.png){kind=small}
.png){kind=small}
BackTable / VI / Article
New Venous Thrombectomy Devices & How to Use Them: The Symphony Catheter
Melissa Malena • Updated Nov 25, 2024 • 36 hits
How do you tackle tricky venous disease cases? With recent advances in venous thrombectomy devices, it might be time to rethink your approach and your toolset. Interventional cardiologist Dr. Adam Raskin offers an in-depth walkthrough of his dual access technique; detailing equipment, common challenges, and the role of the new Symphony catheter.
This article features transcripts from the BackTable Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.
The BackTable Brief
• Given the dynamic and varied presentations of venous disease, interventionalists should maintain a baseline comfort and knowledge level of all available catheters and devices in order to utilize the most appropriate toolset for each individual case.
• Dr. Raskin’s basic technique consists of accessing the posterior tibial vein on the ipsilateral leg, then accessing the contralateral femoral vein and wiring a sheath up and over the rail to the clot.
• Devices can be used both anterograde through the tibial vein and retrograde through the femoral vein to fully clear venous clot.
• The Imperative Care Symphony catheter’s powerful aspiration capability, smooth dilator, and 1:1 torque create an ideal catheter for quicker venous procedures, benefiting both the patient and operator.
Table of Contents
(1) Venous Devices: Picking the Right Tool for the Job
(2) The Dual Access Venous Thrombectomy Technique
(3) The Imperative Care Symphony Catheter: The Next Iteration in Venous Thrombectomy Devices?
Venous Devices: Picking the Right Tool for the Job
Recent technological advancements have created an abundance of venous clot removal devices. With devices now covering many specific clinical scenarios,. Dr. Raskin recommends being comfortable with all available devices so that treatment decisions can be made on the fly to best fit the needs of each individual patient. The most appropriate device for a given venous disease case can vary significantly depending on clot location, access vein and history of pulmonary embolism, among other factors, as the doctors explain.
[Dr. Sabeen Dhand]
The tech has improved over the last, five, six years. There's a lot on the market now from small bore devices to agitating devices, to large bore. How has the tech shaped your practice? What do you like to use? We can use specific case examples if you want, but what do you use or do you use everything?
[Dr. Adam Raskin]
I would say we probably use everything. It could be very patient-specific. It could be access-specific. It could be the location of the clot. You have an IVC thrombus, you're not going to use an 8 French catheter. You have something popliteal, distal fem, popliteal, you don't need a 24 French catheter. It's so variable. You can get phenomenal results based on the choice that you use. If you know what you're going after ahead of time, you have a good game plan. You can access the popliteal vein safely. I would say 90-plus percent of our patients, the access point is the popliteal vein. Typically prone, we feel pretty comfortable. Always in the back of our mind, that PE patient, a couple of days after their event, can they lie prone safely?
If God forbid you cause another one, are they going to be in a safe place in terms of their respiratory status? That's always a big thing in the back of our mind. Are we going to be able to reach? Where are we coming from? I think we have the opportunity now, which is new as I've been able to use it. There's a catheter with Imperative Care, the Symphony catheter, which I actually have been able to go up and over. I used to avoid it like the plague, going up and over in the venous system. What a disaster, but we've had this ability where we can access the tibial vein on the affected side, and then snare a wire up and over.
The patient is on their back, and we can access the femoral vein. We can snare a wire, and then run a sheath from the contralateral side up and over, pretty smoothly. We can run a 16 French GORE DrySeal sheath if someone is on their back, from the contralateral common femoral vein up and over, and run a catheter down. The catheter, Symphony, is really flexible and travels really easily, especially those valves, which we're fighting. If you have the sheath pretty far down, we can get as far down into a tibial vein. I think that's always also the big question, how far do you treat?
If you can get down there and get a result, I think that the more you can get, the better. That's a nice option. Coming from the popliteal vein up, I think that popliteal vein can handle pretty large bore catheters. We can put in a 16, no problem, put in a 24 bareback, no problem. Depends on obviously the patient's size and stuff like that. The beauty of the vein work is you can be pretty aggressive. That's why I love it. The risk is not that high. You could be aggressive. You could be really aggressive. I think one of the things that we're always in the back of our mind sometimes is, bigger is better.
You can get a lot of thrombus removed. You have to be mindful of blood loss, obviously. I think as the bigger the catheter goes up, that's always an issue. I think we're still learning. We really are. Keep your options open. That's what I would tell anyone. Keep your options open. Try different things. Use all different techniques because you can get incredible results. You really can.
Listen to the Full Podcast
Stay Up To Date
Follow:
Subscribe:
Sign Up:
The Dual Access Venous Thrombectomy Technique
When it comes to access, Dr. Raskin primarily operates with a prone patient, accessing the femoral vein and utilizing a snare wire to run a sheath contralaterally up and over the clot. However, prone positioning of the patient can threaten their respiratory status in cases of a previous pulmonary embolism.
Dr. Raskin’s usual technique consists of accessing the posterior tibial vein on the ipsilateral occluded leg, then accessing the contralateral femoral vein and wiring a sheath up and over to the clot. For snaring the contralateral femoral vein, Dr. Raskin recommends using the 035 Advantage wire to create a rail. Once the rail has been established, it is significantly easier to run a sheath, for which Dr. Raskin prefers the 16 GORE DrySeal sheath. Once the sheath is placed, a catheter is run down the leg through the sheath.
Catheter choice will vary based on case necessity, with the end goal being to clear out everything from ankle to iliac. Dr. Raskin recommends running an 8 French catheter antegrade from the tibial vein and a 16 French catheter retrograde from the femoral vein, aiming to meet them in the middle.
[Dr. Sabeen Dhand]
You described your technique. Basically, you get access into the posterior tibial vein on the ipsilateral [occluded] leg and then the contralateral fem, and you bring your sheath up and over. Are you using multiple devices then to clear out iliac, common fem, femoral, pop, and then posterior tibial?
[Dr. Adam Raskin]
Correct. Usually, the times we've done it, the iliacs are probably okay. It's going to be mostly the femoral system. Then what we'll do is, going up and over, I would avoid. That is not easy to do, but if you can get a wire, if you can get an 035 Advantage wire, it's the most common, from the tibial system straight up, then snare it and pull it out the contralateral common femoral vein, you have a rail, and you have a really good rail. Once you've got that rail, you can run anything up and over, instead of trying to do it on your own without that rail is a headache, and it's just very difficult.
It's technically challenging, especially once you're trying to fight all those valves. Now I've taken that out of the equation. I have a good rail. You can then run a sheath. Typically, what we use 99% of the time is we'll take a 16 GORE DrySeal. We'll then put it up and over, over the rail, and then we'll run our catheter down. We'll start with a 16, so that'll clear out as much as we can. The 16 goes pretty far. You can then run a smaller catheter within the 16. You can either run an 8. Most of the time the 8s won't reach through the 16, but again, just use the rail.
You can run the 8 up the tibial vein from the ankle. I think it'll handle it no problem. Most of the tibials can handle an 8 French catheter, sort of above and below, a retrograde and antegrade approach, and meet in the middle. Run the 16 from retrograde and run the 8 antegrade, and that gives you your best shot. We can get some really, really phenomenal results. Trying to clear everything out really from the ankle to the iliac.
The Imperative Care Symphony Catheter: The Next Iteration in Venous Thrombectomy Devices?
Though the Symphony catheter is relatively new to the venous thrombectomy scene, Dr. Raskin now uses it regularly as it offers a successful combination of everything needed from IVC to ankle including a 75-degree angled tip, 1:1 torque control and a dilator. The Symphony catheter also has significant power, sometimes removing clots in a single aspiration. According to Dr. Raskin, this aspiration power allows for a reduction in fluoro, contrast and sedation time, which benefits both the patient and the interventionalist.
[Dr. Sabeen Dhand]
You mentioned you're using the Symphony catheter. Does that come in all these sizes?
[Dr. Adam Raskin]
Really nice catheter, 16, soon to be 24. The 16 for us is just a really nice combination of everything from IVC to the ankle. If you can keep it simple, one catheter can do everything in one shot. We've had some really, really nice results, so we've been really happy with it so far. We look forward to even more experience and some research.
[Dr. Sabeen Dhand]
What are things that you like about it? Is it just as flexible? Is the suction any different, or anything like that?
[Dr. Adam Raskin]
When I say different, I would say it is just as powerful as anything else. The suction capability is really high. To me, sometimes what we've seen is a single aspiration. The more time you're there with any procedure, just the complication risk goes up. If I can tell you I can turn the catheter on and do a single pull, and then do a venogram and you're done, that's a pretty easy sell, and reduces fluoro time, contrast time, sedation time. Anything reducing procedure time is a benefit not only to the operator but also to the patient. We've had some really, really quick results.
Sometimes quick is not always what we're looking for, but if it works that fast, to me, that's a no-brainer. We like the speed of it, the deliverability of it, whether you need to run it. It comes with a dilator. You can run it up the leg with the dilator, you can run it up without the dilator. We can inject through it, so you can do your venograms with the catheter in place. You can also hook it up. It's a multi-port, but you can hook it up to pressures. You can check pressures if you'd want to. I like being able to take isolated pictures and identify specifically where you're going so you can see exactly where there's residual clot.
It's got nice torquability. It's a one-to-one torque, I would say. The tip has got an angle to it, so I can angle where I'm going. Directionality is really nice. All these little tips and tricks that increase the success of not only getting good flow, but as much to 100% thrombus resolution as you can. It's not always what we're looking for, but the closer you can get, the better. We've had, like I said, really nice, safe results thus far. We're really happy.
[Dr. Sabeen Dhand]
I think every iteration, and that's what we're seeing, all companies coming out with catheters, they make each other better. Right?
[Dr. Adam Raskin]
Oh, absolutely.
[Dr. Sabeen Dhand]
Good points. You mentioned multi-port. It's nice to have more ports to be able to do pressures or inject and just a bunch of other features that may seem small, but they all add on, making it something that you want to use. It's nice when it's there. Yes, it's nice when it's there. It's like you don't know what you have until you have it. Right?
[Dr. Adam Raskin]
Exactly.
Podcast Contributors
Dr. Adam Raskin
Dr. Adam Raskin is an interventional cardiologist in Cincinatti, Ohio.
Dr. Sabeen Dhand
Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.
Cite This Podcast
BackTable, LLC (Producer). (2024, September 17). Ep. 480 – Venous Treatments: How Low Do You Go? [Audio podcast]. Retrieved from https://www.backtable.com
The Symphony Thrombectomy System is intended for the non-surgical removal of fresh, soft emboli and thrombi from blood vessels. Injection, infusion and/or aspiration of contrast media and other fluids into or from a blood vessel, intended for use in the peripheral vasculature and it is not for use in the pulmonary vasculature. Rx only. Important Safety Information may be found at http://bit.ly/3pAaUlw.
Views expressed are those of the speakers and not necessarily those of the sponsor. Certain content in this podcast contains forward-looking statements and no assurance of future results should be relied upon. Brands and trademarks referenced herein are those of their respective owners or holders.
Dr. Adam Raskin is a paid consultant of Imperative Care.
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.
Podcasts
Articles
DVT Treatment in 2024: The Critical Role of Interventional Care