Techniques for rapid evacuation of venous and arterial clot with vacuum-assisted thrombectomy

Acute arterial thromboembolism and venous thrombosis are limb-threatening and potentially life-threatening conditions. Acute arterial thrombus prohibits perfusion to affected limbs, resulting in emergent limb salvage situations. Acute lower extremity deep vein thrombosis (DVT) is a common condition that can cause substantial disability, with the most common feared complication being a life-threatening acute pulmonary embolus. In all of these situations, standard treatments—including anticoagulation, thrombolysis, and surgery—have significant limitations and potential complications. Therefore, continued innovation in this area is needed. Many mechanical endovascular techniques for thrombus removal have been explored over the last two decades. Most have failed to be adequately efficacious or have been associated with unacceptable complication rates. Problems have included limited trackability, vessel injury, and incomplete revascularization. One of the main difficulties is designing a device that can remove adequate volumes of variable age thrombus while also maintaining an acceptably small size, flexibility, and ease of use. With the addition of larger 6and 8-F systems and a venous indication, the Penumbra Indigo® System is designed to address many of these limitations by bringing more powerful, larger-bore aspiration catheters with greater trackability to the peripheral vasculature to evacuate greater thrombus burdens from large vessels. Penumbra’s Pump MAXTM and patented SeparatorTM technology help to maintain continuous aspiration, limiting clogging of the catheter’s tip. This percutaneous system is available in four diameter options (CAT3, CAT5, CAT6, and CAT8), with lengths ranging from 85 to 150 cm, allowing smaller-diameter catheters to work coaxially through largerdiameter catheters to treat long lesions in tapering vessels. Smaller sizes can track into vessels as small as those in the foot, and larger sizes can be effective in vessels as large as the vena cava, allowing great flexibility. Unlike thrombolysis, which often requires prolonged infusion times, Indigo is able to provide rapid restoration of flow to thrombosed vessels in settings in which there is inadequate time to allow thrombolysis to work. It can also be used for revascularization when thrombolytic therapy and surgery are contraindicated or prior to thrombolysis to decrease thrombus burden and potentially shorten lengthy infusion times (which can be quite costly). Finally, the Indigo System can be effective in removing more organized, subacute to chronic thrombus after thrombolytic therapy has failed. We have found the Indigo System to be beneficial in removing clot related to a wide variety of thromboembolic conditions. The following cases highlight rapid revascularization with Indigo in both arterial and venous occlusions.