PE lysis

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first decide if massive or submassive PE

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To do case

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access R groin CFV

Place 7F sheath

use 7F montiefiore catheter to access PAs

use bentson or glide as wire

once in PA do angio with breathhold

to use montifiore catheter - not too difficult

just sniggle it up thru the PA, it sorta just finds the outflow of the PA

and then pass an exchange length bentson up thru it

it sorta just goes- maybe not all the time - SG

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Pharmaco-mechanical thrombolysis using Angiojet Zelante DVT device- MM method

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Pop V access, into the clot, ok per MM (some advocate calf vein access)

8F sheath

start with some venography to document thrombus / clot

use exch length stiff angled glide and angled catheter (pref angled glidecath 65-100 cm)

cross into ileocaval level

to use catheter, advance over SAG

catheter has some specifics on back end in terms of how to set up with machine

two modes- suction thrombectomy:  good for removing clot

power pulse:  good for infusing lytic agent, alteplase

in this case, did the suction thrombectomy first and the power pulse second

then use balloon maceration / augmentation to help push the drug into the vein walls

do repeat venography to document progress

consider stenting- per literature and SIR forums, stenting improves patency outcomes because improves outflow

outflow and inflow are keys to understanding venous (and arterial) thrombotic-occlusive disease

after complete, two options, one is leave multisidehole cath in situ and drip tpa through that and heparin thru sheath

or take everything out as single session and no tpa gtt and do IV heparin gtt trans to lovenox or oral anti thrombin or Xa drug

think thats about it

be concerned about risk of intracrani hemorrahge in >70 year old, esp with amyloid plaques (JM told me 'dis)

thats it i guess

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Venous lysis of lower ext with placement of infusion cath

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as by the great HAWK-MAN

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pt with R common and ext iliac thrombus, acute

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access below clot

in this case, was R superficial femoral V

or could do pop

could place prone for pop access

also could frog leg the pt for pop access so stay supine

gotta decide cuz techs be axsin

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use 6F sheath for access

can do venogram to start through sheath

figure out where the occlusion / thrombus is, where the collatearls are

document what you need to

is they an obstruciton?

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to cross occlusion, use angled cath: kumpe, angled glidecath whatev

betnson on the table, amplatz, stiff and non stiff glides

once through to IVC, prove your in IVC with cavagram through cathteter

switch over for a stiff wire

time for some clot bustin

start with 6F BosSci cath for use with Angiojet

the catheter is in a big box

forget what hooks up to what, its on the packaging

plug that big pump thing into the angioJet machine little heart of the machine

turn machine and put in power pulse mode

first have to test, it will splash, dont get splashed in face

power pulse mode with 10 mg of alteplase mixed in 250 bag of saline

do the 250 seconds (i think) of power pulse to put TPA into the clot

just go slowly back and forth through thrombus

afterwards, switch to aspiration thrombectomy mode 

so another 250 seconds or so

apparently the high velocity jets of the angiojet can heat up the intima, its what the 'facturer say

switch over for the infusion catheter

decide the infusion sidehole length of the Unifuse cath

then switch over for it

place the "obturator" in the unifuse, this allows saline or anything else to drip through (the tpa)

secure the sheath with a stich

use steristrips to secure the unifuse.  mark the unifuse catheter so know it didnt move at all

take final image of stuff in situ

hook up drips

heparin at low rate to sheath sidearm

tpa at decided rate through unifuse

label the drips

place decent dressing, remember pt will ooze at the site

remember pt will have myoglobinuria " it ain't hematuria mang, that MYOglobinuria!"

remember to monitor the fibrinogen value, cut if off at 150

remember to let TPA dwell in clot for 2 half lives or approx 12 min

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"do all your lysis cases like this" - CMH

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more tips:

re. IVUS catheter

not much to it really

made byphilips

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the catheter comes on table

flush through it, it goes over 035 wire

its 8F i beleive

give one end to tech which plugs into machine

goal is to track it up and then do pullback venography

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so for a MT case

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get wire up in the IVC from L CFV

then track catheter up

then do nice gentle pullback while recording to see IVC- L CIV- L EIV - L CFV - L FV

then analyze recording to eval diamteres of veins, areas of stenosis and for stent sizing (typ 14-16 mm)

the catheter has 1 cm markings which help with length sizing of stents

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IVUS is really nice to use and not too difficult, gives rreally good 3d information about the inside of the vein, can also help to differentiate chronic from acute clot

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