PROCEDURAL CONSIDERATIONS

0

Pre-Procedure:

  • Heparin: Optional
    • 3000 U bolus (~40U/kg)
      • 1000 U/hr
    • Bivalirudin (Angiomax): Patient’s with heparin allergy
  • Antibiotics: Optional
    • Cefazolin 1 g IV
    • Vancomycin 500 mg IV
  1. Sheath placement
    1. +/- 2-10 mg tPA total
    2. Sheath 2 (retrograde) = 10-15 cm from sheath 1
      1. Optional (tPA 2-4 mg to arterial side of clot)
  2. Central and pullback venogram
    1. Get wire into central circulation
    2. Treat underlying central stenosis/occlusion
  3. Thrombolysis/thrombectomy
    1. Direct contact device
      1. Fogerty
      2. Arrow-Trerotola
      3. Rotating pigtail
    2. Non-contact
      1. Angiojet
  4. Pulse-Spray
    1. 2-6 mg tPA/5-10 cc saline
    2. e.g. Angiojet central to sheath
  5. Antegrade post tPA
    1. Balloon maceration
    2. Angiojet
    3. Suction thrombectomy
    4. Regardless: care not to push clot into arterial side
  6. S/P declot  – occlusion retrograde angiogram should be avoided