AJR 2002; 179:370-372
© American Roentgen Ray Society
Use of the Angiojet Thrombectomy Device to Facilitate Removal of Impacted Intrahepatic Ductal Debris
Stephen P. Loehr1,
Clint Hamilton1,
Kenneth Gargan1 and
John Gilliam2
1 Department of Radiology, Wake Forest University School of Medicine, Medical
Center Blvd., Winston—Salem, NC 27157-1088.
2 Department of Gastroenterology, Wake Forest University School of Medicine,
Winston—Salem, NC 27157-1088.
Received November 26, 2001;
accepted after revision February 11, 2002.
Address correspondence to S. P. Loehr.
Introduction
The use of nonsurgical imaging-guided methods for removing biliary stones
and debris has been a mainstay in interventional therapy for almost 30 years.
Initially performed to remove common bile duct stones that were retained after
cholecystectomy, these techniques are often used for patients with complex
intrahepatic disease. A variety of innovative techniques have been used with a
high success rate to treat patients with complicated intrahepatic and
extrahepatic biliary stone disease
[1]. However, the time and
expense of successfully treating biliary lithiasis may prove to be
prohibitive, especially when devices such as choledochoscopes and
lithotriptors are not readily available. We describe a patient with extensive
intrahepatic biliary stone and debris impaction after choledochojejunostomy in
whom a rheolytic thrombectomy device was used to facilitate biliary ductal
clearance.
A 45-year-old woman with a history of type IV choledochal cyst was admitted
with a 3-day history of severe nausea, vomiting, abdominal pain, and malaise.
The patient had undergone biliary—enteric bypass for a common bile duct
injury 10 years before. She had multiple surgical revisions in the interim,
which culminated in complete resection of segment IV of the liver. A jejunal
chimney had been created to facilitate percutaneous retrograde biliary access
4 years before this admission, because the patient had experienced recurrent
bouts of cholangitis and choledocholithiasis. At the patient's request, this
procedure was reversed 2 years before her current presentation. Given the
patient's symptoms, recurrent intrahepatic biliary obstruction was suspected,
and she was referred to the cardiovascular and interventional radiology
section for percutaneous transhepatic cholangiography and possible
therapy.
From a midaxillary approach, access to a right posterior biliary radical
was achieved with a 21-gauge Chiba needle (Cook, Bloomington, IN). The needle
was exchanged over a 0.018-inch Cope wire (Cook) for an 8-French Neff Set
introducer sheath (Cook), and a cholangiogram was obtained
(Fig. 1A). The sheath was
exchanged over a 0.035-inch Stiff Amplatz wire (Angiodynamics, Queensbury, NY)
for a 5-French Berenstein catheter (Angiodynamics) that was directed across
the choledochoenteric anastomosis. A second 0.035-inch Amplatz wire was placed
into the left ductal system as a safety wire. A 9-French Desilet-Hoffman
sheath (Cook) was advanced over the second (working) wire into the unopacified
left hepatic ductal system. An 8 x 20 mm Marshall angioplasty balloon
(Meditech, Quincy, MA) was advanced over the first wire and used successfully
to dilate the choledochoenteric anastomosis. After the balloon was withdrawn,
a wire basket and then a snare device were advanced into the left hepatic
ductal system to remove the impacted ductal material
(Fig. 1B). Despite multiple
attempts and repeated aspiration from the sheath, only minimal improvement was
seen.
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Fig. 1A. —45-year-old woman with recurrent right upper quadrant pain
after choledochojejunostomy. Percutaneous transhepatic cholangiogram reveals
patent and centrally dilated right intrahepatic ducts with peripheral ductal
attenuation. Left intrahepatic duct is occluded (thick arrow).
Stenosis is present at choledochojejunal anastomosis (thin arrow).
Anastomosis was successfully dilated with angioplasty balloon.
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Fig. 1B. —45-year-old woman with recurrent right upper quadrant pain
after choledochojejunostomy. Digital spot radiograph shows wire snare
extraction device (thick arrow) in left hepatic duct. Safety wire
(thin arrow) is positioned across choledochojejunal anastomosis.
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At this point, we decided to perform rheolysis in an attempt to fragment
and possibly remove the biliary concretions. A 6-French Angiojet rheolytic
device (Possis, Minneapolis, MN) was advanced over a 0.035-inch Bentsen wire
(through the sheath) into the left ducts
(Fig. 1C). Over the wire, the
Angiojet device was passed through the ductal system several times. A repeated
cholangiogram showed near complete clearance of the capacious left ductal
system. The right ductal system and choledochoenteric anastomosis were widely
patent as well (Fig. 1D). Two
8-French biliary drainage catheters (Flexima; Meditech) were placed as safety
catheters (Fig. 1E).
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Fig. 1C. —45-year-old woman with recurrent right upper quadrant pain
after choledochojejunostomy. Digital spot radiograph shows that Angiojet
thrombolytic device ([Possis, Minneapolis, MN], arrow) has been
advanced into left ductal system.
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Fig. 1D. —45-year-old woman with recurrent right upper quadrant pain
after choledochojejunostomy. Transcatheter cholangiogram obtained after
Angiojet passage reveals patent and capacious right and left intrahepatic
ducts. Choledochojejunal anastomosis was successfully dilated with angioplasty
balloon.
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Fig. 1E. —45-year-old woman with recurrent right upper quadrant pain
after choledochojejunostomy. Digital spot radiograph shows two 8-French
biliary drain catheters positioned in left hepatic duct and across
choledochojejunal anastomosis.
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Percutaneous extraction of biliary stones in patients who have undergone
choledochoenteric bypass may be performed using either a transhepatic or a
transjejunal approach [2]. A
well-recognized and effective means for removing impacted biliary stones is
basket extraction. This method usually entails some degree of physical
disruption and maceration of the stones before their removal through a sheath.
Other methods include balloon or catheter manipulation, laser lithotripsy,
electrohydraulic and mechanical lithotripsy, and direct choledochoscopic
removal [3]. La Berge et al.
[4] described the use of a
percutaneous thrombectomy device (Arrow-Trerotola PTD; Arrow International,
Reading, PA) to remove retained common duct stones. McCafferty et al.
[5] described the use of a
rheolytic catheter (Hydrolyser; Cordis, Miami, FL) to recanalize an occluded
biliary Wallstent (Schneider, Minneapolis, MN, and Buelach, Switzerland) from
a transhepatic approach.
The rheolytic device used in our patient does not use a basket system for
particulate removal. The Angiojet system consists of three primary components:
the catheter, pump device, and drive component. The dual-lumen catheters come
in sizes 4- to 7-French and may be used over a 0.035-inch guidewire. The drive
unit produces a high-speed (400 km/hr) saline jet at the catheter tip, which
is directed back into the effluent lumen. The result is a low-pressure stream
exposed to the vessel lumen that disrupts and removes debris by a Venturi
effect. No direct mechanical manipulation is used to remove debris from the
vessel lumen. Because extraction of particulates is carried out indirectly by
creation of a negative pressure stream, potential injury to the vessel or
ductal walls may be minimized
[6]. In our patient, most of
the biliary material was displaced across the choledochoenteric anastomosis,
with a small amount retrieved from the effluent lumen.
In addition to its relatively atraumatic approach to clot removal, several
design features of the Angiojet device were beneficial for use in the biliary
system. The over-the-wire design and low profile allowed us to achieve good
maneuverability and tractability in a tortuous biliary tree. The Angiojet
device effectively fragmented and removed inspissated biliary debris that had
been unaffected by more conventional extraction methods. Although ductal
injury is possible when rheolysis is performed in small ductal branches, no
immediate or late adverse effects occurred in this patient. It is notable,
however, that the Angiojet system is relatively expensive and not widely
available; therefore, a substantial cost-savings may not be realized in
comparison with traditional choledochoscopic methods.
To our knowledge, the use of the Angiojet thrombectomy device to facilitate
biliary duct clearance has not been previously described. The design features
of the device may permit its use in cases of complex intrahepatic biliary
ductal disease. We believe that the use of such devices in treating biliary
lithiasis warrants further investigation.
References
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