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Podcast Transcript: Declots with the Argon Cleaner Device

with Dr. Sabeen Dhand

From the Exhibitor's Hall at SIR 2018 in Los Angeles, Dr. Christopher Beck and Dr. Sabeen Dhand describe their declot techniques, with an emphasis on when and how they use the Argon Cleaner device for these cases. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) The Routine Declot Procedure

(2) Technical Endpoints in Declot Cases

(3) Pros and Cons of the Argon Cleaner Thrombectomy System

(4) Tips and Tricks for Stubborn Declots

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[Chris Beck]
Hello guys, and welcome to the Backtable podcast. Backtable is your resource to connect with your IR colleagues out there and learn the tips, techniques and nuances of the devices in your cabinets. This is Chris Beck, I'm the host, coming to you straight from the Exhibitor's Hall at SIR LA 2018.

First of all we would like to thank Argon Medical for sponsoring this podcast at their booth at SIR. Argon Medical is the manufacturer of the cleaner rotational thrombectomy system and device that we're going to be discussing today as part of the podcast on declots. Cleaner is the only wall contacting rotational thrombectomy system indicated for macerating thrombus and dialysis graft access in the peripheral vasculature.

As I said, my names Chris Beck, I'm your host today. We're here with Sabeen Dhand. Sabeen, want to introduce yourself?

[Sabeen Dhand]
Alright. Hi, my name is Sabeen Dhand, thanks for having me today as we talk about declots and orbital thrombectomy. I trained a couple years ago at Northwestern and then moved out, actually here, locally in LA where I work at a system called PIH Health. We do a wide variety of cases including lots of dialysis access and declots.

[Chris Beck]
Alright. Sabeen, do you want to tell us a little bit about how your dialysis practice is shaped up, just briefly?

[Sabeen Dhand]
Totally. We have several dialysis access centers around our site. Most of them send patients to us - it was already a very high volume dialysis practice when I started. Most declots specifically are added the day of or the next day and things like that.

[Chris Beck]
Okay. For those of you guys who don't know me, my name's Chris Beck. I'm an Interventional Radiologist in private practice in New Orleans. I'm primarily a hospital-based interventionalist and our dialysis work that we do is - we're actually getting scooped a majority of the time by the dialysis access center. As far as fistula routine maintenance, we do very little of. Most of what I get are declot procedures, usually either tough ones or at inopportune times.

Most of what we see is, I'd say 90 percent of my practice is declots that are actually routine maintenance, and the other 10 percent is billed as a declot and they're actually just open fistulas that I just go and angioplasty.

(1) The Routine Declot Procedure

[Chris Beck]
Alright, so let's first go through a routine declot procedure. Sabeen, you want to start it out?

[Sabeen Dhand]
Yeah. What I do, which is now a little bit different than how I trained, is I get access towards the heart, integrate towards the heart, and I determine the clot burden by just going central and pulling back a five french end-hole catheter. Then through that catheter and through the clot burden, I mix Alteplase into the clot and usually I put some contrast in there too so I can see the actual clot on fluoro. Then, immediately, I use - in each case I use an orbital thrombectomy, mostly the Cleaner. I'll use that to make a clot milkshake, you can say, clot Alteplase milkshake while I still haven't pulled the arterial plug.

That allows the TPA to kind of sit and dwell and then about five minutes of doing the Cleaner, I'll get a retrograde access through the arterial anastomosis and pull the plug. Usually that really takes care of most of the clot. Then I'll address the critical lesions, whether there's a stenosis, unless I saw something really severe initially that would maybe hold up my clot.

[Chris Beck]
Yeah, like something central?

[Sabeen Dhand]
Mh-hmm.

[Chris Beck]
Yeah. My process is not that much different from Sabeen's. Maybe the part where we differ - venous access, central run, take care of anything centrally, and then pull back venogram. I'll do some TPA through the sheath mixed with contrast and then, what I'll do, I'll actually start going towards the arterial end. I'll pull the plug and then push everything centrally and then kind of see what that'll look like. Mainly what I use the Cleaner for or any kind of thrombectomy is just kind of troubleshooting. If I have some recalcitrant clot that’s hanging around in the graft or have a mega fistula that we're having trouble cleaning out the aneurismal segments, that's where I'm kind of using the Cleaner.

(2) Technical Endpoints in Declot Cases

I'm interested to hear, Sabeen, why do you start out just going Cleaner? Is it because you found with traditional methods it's harder to get open or this is kind of a faster system for you?

[Sabeen Dhand]
I do find it significantly faster. I referred to being trained a different way where we wouldn't use orbital thrombectomy, we would actually pulse spray the TPA and balloon macerate. I always found declots to be very cumbersome, about a two hour case, two and a half hour case. When I went to my practice now and was taught this way, I noticed the declots go significantly faster.

Whether it's due to this or just experience, I just go to the Cleaner all the time. I get a great result.

[Chris Beck]
What's your end point when you're running the Cleaner the first time through?

[Sabeen Dhand]
I make the - with the contrast and the TPA, it makes a uniformed kind of haze and then I feel like I really got it mixed up like a milkshake.

[Chris Beck]
Okay. So you can kind of see it spun up.

[Sabeen Dhand]
Yeah. You can see it and that's why I added that contrast thing recently and I liked it more.

[Chris Beck]
Okay, nice. Do you ever direct it towards arterial?

[Sabeen Dhand]
My partners do, I don't. I get scared.

[Chris Beck]
Okay, so no bad results with - no. I'll sometimes use the Cleaner directed towards the arterial end and haven't had any problems with it. Before we had the Cleaner we had the Trerotola and I was fairly accustomed to bringing it across the arterial anastomosis, so I kind of felt comfortable with it, something you can try.

Some of your partners do it and no problem?

[Sabeen Dhand]
Yeah. I see my partners do it, again, using an over the wire device sometimes can be better in that regard. I'm always scared of throwing a clot.

[Chris Beck]
I get it. Lets kind of talk some of the nuances of the Cleaner. What are some of the things you like, what are some of the things you don't like?

(3) Pros and Cons of the Argon Cleaner Thrombectomy System

[Sabeen Dhand]
The only thing I can think of that's negative, what I have to deal with in the Cleaner, is that it's not over the wire. In some instances when you have a really tough venous anastomosis, you do have to bail on your wire access and when I'm doing that I can get a little bit worried.

I do like that it comes in six and seven french, I feel the seven french system I'll use too. Usually I use the six french, but I'll use the seven french system if I have a pseudo aneurysmal fistula. I feel like it gets me better wall apposition. It works well, the only thing would be the wire, the loss of wire access.

[Chris Beck]
Now, I get what Sabeen's point in that I think most of us, it's just inherent that you want something over the wire, it feels very stable, it feels very safe. Pulling the wire access - or actually, I guess you don't start with wire access, it's like you're using it originally? Yeah, okay. Most of the time I'm using it, I've already gotten wire access so I've got to pull it and then start running the Cleaner though.

[Sabeen Dhand]
Yeah. No, I'm doing that too. Then sometimes if I have to - a little twist I'll use a longer sheath and I'll pin-pull the Cleaner out and I'll pull it back while I'm making the milkshake.

[Chris Beck]
Okay, nice. One of the things that I do like about the Cleaner that maybe some other thrombectomy systems are lacking is that it's got some body to it and it's also got some directionality. Just by kind of changing how much of the Cleaner is exposed, you can kind of get some directionality to the Cleaner.

For me, that's one of the things I really liked about it is that I found it easier to navigate. Sometimes if you find yourself in a stick-site fistula and if you're not dealing with an over the wire system but you have the Cleaner, you can kind of direct it towards the outflow of the fistula, which I find helpful.

Talk about - you got any tips or tricks as far as how to maximize or optimize the use of the Cleaner? Like do you use the side port at all, massage the fistula at all?

[Sabeen Dhand]
Yeah, that second point I was gonna say, I use the massaging the fistula. You can feel the Cleaner actually working under your hand and you know that you're getting that wall apposition. As far as tips, again, unsheathing trick if you're worried about not being able to advance it through a fistula circuit. I think it's generally very easy to use, straight forward and, again, atraumatic so you're not going to have any problems.

Someone had suggested to me using a Cleaner through an aspiration catheter, and eight french aspiration catheter, that could maybe increase it's utility, but I haven't tried that.

(4) Tips and Tricks for Stubborn Declots

[Chris Beck]
Sure. One of the things that I have done with some really stubborn clot, and some big fistula segments, like Sabeen said, the massage technique works really well. I'll also take some diluted TPA, and I inject it directly into the clot in the fistula and then you can kind of massage that out. I will say that if anyone out there is going to try that trick, you want to use a really small gauged needle, like a 25 gauge, and you don't want to stick the fistula at five different sites. You want to basically have like one access zone. I usually, maybe the same as you, you have ultrasound prepped on the table.

[Sabeen Dhand]
Yeah.

[Chris Beck]
Yeah. I always have ultrasound prepped. Ultrasound guided, I inject it directly into the clot and you try and use one stick site and get the needle to puncture a lot of different parts of the clot because at the end of it, which actually has happened to me before where I stuck it at five different sites, as soon as I pulled the plug and opened up the fistula, then I have blood squirting out at all those five different parts. You know, they're on anticoagulants - it's not a big deal, it's a 25 gauge, it'll stop, but it's just a pain.

[Sabeen Dhand]
It's a neat idea, I like that. I've never tried that. I usually just inject that TPA in the beginning, but I like your tip.

[Chris Beck]
Yeah. Alright, any final closing remarks here, Sabeen?

[Sabeen Dhand]
No. I mean, again, I think it's very easy to use and I do think it has significantly decreased my declot times, especially in a dialysis graft or sometimes now some of those declots take 15 to 20 minutes, whereas, I remember, in fellowship, the last thing you wanted to do was a declot at three P.M.

I do think the Cleaner is significantly helping me get a better result.

[Chris Beck]
For my standpoint, I'm a fan of the Cleaner, I like the Cleaner. For most of the declots I do I try and do it on the cheap and try just use basic stuff, but I certainly use it as a troubleshooting mechanism. I find it particularly helpful for big stick site aneurysms where I gotta go and clean out a large clot burden. Not that you can't do that with some traditional techniques like balloon maceration or just lysing the clot, but I found that the Cleaner decreases my procedure time. As far as success rates, I think I'm getting the same technical success, it just takes me a shorter period of time, which is helpful.

[Chris Beck]
Alright so, guys, I think we're going to wrap it up here. I'd like to thank, again, Argon, our sponsor, Argon Medical, and I encourage our listeners to check out our new procedure based app, which includes videos, articles and even our podcasts to help you tackle these cases on the board. The app is free and available on the iTunes and Google Play stores.

I also should mention our disclaimer, the opinions shared during this podcast are the opinions of the podcast participants, just me and Sabeen, and are not necessarily representative of the official policy of Argon Medical.

[Chris Beck]
Alright. Thank you guys and like I said, we're here at SIR LA 2018.

[Sabeen Dhand]
Thanks a lot. Thank for having me.

Podcast Contributors

Dr. Sabeen Dhand

Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.

Dr. Christopher Beck

Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.

Cite This Podcast

BackTable, LLC (Producer). (2018, March 21). Ep. 25 – Declots with the Argon Cleaner 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.