Intravascular Ultrasound–Directed Thrombectomy Using the Penumbra Indigo System in the Inferior Vena Cava: A Novel Technique for Minimizing Blood-loss

Purpose: Concurrent use of intravascular ultrasound (IVUS) with the Penumbra Indigo System for mechanical suction thrombectomy in large vessels can prevent procedure-limiting blood loss by allowing the operator to continuously and directly engage thrombus, compared with traditional methods, which rely on visual observation of open versus stagnant blood flow through the CAT System catheters.

Materials and Methods: A 28-year-old man was admitted for management of acute symptomatic iliocaval and lower extremity venous thrombosis. A prophylactic inferior vena cava (IVC) filter had been placed 10 years ago in the setting of trauma but was lost to follow-up. Imaging showed acute thrombus extending from the filter to the posterior tibial veins bilaterally. Emergent suction thrombectomy was performed with the Penumbra Indigo System using a CAT8 catheter before terminating because of maximal blood loss of 500 mL. Catheter-directed thrombolysis was then initiated with bilateral infusion catheters placed from the IVC to the femoral veins via popliteal access. Twenty-four-hour follow-up venography was performed showing extensive residual thrombus burden in the IVC within the filter cone. Concurrent IVUS was used with repeat suction thrombectomy to direct the CAT8 catheter into the remaining subocclusive thrombus to avoid a second day of significant blood loss as would typically result from blind sweeps in a large vessel.

Results: The combination of IVUS and the Penumbra Indigo System resulted in successful removal of the remaining thrombus such that the inciting IVC filter was able to be removed at the procedure conclusion. Day two blood loss was limited to 200 mL. Final venography showed a widely patent iliocaval system with minimal residual thrombus. The patient was discharged on rivaroxaban and returned for a 6-week follow-up visit with computed tomography venogram, showing complete resolution of symptoms and no residual thrombus.

Conclusions: Concurrent use of IVUS with the Penumbra Indigo System for mechanical suction thrombectomy in large vessels is an effective method for preventing procedure-limiting blood loss. Although this approach requires two access sites, the utility of directed suction thrombectomy in the IVC and iliac veins clearly allows for maximization of thrombus reduction, which can lead to successful patient outcomes. This approach may be extrapolated to facilitate single-session mechanical thrombectomy in select patients.