Managing Arrow-Trerotola Percutaneous Thrombolytic Device Complications

Abstract

Dialysis access interventions are frequently performed by interventional radiologists. Several commercially available percutaneous thrombolytic devices can help restore patency to thrombosed arteriovenous access circuits. The Arrow-Trerotola Percutaneous Thrombolytic Device is one such device, and has a long track record of safe and effective use. However, like any medical device, complications can occur during its use. This article describes three complications and associated management strategies utilizing fundamental interventional radiology techniques of balloon tamponade, stent placement, and snare mediated foreign body retrieval.

Keywords: dialysis interventions; foreign body retrieval; interventional radiology; venous rupture.

Fig. 1

( a ) Digital subtraction venogram with a catheter positioned in the left subclavian vein demonstrates a patent central venous system. ( b ) Fluoroscopic image during pullback venography demonstrates minimal clot in the cephalic arch, which is under-filling secondary to fistula thrombosis. ( c ) Fluoroscopic image demonstrating the percutaneous thrombolytic device in the cephalic outflow ( white oval ). ( d ) Venogram from a sheath positioned in the cephalic vein outflow ( black asterisk ) demonstrating frank extravasation of contrast from the cephalic arch ( black oval ). Note the marker wire extending into the area of extravasation rather than across the injury into the subclavian vein. ( e ) Spot radiograph after reestablishment of wire access across the injury and following placement of the first uncovered metal stent. ( f ) Postdilation of the stents with a balloon, also used for tamponade of the injury. ( g ) Final venogram demonstrates patency of the overlapping stents (extending between white arrows ), and no further extravasation. Note the new stenosis of the left subclavian vein due to mass effect of the hematoma ( black arrowhead ). Case courtesy of Dr. Robert K. Ryu.

Fig. 2

( a ) Digital subtraction venogram of a left arm brachiocephalic fistula demonstrates a patent brachiocephalic fistula with stenosis in the outflow cephalic vein ( black arrow ). The patient returned 7 months later with thrombosis. ( b ) Fluoroscopic image during attempted declot of the thrombosed brachiocephalic fistula, showing angioplasty of the cephalic outflow stenosis with an elastic waist ( white arrow ). Persistent narrowing secondary to elastic recoil was noted on follow-up venography (not pictured). ( c ) A 10-mm bare metal stent was placed across the stenosis and postdilated to 8 mm. During percutaneous thrombolytic device (PTD) activation in the newly placed stent to remove recurrent thrombus, the stent became enmeshed in the rotational basket (not pictured). ( d ) The PTD was successfully removed, but the stent ( black oval ) was markedly deformed and peripherally migrated as a result.

Fig. 3

( a ) Fluoroscopic image during mechanical thrombectomy with a percutaneous thrombolytic device (PTD) in a left arm axillo-axillary AV loop graft. Note the indwelling stent grafts bridging the venous anastomosis ( white arrowheads ). ( b ) Following thrombectomy, a linear radiopaque foreign body was noted in the graft ( black arrow ) and retrieved with a snare device. ( c ) Photo of the PTD with the plastic tip retrieved from the graft ( black arrow ).

Fig. 4

Photo of an assembled percutaneous thrombolytic device. The black oval encircles the expanded fragmentation basket, and the white arrow points to the activation trigger on the external rotator unit.