ARTERIAL OCCLUSIVE
EKOS
Introduction
Last updated: apr 5, 2023
EKOS was the first interventional device indicated for the treatment of pulmonary embolism. EKOS is used for the infusion of physician-specified fluids, including thrombolytics, into the peripheral vasculature. EKOS' ultrasound technology accelerates drug dispersion, requiring less lytic agent.
Indications
- Acute arterial embolism.
- Acute arterial thrombosis.
- Underlying stenosis.
- Aneurysm presenting with acute thrombosis of the run of vessels.
- Acute arterial bypass obstruction.
- Trauma (cases of acute arterial thrombosis or dissection; only when bleeding risk of concomitant injuries is low and the vitablity of the limb is at risk).
- Dissection.
- Thrombolysis during endovascular proce-dures.
- Dialysis grafts presenting with acute thrombosis.
- Intraoperative thrombolysis.
Contra indications
Absolute
- Ischemic stroke within the last 2 months. TIA excluded.
- Hemorrhagic stroke within the last 6 months.
- Coagulation disorders (thrombopenia, von Willebrand disease).
- Recent gastrointestinal or urogenital bleeding (<10 days).
- Neurosurgery procedure within the last 3 months.
- Surgical procedure or trauma within the last 10 days.
- Craniocerebral injury within the last 3 months.
- Cardiopulmonary resuscitation within the last 30 days.
Relative
- Cardiopulmonary resuscitation within the last 30 days.
- Uncontrolled hypertension (systolic > 185 mmHg, diastolic > 110 mmHg).
- Highly calcified artery, noncompressible.
- Intracranial malignancy.
- Recent ophthalmologic procedure.
- Liver failure combined with coagulation disorder.
- Bacterial endocarditis.
- Pregnancy.
- Menstrual period
- Less
- Pancreatitis
- Sepsis
- Endocarditis
- Diabetic hemorrhagic retinopathy
Pre procedural
- Cross check blood
- Blood count, platelets, a full coagulation profile (prothrombintime and/or international normalized ratio, activated partial thromboplastin time [aPTT], and fibrinogen levels), and renal and hepatic function.
- ICU bed
- Urine katheter
- Peripheral acces x 2
- Arterial pressure system
Dosage
rTPA
- Bolus infusion of 5 mg through a catheter within the thrombus,
- Followed by a continuous infusion 1 mg/h (1 mg/ml) Actilyse through a pump
- 250.000 IU bolus
- Folllowed by 100.000 IU/h (10.000 IE/ml)
The procedure in steps
- Time out
- Positioning the patient
- Prepare with desinfectans and sterile cloth
- Depending on the location of the thrombosis an integrate or up-and-over approach is chosen
- Administer 5000 IE Heparin
- Document outflow and run-off vessels
- Try to promote the wire through the lesion.
- Pass through the thrombus using a 0.035 wire.
- Prepare EKOS catheters (see attachment).
- Flush the DRUG lumen with 3 cc heparin.
- Flush the coolant lumen with NaCl.
- Flush the central guiding wire lumen.
- Flush the ultrasonic core and ensure it does not kink.
- Keep the connector dry.
- Advance the infusion catheter over a 0.035 wire, ensuring the distal marker is positioned distal to the clot.
- Remove the guiding wire and flush the central lumen.
- Insert the ultrasonic core element into the central lumen of the infusion catheter. Lock the ultrasonic core to the catheter with a Luer lock.
- Connect the infusion line to the infusion pump at the drug and coolant ports.
- Lytic agent: Alteplase or urokinase.
- Cool saline solution: 35 ml/hour, maximum 120 ml/hour.
- Press the power button.
- Connect the interface cable to Channel A or B.
- Connect the catheter cables to the CIC (Catheter Interface Cable).
- Press start. When treatment begins, a green light will illuminate.
- Angiographic control after ~24 h
- Continue if necessary
- Treat causative stenosis
Observations
- Every day bloodwork see IC protocol
- Every 4 hours Hb, Ht, trombo’s (in case of hemorrhagic complications also PT, APTT, INR and fibrinogen)
- Every hour Check groin for hemorrhagic complications
- Every day thrombus chasing by angiography, confer treating physician
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