vessels. But similarly, um, when you talk about PAD, what, what's the, what's the location of the vessels? What's the, how am I gonna get there? Am I gonna cause damage and trying to deliver my device to this, uh, location to ultimately be able to retrieve this catheter or, uh, thrombus? What happened? Green. It is the green button. Just move that forward. We almost got there. Sabotage. All right, so in the venous considerations, a little bit different. Typically DVT and PE, right? Much larger vessels, but also significantly greater clot burden, right? So here's an example of a patient who's got ileofemoral DVT, significantly larger blood vessels, significantly greater extent of thrombus that we have to take out, uh, in this, so a little bit of different consideration in these settings. And that one in these settings, you obviously have much larger vessels. It's a PE case. Um, and some different considerations to think about. I think I've shared it on my previous slide. In the Venus setting Oh boy. We just call you to Yeah, so in venous considerations there's large clot burden. Larger devices are effective and efficient for removal, but when it's too big, too big, and that's the, that's a clear delineation here. There's a sweet spot that we need to try to find. We wanna minimize clot embolization, particularly in the DVT setting. You don't wanna, uh, transition a patient from just a DVT to now having a QPE and perhaps. A Different set of problems. And then the mechanism becomes relevant as well as a large clot burden, and you, you take a, a realistic approach, you might have increased hemolysis, hemoglobinuria, and kidney injury. So other considerations you have to keep in mind. So how do I choose? You wanna make sure, can I get my device there, particularly, uh, ileofemoral DVT relatively straightforward, generally straight, relatively straight vessels. Although in the iliac segment, there is a degree of uh uh posterior curvature of the iliac vein you want to be mindful of, but in the uh pulmonary arterial segment, you want to be much more careful, right? Depending on, uh, right atrium and uh right ventricular size and enlargement, and as well as the pulmonary outflow tract, you may have a little bit more tortuosity to consider, particularly with a very large and stiff device. Um, access and trackability becomes, uh, really critical, and I mentioned this in the arterial side because you may have concomitant small vessels or, uh, uh, concomitant stenosis. So you want a low profile trackable catheter that is size to the vessel. You're going to have your most efficient aspiration if the device that you're looking to aspirate, uh, particularly in the arterial side matches. Closely matches the size of the vessel that you're, uh, that you're in. Now, that's a little bit of uncomfortableness sometimes to take a larger, uh, uh, device to a vessel like that, but you're gonna have a much more success with being able to retrieve something like that, particularly if you're talking about aspiration systems. Stent retrievers, a little bit different mechanism, and they take a little bit of a mechanical approach to pull that device back in. Here's a case, uh, patient who had popliteal aneurysms, um, on a bypass that was performed that had gone down. Patient had lysis. This is an old school drip case, and in that setting, um, had this runoff, and obviously you need runoff to maintain a bypass or an endovascular intervention, and one is mandatory, but two is certainly better than one. In this setting, it looked like an acute embolus from the lysis down that poster tibial. And so there's the distal runoff and reconstitution from that perineal. But we weren't satisfied with that. We said, can we go down and try to pluck this out with an aspiration catheter or stent retriever type approach? We're able to get a catheter down, uh, retrieve that, do a little, uh, angioplasty to that segment, we're able to give this patient a two vessel runoff versus a one vessel runoff, improve patency, and then followed up in on imaging subsequent to this, you can see. Uh, persistence of that two vessel, uh, runoff from where we would have left the patient with one. So this is an example where, you know, arterial thrombectomy became, hey, this is something we can do for rescue and, and, and peripheral interventions with small devices that work really well, whether it's aspiration or now some of the mechanical stent retriever type uh uh settings. In, in the venous, uh, setting, you wanna make sure that you can, uh, uh, get enough thrombus out. I've already mentioned this already. Um, here's a patient with, uh, bilateral PE, uh, pulmonary pressures are elevated. Uh, PET team called. We did our, uh, pulmonary angiogram. You can see here you have to have a sheath and a device that's, uh, flexible enough to, to be delivered there but also large enough to be able to get enough thrombus out. Um, just a couple of passes here, uh, with an aspiration. Can you hit the next, uh, video on the right. Able to remove that with 2 passes. Improvement of uh PA pressures in a relatively short aspiration time as you can see the time stamps there for the initial angio and subsequent post angio uh really doesn't take very long, but you need to have a large enough catheter to be efficient with your thrombus removal. So the other question to ask is what is the clot morphology? Am I dealing with acute clot, which is gonna be the easiest to remove, but oftentimes I think we think we're dealing with acute clot, and there tends to be much more mixed age clot. Simple aspiration will work really well with acute thrombus, but chronic clot tends to be much more organized and firm. Clearly in the venous setting, we tend to see much more mixed. To H thrombus and you have to be much more uh uh cognizant that this is going to be as efficient perhaps as a truly acute clot. And so in this couple of venous examples here, this is a femoral popliteal uh or ileofemoral DVT and you can see um what appears to be relatively acute thrombus, uh, tram tracking, uh, uh, venogram here where you can see the filling defect through the lumen of the, the vein. Uh, aspiration thrombectomy was performed in the femoral segment from a popliteal segment, relatively easy, but then we found, or we knew that going in, but in this case, this was, uh, an old stent that had gone down. And so in that stent, we were able to actually thrombectomize because it had an acute. Component, but clearly there was a chronic component too, and that's evidenced by the type of thrombus or material you pull out the very acute red thrombus, but that more white organized, uh, thrombus was the issue in this patient who had, uh, multiple stents and multiple venous reinterventions, uh, and came to us in the acute setting. So, is there an underlying disease that I have to manage in, in combination with the uh thrombus that I have to remove? If there is, then you may wanna consider, um, and particularly in the arterial setting, am I gonna use a mixed type of atherectomy, thrombectomy device? Ibis can be very helpful in differentiating this. You may wanna consider that as well. This is an, uh, ALI case, not unlike what Tino had showed in the previous. It's a Rutherford 2A patient. Embolus in the mid-SFA, uh, distal SFA makes you wonder why would it stop there? Probably because there's some underlying disease. And so there's thrombus or embolus that's formed but stopped right there. Here's the angio, um, selectively, first pass, you can see we've created a channel, but there's clearly an underlying lesion there. Second pass, we've kind of debulked the thrombus portion and ultimately this patient got, um, uh, uh, a stent. For revascularization. So there's been an explosion of growth in thrombectomy devices, arterial and venous, that'll only continue. The market shows that it's not just in the US, it's globally. I think you're gonna see increased investments in this space. But the new devices if they're gonna come to market, have to show improved efficacy, improved efficiency in removing that subacute and chronic clot while also minimizing the amount of blood loss and trauma to the vessels. Thank you. Wonderful Published Created by
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