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FEATURED TECHNOLOGYINDIGO SYSTEMSponsored by Penumbra, Inc.Figure 1. Venogramdemonstrating anextensive iliofemoral thrombosis.Figure 2. Parts of thrombus removed,which wrapped around the SEP8.Thrombus was laced with 10 mg of tPA administeredthrough a multipurpose catheter (Glidecath, TerumoInterventional Systems) and left for 15 minutes. Theorigin of the left common iliac vein was then dilatedusing a 10-mm balloon (Advance, Cook Medical);a marked degree of balloon wasting was observed.The 115-cm CAT8 XTORQ aspiration catheter easilytracked into the thrombus. Under power aspiration,the CAT8 was slowly advanced distally into the common iliac vein in combination with SEP8 allowing forthrombus removal in a single passage. By cycling theSeparator back and forth under aspiration, the thrombus was removed (Figure 2).Repeat venography revealed a good result with a verysmall amount of residual thrombus (Figure 3).Venous access was then secured using a 6-F sheath(Avanti ; Cordis, a Cardinal Health company) viathe left popliteal vein. Thrombolysis was continuedovernight using tPA and a heparin infusion. Repeatvenography the following day revealed a moderatedegree of residual thrombus involving femoral and iliacveins; however, the veins were patent. A 10-F Brite Tipsheath was placed in the left common femoral vein toplace an 8-cm X 16-mm sinus-Obliquus stent (optimedMedizinische Instrumente GmbH) to cover the leftcommon iliac stenosis. A final venogram confirmedgood venous flow (Figure 4).Figure 3. Following use ofthe Indigo System, a venoFigure 4. Final venogram congram showed patency offirming good venous outflow.the iliofemoral segmentwith a small amount ofresidual thrombus.PATIENT OUTCOME AND FOLLOW-UPA mild degree of left leg swelling persisted the day aftertreatment, although this had improved. The pain had alsoreduced. The patient was discharged the following daywithout complication with continued oral rivaroxaban.DISCUSSIONEndovascular management is currently recommendedfor acute presentations of thrombotic May-Thurnersyndrome with moderate to severe symptoms.1 Weprefer to place a temporary IVC filter prior to intervention to protect against PE, although the British Societyfor Haematology guidelines state thrombolysis is not anindication for filter insertion.2The Indigo System was well tolerated and allowed forrestoration of flow. The Separator helped evacuate thethrombus effectively by limiting catheter clogging, whichhelped to reduce the procedure time. The appropriatelysized venous stent was not available at the time of aspiration. Had this been available, venous stenting couldhave been completed immediately after clot aspirationto help avoid the risks of overnight catheter thrombolysis and a second procedure.1. Patel NH, Stookey KR, Ketcham DB, Cragg AH. Endovascular management of acute extensive iliofemoral DVT causedby May-Thurner syndrome. J Vasc Interv Radiol. 2000;11:1297-1302. doi: 10.1016/s1051-0443(07)61304-92. Baglin TP, Brush J, Streiff M. Guidelines on use of vena cava filters. Br J Haematol. 2006;134:590-595.doi: 10.1111/j.1365-2141.2006.06226.x2020 VOLUME 8, NO. 5 INSERT TO ENDOVASCULAR TODAY EUROPE 25

FEATURED TECHNOLOGYINDIGO SYSTEMSponsored by Penumbra, Inc.ACUTE UPPER LIMB THROMBOSIS TREATEDWITH INDIGO SYSTEMJuan José Ciampi-Dopazo, MD, EBIRInterventional Radiology UnitHospital Virgen de las Nieves Granada, Spainjuanciampi@hotmail.comPedro Pardo Moreno, MD, PhDInterventional Radiology UnitHospital Virgen de las NievesGranada, Spainpedropardomoreno@gmail.comGonzalo Ruiz Villaverde, MD, PhDInterventional Radiology UnitHospital Virgen de las Nieves Granada, Spainlalousso@hotmail.com(Figure 1). An 85-cm CAT8 XTORQ85 aspiration catheter was advanced over an 0.035-inch guidewire facingthe occlusion. Aspiration was initiated and CAT8 wasused with the SEP8 to facilitate thrombus engagementinto the canister. After only 10 minutes of a few passeswith power aspiration, a 90% thrombotic load reductionwas achieved (Figure 2). Subsequent venography showedunderlying focal stenosis in the infraclavicular subclavianvein segment, which could be secondary to thoracicoperculum syndrome. Simple angioplasty was performedusing an 8-mm X 4-cm balloon catheter (Mustang,Boston Scientific Corporation), with significant stenosisresolution (Figure 3A and 3B).PATIENT FOLLOW-UP AND DISCHARGEA control venogram showed minimal residual clot(Figure 4). The procedure lasted approximately 45 minutes. The patient was asymptomatic at 24 hours anddischarged with low-molecular-weight heparin for3 months. The patient’s thoracic operculum syndromewill be followed on an outpatient basis to plan surgery.PATIENT PRESENTATIONDISCUSSIONA woman in her 50s with no previous diseases preThe Indigo System can be considered a safe andsented with an acute left arm and shoulder edema andefficient instrument for the removal of acute venouspurple skin coloration after sudden physical exercise. Dopplerultrasound was performed,identifying a complete thrombosis of the left axillary and subclavian veins.Therapeutic anticoagulationtreatment with low-molecularweight heparin was initiated,and 12 hours later, the patientwas sent for treatment in thevascular and interventionalFigure 1. An intraoperative venogramFigure 2. The first result after power aspiradiology unit.showed occlusion of the subclavian vein.INTERVENTIONThe procedure was performed under conscious sedation and a total volume of5,000 IU heparin was administrated intravenously. Retrogradevascular access to the venoussegment was performed underultrasound guidance usingan 8-F short sheath in the leftbrachial vein. Venographyconfirmed thrombus in thesubclavian and axillary veinsAration using CAT8/SEP8 showed successful thrombus removal.BFigure 3. Placement of the 8-mm X 4-cm Mustang balloon catheter for angioplasty ofstenosis in the infraclavicular subclavian vein segment.26 INSERT TO ENDOVASCULAR TODAY EUROPE 2020 VOLUME 8, NO. 5

FEATURED TECHNOLOGYINDIGO SYSTEMSponsored by Penumbra, Inc.thrombosis of the upper limb. In cases of heavy clotburden, its main advantage includes the use of continuous power aspiration through large lumen cathetersto help with thrombotic load removal while helpingto reduce hemolysis complications. In addition, it mayreduce the risk of bleeding complications by potentiallylimiting or diminishing the need of fibrinolytic agents,which can help avoid the need for intensive care tohelp shorten the length of hospital stay.1Figure 4. The final venogram demonstrated almost completeremoval of thrombus in the subclavian and axillary veins.PORTAL VEIN THROMBOSIS AFTERLIVER TRANSPLANT TREATED WITHINDIGO SYSTEM AND THROMBOLYSISAbdulRahman Alvi, MRCS, FRCRConsultant Vascular and InterventionalRadiologist King Abdul Aziz Medical City, Ministry ofNational Guard Health AffairsRiyadh, Saudi Arabiaarjalvi@gmail.com; @DRARJA VIRPATIENT PRESENTATIONA 71-year-old man presented to a local hospital withabdominal pain, vomiting, and weight loss. He had aliver transplant for hepatitis C cirrhosis in 2006. His initial blood tests, including white blood cell count, liverfunction tests, and serum lactate, were normal. A dualphase CT of the liver demonstrated extensive portalvein thrombosis involving the intrahepatic portal veinbranches and extending into the superior mesentericvein (SMV) and splenic vein. Despite mesenteric fatstranding, there were no signs of bowel ischemia. Lowmolecular-weight heparin was started, and the patientwas subsequently transferred to our tertiary liver transplant center for further management.Despite a prolonged lytic drip, a second CT scanshowed no change in the distribution and volume ofportal venous-mesenteric thrombosis. Endovasculartreatment options included either a transjugular intrahepatic portosystemic shunt (TIPS) or percutaneous transsplenic/transhepatic thrombectomy and thrombolysis.A TIPS procedure was undertaken given the extensiveintrahepatic portal vein thrombus and the need toestablish satisfactory outflow.1. Vemuri C, Payam S, Benarroch-Gampel J, et al. Diagnosis and treatment of effort-induced thrombosis of the axillary subclavian vein due to venous thoracic outlet syndrome. J Vasc Surg Venous Lymphat Disord. 2016;4:485-500.doi: 10.1016/j.jvsv.2016.01.004ABCFigure 1. Initial portal venogram showed extensive portalvein (A, B) and SMV (C) thrombus.ABFigure 2. Significant residual thrombus in portal vein afterTIPS implantation (A). Improved flow across the TIPS afterdeployment of 12-mm Venovo stent into the thrombosedmain portal vein (B).INTERVENTIONThe thrombosed portal vein was accessed from theright hepatic vein under ultrasound guidance, and initialvenography correlated with the CT findings of the extensive portal and SMV thrombosis (Figure 1). A 10-mm (7 2 cm) Viatorr TIPS endoprosthesis (Gore & Associates)2020 VOLUME 8, NO. 5 INSERT TO ENDOVASCULAR TODAY EUROPE 27

FEATURED TECHNOLOGYINDIGO SYSTEMSponsored by Penumbra, Inc.was implantedbetween the rightportal vein andright hepatic vein.Extensive residualthrombus remained,therefore, a 12-mmVenovo venous stent(BD Interventional)was placed into theportal vein, resulting in improvedflow; however, significant thrombusremained (Figure 2).Figure 3. Extensive residualConsequently, an overSMV thrombus after 24 hours ofnight lytic drip wascatheter-directed thrombolysis.attempted.After 24 hours of lysis, repeat venography demonstrated suboptimal results with residual thrombus (Figure 3).Mechanical thrombectomy of the portal vein, SMV, andits tributaries was undertaken using the Indigo System.The CAT8 XTORQ aspiration catheter was deliveredthrough a transjugular approach via the 10-F sheathto the thrombus. Aspiration was commenced allowingfor gentle removal of the high thrombus burden at themain portal vein using the CAT8 in conjunction withSEP8. An Indigo CAT6 catheter was telescoped throughthe CAT8 XTORQ to facilitate thrombus removal in thesmaller vessel of the SMV and deep into its tributariesto improve the inflow to the portal vein (Figure 4). Thepostprocedure venogram showed restoration of flowthrough the TIPS, portal vein, and the main trunk of theSMV and its tributaries (Figure 5).Liver Doppler ultrasound performed on day 3 afterTIPS demonstrated patent TIPS and portal vein withresidual nonocclusive thrombus within the SMV andsplenic vein. Systemic anticoagulation (apixaban) wascommenced on discharge. CT scan at 2 months anda TIPS surveillance angiogram (Figure 6) at 3 monthsshowed a patent portal vein, SMV, and TIPS stent with aportocaval pressure gradient of 7 mm Hg.DISCUSSIONThe incidence of portal vein thrombosis after liver transplantation is uncommon but can cause significant mortalityand morbidity. TIPS provides access into the portal veinwith a theoretically lower bleeding risk because of a reducedrisk of liver capsule transgression as well as increased portalvein flow, which helps dissolve residual thrombus.This case illustrates the versatility of the Indigo System,with its wide range of highly trackable and atraumatic28 INSERT TO ENDOVASCULAR TODAY EUROPE 2020 VOLUME 8, NO. 5ABFigure 4. Power aspiration with CAT8/SEP8 the SMV and portal vein (A). Telescoping of the CAT6 through CAT8 (B).Figure 5. Postthrombectomy venogram demonstrated patent TIPS, portal vein, main trunk of the SMV, as well aspartial recanalization of some of its tributaries.Figure 6. TIPS surveillance angiogram at 3 months showed apatent TIPS. The portocaval pressure gradient was 7 mm Hg.

FEATURED TECHNOLOGYINDIGO SYSTEMSponsored by Penumbra, Inc.catheters facilitating thrombectomy deep within themesenteric venous system. The powerful aspirationpump generates a sustained vacuum that facilitatesthrombus extraction in cases with significant thrombusACUTE ISCHEMIA OF THE LEFT UPPER LIMBTREATED WITH INDIGO SYSTEMFrancesco Intrieri, MDChief of Vascular SurgeryOspedale Annunziata–AO CosenzaCosenza, Italyf.intrieri@alice.it; francesco.intrieri@pec.itVincenzo Molinari, MDVascular SurgeryOspedale Annunziata–AO CosenzaCosenza, Italyvincenzomolinari79@gmail.comPATIENT PRESENTATIONA 70-year-old man presented in the emergencydepartment with acute ischemia of the left hand.He had a history of coronary artery disease, cardiacarrhythmia, chronic obstructive pulmonary disease,and chronic lymphatic leukemia and was undergoingantiplatelet therapy. CTA showed evidence of parietalthrombosis in the subclavian and axillary arteries thatlooked slightly dilated. Furthermore, the distal part ofFigure 2. CAT6 and SEP6 tracked tothe distal radial artery.burden. The Indigo System can potentially reduce thevolume of fibrinolytic agents administered, which mayhelp lowering the risk of hemorrhage in these patients.the radial artery,ulnar artery, and thesuperficial and deeppalmar arch werethrombosed. In theclinical examination,the hand lookedcyanotic and ischemic with a deficit inmobility and sensitivity and, therefore,was scheduled forrevascularizationwith thrombolysis.The cause of theFigure 1. Preprocedural angiogramischemic hand wasshowed total occlusion of the radialan embolic eventartery after thrombolysis.from atrial fibrillation. An attempt ofintra-arterial thrombolysis was unsuccessful (heparinand urokinase infusion).INTERVENTIONPercutaneous access was performed throughthe right femoral artery with a 6-F, 90-cm sheathFigure 3. Postprocedural angiogramafter CAT6 and CAT3 showing successfulrecanalization.Figure 4. Complete restoration of flowafter Indigo System and thrombolysis.2020 VOLUME 8, NO. 5 INSERT TO ENDOVASCULAR TODAY EUROPE 29

FEATURED TECHNOLOGYINDIGO SYSTEMSponsored by Penumbra, Inc.(Destination, Terumo Interventional Systems) up tothe left axillary artery, and angiography was performed.Despite the thrombolysis treatment, the radial arterywas occluded distally with no runoff into the palmar orinterdigital branches (Figure 1).A 135-cm Indigo CAT6 aspiration catheter was inserted through the Tuohy-Borst adapter of the 6-F sheath. Iteasily tracked over an 0.018-inch Command ST (Abbott)guidewire into the radial artery. Mechanical thrombectomy using power aspiration was performed. CAT6and SEP6 were used to engage the emboli occludingthe distal radial artery (Figure 2). Partial thrombectomywas achieved with CAT6, and a 150-cm CAT3 was telescoped through the CAT6 to reach the superficial anddeep palmar arch, resulting in complete revascularization. The patient’s clinical conditions improved, showingparenchymal enhancement at the level of the radial andpalmar artery as well as the interdigital branches. Controlangiography was performed (Figure 3).THROMBOSIS OF THE MAIN BODY AND RIGHTLIMB OF AN AORTIC STENT GRAFT TREATEDWITH INDIGO SYSTEMHeiko Wendorff, MD, FEBVSSenior Physician Vascular Surgery Specialist, EndovascularSurgeon and Specialist, PhlebologyClinic and Polyclinic for Vascular andEndovascular SurgeryTechnical University of MunichMunich, Germanyheiko.wendorff@mri.tum.dePATIENT PRESENTATIONA 79-year-old man underwent total endovascularaneurysm repair (EVAR) of his abdominal aortic aneurysm in 2015. The patient’s medical history includedarterial hypertension and hyperlipidemia. In 2019,he presented with bilateral iliac aneurysms. Iliac sidebranch (ISB) grafts were planned on both sides tomaintain blood flow into the internal iliac arteries andprevent buttock claudication. In May 2019, he receivedhis left ISB, and in July 2019, an E-liac side branch prosthesis (Jotec) was implanted. Before discharge, thepatient underwent a control CTA showing thrombusformation in the aortic stent graft bifurcation extending into the right limb.30 INSERT TO ENDOVASCULAR TODAY EUROPE 2020 VOLUME 8, NO. 5To further improve flow, a 24-hour intra-arteriallow-dose thrombolysis was continued. Final angiography showed a complete resolution of the thromboticobstruction of the radial artery, the superficial palmararch, and a full recovery of the interruption of theinterdigital arteries (Figure 4). The patient was discharged with anticoagulation therapy considering theembolic background of acute ischemia.DISCUSSIONCatheter-directed thrombolysis provides a therapeutic option in situations of acute occlusive thrombusof the hand. There are times when thrombolytics arecontraindicated or fail to lyse the thrombus. In thiscase, the Indigo System offered an alternative treatment option for thrombus removal in vessels of different diameters. The Indigo System catheters range from3 to 8 F, permitting power aspiration as far as into thesuperficial palmar arch.INTERVENTIONRight femoral access was achieved with a 5-F shortsheath. An angiogram through a 5-F pigtail catheterconfirmed the findings from the CTA. There was freefloating thrombus formation riding on the bifurcation ofthe main body extending into the right ISB (Figure 1).An 8-F, 45-cm sheath (Destination, TerumoInterventional Systems) was inserted to stabilize theposition of the Indigo aspiration catheter within thestent graft limb (Figure 2).An 85-cm CAT8 TORQ aspiration catheter was carefully advanced over an 0.035-inch guidewire aspirationcatheter through the crosscut valve of the 8-F sheathusing the peel-away introducer. Once the CAT8 wasfacing the thrombus, the guidewire was removed andpower aspiration was turned on. The first pass was completed without the Separator, however, the thrombuswas already too organized to be removed without theSeparator technique. CAT8 and SEP8 were advancedcarefully into the thrombus from proximal to distal. TheSeparator was cycled back and forth to facilitate clotfragmentation at the catheter tip.When the tip of the catheter appeared to be blocked,the CAT8 was withdrawn by the millimeter with thorough movement of SEP8 until flow appeared in the tubing and then advanced again.A shot of contrast through the sheath confirmedthe full removal of thrombus after only 20 minutes(Figure 3). Control angiography showed runoff in bothlegs and ruled out distal thrombosis or emboli resulting

FEATURED TECHNOLOGYINDIGO SYSTEMSponsored by Penumbra, Inc.Figure 1. Thrombus presenting in the mainbody extending into the right limb.Figure 2. Stabilization of retrograde accessthrough the right ISB.from the intervention. The total procedure time was52 minutes.The patient was discharged with 100 mg of aspirin and75 mg clopidogrel for 3 months, then monotherapy withaspirin.DISCUSSIONThe treatment of occluded or partially occludedstent graft limbs is challenging. Full anticoagulationwith vitamin K antagonists or open embolectomymight be an option in patients without symptoms. Therisks associated with full anticoagulation are a potentialincreased risk of hemorrhagic or other complications.Residual thrombus removal and the risk of dislodgingstent graft limbs with open embolectomy may limit thesuccess rate of these procedures.The Indigo System is an essential tool that can helptreat challenging complications that may arise afterFigure 3. Successful thrombusremoval after the procedure withCAT8/SEP8.EVAR. In this case, continuous power aspiration resultedin restoration of blood flow in only 20 minutes withoutcomplication. The Indigo System’s large lumen aspiration catheter and its atraumatic distal tip allowed savingaccess into the existing prosthesis and enabled targetedthrombus removal. nDrs. Robert A. Lookstein, Miguel A. de Gregorio, AndrewGemmell, Juan José Ciampi-Dopazo, AbdulRahman Alvi,Francesco Intri

An infrarenal IVC filter (Celect Platinum, Cook Medical) was placed initially accessing the right internal jugular vein with a 9-F sheath (Brite Tip; Cordis, a Cardinal Health company). A hydrophilic guidewire passed easily through the left iliac thrombus. Venography confirmed thrombosis extending to the mid femoral vein level (Figure 1).