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BackTable / VI / Article
Pearls for Using the Inari RevCore Device in Venous Stent Occlusions
Rajat Mohanka • Updated May 1, 2024 • 98 hits
The RevCore device is a multidirectional debulking device commonly employed for recanalizing occluded venous stents. While achieving patency with the RevCore device may take time, the slow erosion of the clot contributes to improved patient outcomes and technical success. It is considered a relatively safe device to use; however, caution should be exercised when initially employing it. Clinicians can gradually increase aggressiveness as comfort allows.
Vascular surgeon Dr. Steven Abramowitz and interventional radiologist Dr. Angelo Marino provides further insights into the use of the RevCore device, and also share technical pearls aimed at enhancing clinical success. This article includes excerpts from the BackTable Podcast. You can listen to the full episode below.
The BackTable Brief
• The RevCore device was developed to debulk thrombotic material in venous stents and native vessels, offering a new solution to thrombectomy practices.
• Accessing the popliteal and internal jugular vein have their respective advantages in assessing inflow lesions and facilitating material collection.
• To efficiently gather organized, calcified material, clinicians can utilize the Protrieve Sheath while accessing the internal jugular vein.
• Initially use the device with caution and then progressively increase assertiveness based on tactile feedback and procedural response.
• For chronically occluded stents, techniques such as direct puncture with an 18-gauge needle and sharp recanalization are mentioned, along with the strategic use of groin access to maintain support.
• The RevCore device’s effectiveness extends to native veins, efficiently addressing chronic adherent thrombi and aiding in stent extension procedures.
Table of Contents
(1) Introduction to the Inari RevCore Device
(2) Strategic Access Site Selection for the RevCore Device
(3) Mastering the RevCore Device: Advice for New Users
(4) Techniques for Crossing Chronic Venous Occlusions
Introduction to the Inari RevCore Device
The RevCore device is a thrombectomy tool designed specifically for debulking thrombotic material in venous stents and native vessels. Characterized by its versatility, the device caters to a range of stent sizes (10 to 20 millimeters) and is suitable for native vessels 6 millimeters or larger. Its unique operating mechanism, facilitated by a catheter that includes an expandable coring element controlled via a handle, allows for precise directional movements—clockwise, counterclockwise, antegrade, and retrograde. This design not only macerates the thrombus effectively but also ensures removal from the stent wall. Viewing the RevCore device as a meticulous material eroding tool rather than merely a debulking instrument, allows the operator to be more patient during the case, enhancing both the procedure's efficacy and patient management strategies.
[Dr. Ally Baheti]
Let's move on to the topic of this podcast, which is the RevCore device. I am familiar with the device but haven't gotten to use it in clinical practice. Dr. Marino, could you just give me an introduction to the device?
[Dr. Angelo Marino]
Yeah. The RevCore device, it's a novel thrombectomy device, and it was made to debulk the thrombotic material in venous stents. The stent size that you can use it in, it ranges, but it's usually from 10 to 20 millimeters. You can also use it in native vessels, which are 6 millimeters or greater. It works over the wire. It's a catheter that consists of a coring element that you can expand, and you control it on a handle. What that does is you can basically turn it back and forth, clockwise, counterclockwise. You can push it over the wire forward and backwards, and it really helps to macerate the thrombus and pull it off of the stent wall.
[Dr. Ally Baheti]
Dr. Abramowitz, could you tell us a little bit about your initial case experience with this device?
[Dr. Steven Abramowitz]
We've done about 22 cases using the RevCore system since it was released. I found it to be very effective with patients and some caveats, and they aren't negative caveats. It's just this disease process and state generally tends to be more organized, more chronic. We've seen patients with calcium lining their re-thrombotic stents. We've seen patients with stent overlap zones where we have deformation of a wall stent, for example, within an Abre or another venous stent. No venous stent is more of a culprit than the other. It's just these are all considerations when using the device.
What the device really allows you to do with variable expansion and those three axes of intervention, clockwise, counterclockwise, as well as anti-grade and retrograde movements is mobilize that material. Initially, when I started using the device, I really thought of it as, well, this is just an aggressive debulking tool. I've changed my mentality, which has also changed, I think, the efficacy and my approach, where I think of it more of a lathe or a--- I'm not a cheese person, but what's that? There's that cheese knife that shaves off strips of cheese. When I think about the RevCore system as something that is grinding down or slowly eroding and working against this material, it's changed my case flow in terms of both work and that's made me more patient. That's led to, I think, great success in using the device as a tool for removing this material.
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Strategic Access Site Selection for the RevCore Device
When using the RevCore device, it is important to access both the popliteal and internal jugular (IJ) vein to maximize procedural success. Popliteal access is favored for its ability to thoroughly assess and address inflow lesions, which are crucial for the long-term patency of the stent. Conversely, the IJ approach can efficiently facilitate the collection of large volumes of mobilized material This is achieved with the utilization of adjunctive devices like the Protrieve Sheath. Furthermore, the practice of achieving 'through and through' access with a wire enhances the control and effectiveness of the RevCore device, allowing for more precise antegrade and retrograde manipulations.
[Dr. Ally Baheti]
What's your access site when you use the device?
[Dr. Steven Abramowitz]
I'm generally a proponent of popliteal and IJ access. This is for two reasons. One, I think that the popliteal access gives you a really good assessment of the inflow, because not only do you want to clear out the material that's thrombosed or organized within the stent itself, but you also want to address any inflow lesions that may have led to stent failure and really diagnose and work on those. There are certainly patients where we've put them on the table and I've said, "You know actually, this is not a RevCore candidate because even if we open the stent, the inflow is unsalvageable and the stent is just going to re-thrombose.”
Then from an IJ approach, it really allows you to use a device like the Protrieve Sheath to aid in the collection of the material that's mobilized from within the stent. Because when we see what's gathered, it generally tends to be very organized, white calcified material, collagenated material, and it comes out in large volume pretty quickly. That's a protective tool.
The last thing I'll say in there is I have found that my use of the system is more effective and more controlled when I have a wire flossed through and through the patient. Really giving somebody the ability to pull the wire on both ends, give a rigidity to the system so that I have the utmost amount of control when engaging in anti-grade and retrograde movements has really given me the optimal outcome I'm looking for.
[Dr. Ally Baheti]
Dr. Marino, do you usually go through the Protrieve Sheath to get to the occluded stent or do you find that popliteal access works best for you, too?
[Dr. Angelo Marino]
I always get popliteal access as well. What I do is once I have popliteal access, I also make sure that the groins and the neck are prepped and I always get right IJ access for the Protrieve Sheath. The groin access sometimes is very useful because when you're going up from the popliteal, you lose some of that support when you're trying to get through these chronically occluded stents. A lot of times, I find myself puncturing directly into the stent with an 18-gauge needle and then using some sharp recanalization to find my way up. Then coming down from the IJ through that occluded stent and then connecting down to the pop to get through and through access.
[Dr. Ally Baheti]
We haven't talked much on this show about venous CTOs and how we do through and through access for them. This seems like it's the ideal scenario for it is in a post-thrombotic patient. For the uninitiated, what size is the device? What size of sheath does it go through?
[Dr. Angelo Marino]
It is a 12 French OD.
[Dr. Ally Baheti]
Cool. It sounds like you can use the RevCore through the IJ access Protrieve Sheath. Just to be clear, are you guys using Protrieve for all of these cases?
[Dr. Angelo Marino]
I use the Protrieve for all of these cases.
[Dr. Steven Abramowitz]
I am. I have used other tools, but it goes back to what is the best access for a worst case scenario. When I have used other systems, I have ultimately converted to the Protrieve Sheath for that workability from the IJ for aspiration or re-stenting or snaring or having a dual-wired system from the contralateral popliteal as well.
Mastering the RevCore Device: Advice for New Users
New users should familiarize themselves with the RevCore device's feel and responsiveness so that they can adopt an adaptive approach that allows for increased aggressiveness when warranted by the procedure's progress. However, the RevCore is designed for safe use within stented segments, minimizing the risk of perforation or laceration. Furthermore, defining procedural endpoints based on the clinical scenario—whether aiming for complete material removal or sufficient luminal gain for additional interventions—helps tailor the technique to patient needs. Dr. Marino underscores the importance of gradual acclimatization to the device, highlighting its efficacy in native veins and the necessity of cautious advancement, especially in cases of stent fractures observed under fluoroscopy. This collective guidance not only accelerates the learning curve, but also enhances procedural success and patient outcomes.
[Dr. Ally Baheti]
…You both have a fair amount of experience with the RevCore device. Any initial tips and tricks that you would want to share with early users? Steven, let's start with you.
[Dr. Steven Abramowitz]
I think one of the things that I would share is to be timid, but don't be afraid. As you get used to the device, really get an assessment of the feel, the pushability of the haptics. Then at some point, if you find that you're not making progress, you can be more aggressive. You're dealing with a variable diameter revving system within a stented segment, and so you aren't likely to perf or to lacerate or to cause damage. That integrated retrograde motion over a snared wire that's through and through the body really gives you a next level ability to address the thrombus.
The other thing I would say is think about what your endpoint is. In an ideal world, I would be using the RevCore system to completely remove all of the material from within the stent. But there are situations where I'm just hoping for luminal gain. I know that I'm going to need to place another stent. I know that I'm going to need to extend an untreated segment of the external iliac vein or the common femoral vein. In that case, I think the technical endpoint that you're striving for is slightly altered. Putting that in the context of what you're hoping to accomplish, I think gives people a little bit more of that ability to feel like they can modulate their technical endpoint for the appropriateness of the case.
[Dr. Ally Baheti]
Dr. Marino, do you have any tips and tricks for early users?
[Dr. Angelo Marino]
Yeah, I agree. You want to start slow. You don't want to be too aggressive until you get a feel for it. The device works really well. You can also use it in native veins, which I was a little hesitant at first, but now I've done almost 20 cases. It works really well to get some of that chronic wool adherent thrombus, say, from the common femoral vein if you're trying to extend the stent down and you need a good landing zone.
Something to watch out for, which I found is pay close attention on fluoroscopy to see if there's a stent fracture, if some of the interstices of the stent are already fractured because you can get caught on that a little bit, especially with the wall stents when they're fractured. You just take it nice and slow. After you use it a few times, you'll get pretty comfortable. It's pretty straightforward to use.
Techniques for Crossing Chronic Venous Occlusions
In order to use the RevCore device, the operator must first be able to cross the occlusion. Dr. Abramowitz advocates for a methodical progression starting with a telescoping system and then utilizing a coaxial sheath approach paired with a stiff angled glide wire. If needed, clinicians can escalate to more aggressive tactics like balloon expansion and the use of a Chiba needle or metal cannula for enhanced guidance through scarred occlusions. Dr. Marino complements this with his preference for a nine French sheath and tools such as the Navicross, glide wire, and, in more complex scenarios, direct puncture methods and metal cannulas from liver biopsy sets for navigating occlusions.
Crucially, both experts highlight the importance of recognizing procedural boundaries, particularly in the face of potential complications such as perforation or adjacent artery injury, while also considering the patient's clinical context to determine the aggressiveness of the intervention.
[Dr. Ally Baheti]
I'll start with you, Dr. Abramowitz. What is your technique for crossing a chronically occluded venous stent?
[Dr. Steven Abramowitz]
I think there's definitely a workflow that we go through. I'll start with telescoping or coaxial system, so an 8 or an 11 French sheath in the popliteal, then using a six or a seven angled destination sheath through that and a stiff angle glide wire. If that doesn't work, we'll try to be a little bit more aggressive with balloon expansion to center and increase pushability with conversion to either using a Chiba needle or different systems. Even going so far as to using a metal cannula to help drive up and guide myself as I'm crossing through the stent, I find that really keeping intra luminal, once you're curving in the pelvic can be a challenge for some of these really chronic and scarred occluded stents.
[Dr. Ally Baheti]
Dr. Marino, what's your algorithm for crossing a venous occlusion?
[Dr. Angelo Marino]
Yeah, similarly. When I start out with these cases, I always put a nine French sheath in, and then through that sheath, I'll put in a six or a seven catheter or sheath to guide myself. I usually use the Navicross and the glide wire advantage. Start with the front end of the wire, but more often than not, you have to go to the back end for a sharp recan. Sometimes I'll use a TriForce catheter. You make one centimeter at a time, you get through it. Sometimes you have to use a balloon to make a little channel so you can change your direction and have some room to change your direction. In the more complex cases, I find that sometimes I have to use direct puncture into the stent if it extends down to the external or the common femoral and metal cannulas, like the cannula from a transjugular liver biopsy set to help you get across.
[Dr. Ally Baheti]
For operators who maybe do this less frequently, what's the stopping point to say, "I'm not going to cross this," or do you guys cross every occlusion that you see in venous stent? Dr. Marino, let's start with you.
[Dr. Angelo Marino]
I've been lucky enough so far that I've been able to cross most occlusions, but they can be challenging and they can take a really long time. I think a stopping point would be if you really perforate out or if you have some kind of injury to the adjacent artery, then I would stop. You have to make sure you do a lot of obliques. You do intravascular ultrasound. We have Cone-beam CT available to us too, just in case we want to have some extra imaging. If you use all the tools available, you should be able to cross.
[Dr. Ally Baheti]
Dr. Abramowitz, what's your take on that?
[Dr. Steven Abramowitz]
Yeah, I totally agree. I think the other thing is just always going back to indications. The patient who has C3 disease or some minimal swelling is very different from the patient who has an active ulcer or progressing hemosiderosis. Those are the patients where I find myself much more aggressive and will then tolerate a perforation, or even potentially the need to-- I've only had to do it once or twice, but place a covered stent in the arterial system after a perforation, but just to keep on persevering.
Podcast Contributors
Dr. Steven Abramowitz
Dr. Steven Abramowitz is a practicing vascular surgeon at MedStar Georgetown University Hospital in Washington, D.C.
Dr. Angelo Marino
Dr. Angelo Marino is an interventional radiologist with Yale Medicine in Connecticut.
Dr. Aparna Baheti
Dr. Aparna Baheti is a practicing Interventional Radiologist in Tacoma, Washington.
Cite This Podcast
BackTable, LLC (Producer). (2023, October 30). Ep. 380 – Managing Venous Stent Rethrombosis with the RevCore Device [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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