Bradyarrhythmias during Rheolytic Pharmacomechanical Thrombectomy for Deep Vein Thrombosis

Purpose: To explore possible mechanisms of bradycardia occurring during rheolytic pharmacomechanical thrombectomy (PMT) for deep venous thrombosis (DVT) and to propose a treatment algorithm for this phenomenon. Methods: Intraoperative anesthesia records, operative notes, and hospital records of 57 patients treated with the AngioJet rheolytic thrombectomy device for DVT over a 3-year period were retrospectively reviewed. Of the 57 patients, 7 (12.3%) patients (5 women; mean age 67 years, range 23–78) experienced bradyarrhythmias: 2 had a brief period of asystole and 5 patients experienced sinus bradycardia, 4 of which had >1 episode. All patients were in normal sinus rhythm (NSR) preoperatively, and only 2 had underlying coronary disease. Results: The AngioJet device was located in the infrarenal inferior vena cava in over half of the patients and in other peripheral venous beds in the others when the bradyarrhythmias occurred. Five of 7 patients reverted to NSR with cessation of the device alone, while 2 required a dose of atropine in addition. External pacing was not required, and all patients did well postoperatively. Since sinus bradycardia resolved immediately upon cessation of the device in all cases, the theory that adenosine (a product of hemolysis affecting conduction) plays an important role is called into question. Stretch receptor activation in the right heart from cyclical high-pressure gradients generated by the device may play a more important role mechanistically. Conclusion: The occurrence of bradyarrhythmias during peripheral venous use of the AngioJet device is poorly described in the literature. Routine pre-treatment with various agents is not recommended during use of the device in peripheral venous beds as the incidence of bradyarrhythmias appears to be very low, with no defined mechanism of onset.

[1]  D. Gould,et al.  AngioJet Thrombectomy for Occluded Dialysis Fistulae: Outcome Data , 2009, CardioVascular and Interventional Radiology.

[2]  B. Murad Intracoronary aminophylline for management of bradyarrhythmias during thrombectomy with the AngioJet catheter. , 2008, The Journal of invasive cardiology.

[3]  A. Delago,et al.  Aminophylline for prevention of bradyarrhythmias induced by rheolytic thrombectomy. , 2008, The Journal of invasive cardiology.

[4]  D. Antoniucci Management of dysrhythmias during coronary AngioJet: how to minimize the need for temporary pacemaker during rheolytic thrombectomy. , 2008, The Journal of invasive cardiology.

[5]  G. Dehmer,et al.  Guidewire pacing safely and effectively treats bradyarrhythmias induced by rheolytic thrombectomy and precludes the need for transvenous pacing: the Scott & White experience. , 2008, The Journal of invasive cardiology.

[6]  Dennis W X Zhu The potential mechanisms of bradyarrhythmias associated with AngioJet thrombectomy. , 2008, The Journal of invasive cardiology.

[7]  M. Hong,et al.  Can glycopyrrolate replace temporary pacemaker and atropine in patients at high risk for symptomatic bradycardia undergoing AngioJet mechanical thrombectomy? , 2008, The Journal of invasive cardiology.

[8]  S. Kakkos,et al.  Percutaneous Rheolytic Thrombectomy for Thrombosed Autogenous Fistulae and Prosthetic Arteriovenous Grafts: Outcome after Aggressive Surveillance and Endovascular Management , 2008, Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists.

[9]  D. Karnabatidis,et al.  Re: Bradyarrhythmias during use of the angiojet system. , 2007, Journal of vascular and interventional radiology : JVIR.

[10]  Michael J O'Brien,et al.  Bradyarrhythmias during use of the AngioJet system. , 2006, Journal of vascular and interventional radiology : JVIR.

[11]  J. Borsa,et al.  Type III heart block with peripheral use of the Angiojet thrombectomy system. , 2001, Journal of vascular and interventional radiology : JVIR.

[12]  E. Mascha,et al.  Rheolytic thrombectomy in the management of acute and subacute limb-threatening ischemia. , 2001, Journal of vascular and interventional radiology : JVIR.

[13]  M. Hicks,et al.  Comparison of the angiojet rheolytic catheter to surgical thrombectomy for the treatment of thrombosed hemodialysis grafts. Peripheral AngioJet Clinical Trial. , 1999, Journal of vascular and interventional radiology : JVIR.

[14]  G. Seabrook,et al.  Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry. , 1999, Radiology.

[15]  Michael S. Lee,et al.  Pre-procedural administration of aminophylline does not prevent AngioJet rheolytic thrombectomy-induced bradyarrhythmias. , 2005, The Journal of invasive cardiology.

[16]  M. Lim The AngioJet rheolytic thrombectomy system: does the end justify the means? , 2005, The Journal of invasive cardiology.