Percutaneous thrombectomy (PT) is an established technique for the removal of acute thrombus in occluded arteries, veins and vascular grafts. Two passes of the device usually provide optimal clot fragmentation.38, Damage to the veins after thrombectomy with the ATPTD was assessed in an experimental canine model. The saline jet may reduce the risk of catheter clogging while avoiding hemolysis, as the jet resides on the inner lumen of the catheter. Another consideration is shaping the tip of the AngioVac device, which is stiff to maneuver, to assist passage into the main PA. Early restoration of venous patency and preservation of valvular function by endovascular surgery has been advocated. 2019 Jun 27;2(1):12-15. doi: 10.1016/j.jimed.2019.05.004. HHS Vulnerability Disclosure, Help sharing sensitive information, make sure youre on a federal Therefore, direct injection of local tPA into the clot during simultaneous fragmentation is likely advantageous compared with systemic administration as a greater surface area of fragmented clot is exposed to the thrombolytic agent. If subsequent thrombolytic infusion is planned, at least one sheath access should be at least 2 Fr larger than the infusion catheter to allow adequate PA pressure measurements through the sheath sideport. Patients with chronic PE and longstanding pulmonary hypertension will have elevated baseline PAPs and this should be correlated with other clinical findings. Eur J Vasc Endovasc Surg. Surgical removal of an obstructing clot or foreign material from a blood vessel at the point of its formation. Major bleeding was defined as the need for blood transfusion, surgical reintervention, or intracranial hemorrhage. 18, Since patients with submassive PE by definition are not in hemodynamic shock, aggressive mechanical maneuvers are usually unnecessary and may be associated with higher risk of complications such as distal embolization into patent vessels which could alter hemodynamics. An official website of the United States government. Access your health information from any device with MyHealth. Kucher N, Boekstegers P, Mller O J et al. Fifteen minutes after hemostasis, full therapeutic anticoagulation can be resumed with continued monitoring of the venous access sites. and transmitted securely. Vasa. The novel percutaneous thrombectomy device (ClotTriever; Inari Medical, Irvine, Calif) can minimize or even alleviate the need of thrombolytics while restoring venous patency. Pressure infusion requires a sheath which is at least 1 Fr larger than the size of the selected Aspirex catheter, keeping in mind that the suggested aspiration volumes are 45 mL/min (6 Fr), 75 mL/min (8 Fr), and 180 mL/min (10 Fr). The superior mesenteric arterial route has been used for pharmacologic thrombolysis. 1 Please enable it to take advantage of the complete set of features! The JETi AIO Peripheral Thrombectomy System is contraindicated for use in: 4 Patient outcomes should be assessed at 3 months, preferably using the modified Rankin score. 8600 Rockville Pike 4 As a Stanford Health Care patient, you may have access to the latest, advanced clinical trials. PMC Fig. 2015 Jul;29(5):995-1002. doi: 10.1016/j.avsg.2015.01.014. JETi Saline Drive Unit. The site is secure. Results: 2002 Nov;12(11):2627-43. doi: 10.1007/s00330-002-1615-8. Two such devices are currently in clinical use: the Hydrolyser (Cordis Endovascular Warren, NJ) and the AngioJet (Medrad, Warrensdale, PA). Fei J, Qin X, Ma H, Zhang X, Wang H, Han J, Yu C, Jiang J. Inflammation. Rheolytic techniques use a high-pressured jet system to infuse saline to mechanically disrupt the thrombus.80 Ultrasound energy can be used to dissociate the fibrin bonds within the thrombus to increase clot permeability and increase the number of receptor sites for fibrinolysis.81 Rotational techniques involve using a specifically designed thrombectomy catheter, with a covered, high-speed spiral fragmentation tip that rotates at up to 40,000rpm and also aspirates thrombus fragments.82, Complications include distal thrombus embolization, perforation, or dissection of the pulmonary artery, injury to the RV, arrhythmia, pulmonary hemorrhage, pericardial tamponade, and femoral venous injury. Before Fig. The use of neuroimaging is critical to exclude hemorrhage and large ischemic cores. The Argon Cleaner (Argon, Plano, TX) is a 6- to 7-Fr mechanical thrombectomy device that can fragment clot without causing hemolysis, but insertion requires prior sheath tip placement at the target vessel as the Cleaner in its current form cannot be inserted over a wire. Technical success was achieved in 73% of AngioJet and 78% of surgical cases. The .gov means its official. sharing sensitive information, make sure youre on a federal Physicians should claim only the credit commensurate with the extent of their participation in the activity. Once thrombus is engaged, the retraction aspirator handle is pulled once and combines the forces of aspiration and mechanical retraction to remove the nitinol disks containing clot through the large aspiration catheter. The FlowTriever thrombectomy system (Inari Medical, Irvine, CA) can reduce right ventricle (RV) strain in acute submassive pulmonary embolism (PE) patients. http://www.straubmedical.com/faq_aspirexs_en.html. The inner wire form is composed of three soft, braided nitinol disks ( There were seven men and three women. While the optimal protocol for treating submassive PE is evolving, a prior meta-analysis demonstrated that systemic thrombolysis may improve mortality, 15 The fragmentation cage self-expands as it rotates at 3000 to 4500 rpm. Thrombotic obstruction of the pulmonary arteries results in a hypoxemic state with local release of pulmonary artery (PA) vasoconstrictors. The new PMC design is here! April 2017. Umberto G. Rossi, Alberto M. Settembrini, in Vascular Surgery, 2022. A Case Report of Intravascular Hemolysis and Heme Pigment-Induced Nephropathy Following AngioJet Thrombectomy for Thrombosed DIPS Shunt. Acute ischemia of the limbs: which is the correct approach. Compared with CDT alone, PMT offers a lower risk of PTS and bleeding complications. 5 2 and DC cardioversion if necessary. Percutaneous pharmacomechanical thrombectomy offers lower risk of post-thrombotic syndrome than catheter-directed thrombolysis in patients with acute deep vein thrombosis of the lower limb. It has been used effectively in conjunction with thrombolytic infusion. Li W, Li Q, Zhai S, Li T, Cheshire N, Zhang Z, Liang K. J Interv Med. Ultrasound-guided access is recommended to minimize bleeding risk and to avoid inadvertent puncture of arterial structures as the consequences of an arterial puncture or multiple venous punctures are augmented by thrombolytic infusion. 3 For example, a 7 or 8 Fr vascular sheath (e.g., Flexor sheath, Cook, Bloomington, IN) extending from the access point to the main pulmonary trunk would accommodate a 5-Fr Unifuse infusion catheter (Angiodynamics, Latham, NY) to permit simultaneous PAP measurements through the sheath. Thrombolysis and thrombectomy have been used alone or combined. Of particular importance is the observation that no symptomatic pulmonary emboli were noted. Two possible iatrogenic complications have been described using PMT devices: risk of vessel dissection and/or perforation, especially in high calcified and stenotic arteries, and possible microembolization with subsequent loss of distal limb vascularization [21,3537]. J Vasc Interv Radiol. 3rd ed; p. 443. Percutaneous thrombectomy can be used as an adjunctive treatment to other methods of thrombus removal such as thrombolysis or as sole therapy. Semba C P, Weck S, Patapoff T. Alteplase: stability and bioactivity after dilution in normal saline solution. The device is connected to a suction generator which can be either a Penumbra pump or a less expensive option which is the Gomco 405 Aspirator (Allied Healthcare Products, Saint Louis, MO). Endovascular thrombectomy is an effective treatment for major acute ischemic stroke syndromes caused by major anterior circulation artery occlusions (commonly referred to as large vessel occlusion) and is superior to intravenous thrombolysis and medical management. The current generation device intended to treat PE is inserted through a 22-Fr aspiration sheath; therefore, it necessitates a larger incision at the venotomy site and placement of this large-diameter sheath into the PA. For those who wish to avoid large sheath placement and who do not need the aspiration component, the inner nitinol wire form may be inserted through a 12-Fr flexor sheath and used for clot fragmentation and disruption. For larger vessels, partial retraction of the inner sinusoidal wire can create a larger diameter sweep of the device. Another method is aspiration thrombectomy which can be performed manually with any 8- to 10-Fr end-hold catheter such as a Pronto catheter (Vascular Solutions, Minneapolis, MN) or 8-Fr JR 4 (Cook, Bloomington, IN). 7 During suction, a micro transducer within the saline drive unit activates the saline jet and audibly communicates aspirate flow status to help improve procedural efficiency and minimize blood loss. For submassive PE, the goal of CDT is to alleviate RV strain and prevent development of hemodynamic shock. Epub 2015 Mar 9. The speed of these devices in clearing clot is a significant advantage. Squeezing two infusion catheters into a single large sheath is generally not recommended due to leaking around the catheters, unless a sheath is available with sufficient hemostatic valve or adjunct port apparatus that can accommodate both infusion catheters. Therefore, interventionalists should be aware of the variety of catheter-based treatment options, specific pitfalls to avoid during therapy, and the appropriate treatment endpoints. The mechanical devices clear the clot in a graft within minutes.8, Nicolas A. Nelken, in Endovascular Surgery (Fourth Edition), 2011, Purported advantages to PTDs in clotted hemodialysis access include (in decreasing order of likelihood), Access to surgically inaccessible locations, Almost certain improvement over surgery for native, autogenous fistulas9, Improved definition of anatomy both during the endoluminal procedure and in prior knowledge of the underlying anatomy from previous contrast studies when surgery becomes necessary, Ability to treat repetitively with percutaneous means without detriment to immediate outcome, Decreased success of repetitive surgical salvage, Improved patient flow through an overcrowded medical system (easier scheduling) leading to decreased use of percutaneous catheters as temporary access, COLLEEN M. JOHNSON, ROBERT B. MCLAFFERTY, in The Vein Book, 2007, The Arrow-Trerotola Percutaneous Thrombectomy Device (ATPTD) fragments thrombus utilizing a self-expanding 9-mm fragmentation cage. Percutaneous pulmonary arterial thrombectomy procedures are performed using a transvenous approach to access the pulmonary arterial system. Careers. Once the catheter is in place, the catheter is used to break up the embolism or extract it (suck or pull it out). Patients who underwent percutaneous venous thrombectomy using the ClotTriever device for iliofemoral DVT between 2019 and 2020 were identified. Eur Radiol. ) connected to a high-pressure suction pump. Clinical trials are research studies that evaluate a new medical approach, device, drug, or other treatment. Objectives: The FlowTriever All-Comer Registry for Patient Safety and Hemodynamics (FLASH) is a prospective multi-center registry evaluating the safety and effectiveness of percutaneous Hirad S. Hedayat, Erol Veznedaroglu, in Complications in Neurosurgery, 2019. It has the ability to dissolve fresh thrombus, as well as compacted white thrombus found at the arterial anastomosis.12 In a randomized trial comparing the Trerotola cage with pulse-spray thrombolysis, results of the two techniques were comparable.13 The immediate technical patency rates were equal (95%), the complication rates were equivalent (8% vs. 9%), and the 3-month patency rates were equivalent (39% vs. 40%). The primary application of these catheters is treatment of thrombosed hemodialysis fistulas and grafts. Therefore, in the massive PE patient with elevated PAP, power injection should be avoided. will also be available for a limited time. An official website of the United States government. It happens most often in a leg. Once the catheter is in place, the catheter is used to A pigtail catheter may be used to mechanically debulk central thrombus and also to infuse thrombolytic drug through the side holes ( During activation, negative pressure is created within the catheter lumen to aspirate and macerate thrombus through an L-shaped aspiration port ( Careers, Guest Editors, Ronald Winokur, MD and David C. Madoff, MD, Pulmonary Embolism, catheter, thrombolysis, thrombectomy, interventional radiology. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Tufts University School of Medicine (TUSM) and Thieme Medical Publishers, New York. A D-Stat dressing may be applied in some patients to help achieve hemostasis. All patients had iliofemoral DVT and four patients had clot extension into the vena cava. Once the infusion is started, a final fluoroscopic image should be obtained to confirm appropriate positioning of the infusion catheters and to serve as a baseline reference. HHS Vulnerability Disclosure, Help If needed, further clot fragmentation can be performed with an angioplasty balloon size smaller than the target arterial diameter. Kuo W T, Gould M K, Louie J D, Rosenberg J K, Sze D Y, Hofmann L V. Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques. This study states that Iliofemoral deep venous thrombosis (DVT) is associated with significant short- and long-term morbidity. The FlowTriever Retrieval/Aspiration System (Inari, Irvine, CA) is 510k cleared for peripheral thrombectomy and is currently undergoing an IDE trial called FLARE for the treatment of acute PE. Would you like email updates of new search results? FILTER - Filter Initial & Long Term Evaluation After Placement and Retrieval (Including Laser-Assisted Retrieval) Registry, Pulmonary Embolism Response to Fragmentation, Embolectomy, & Catheter Thrombolysis: PERFECT, Doctors, Clinics & Locations, Conditions & Treatments, View All Information for Patients & Visitors , Protections Against Surprise Medical Bills. reported successful PMT using the ATPTD in a patient that presented with a subacute iliocaval thrombosis. 2022 Jun 2. doi: 10.1007/s10753-022-01689-y. The Triever thrombectomy systems (Inari Medical) is approved by the food and drug administration (FDA) for the removal of clot through mechanical (ClotTriever) extirpation 10 The overall mortality rate was 0.26%. Background: The FlowTriever thrombectomy system (Inari Medical, Irvine, CA) can reduce right ventricle (RV) strain in acute submassive pulmonary embolism (PE) patients. Epub 2002 Aug 2. After 3 hours from onset diffusion MRI is the most reliable method to define ischemic core size and should be used in centers that can offer it rapidly. The process creates Venturi-effect suction while the pressurized stream erodes the thrombus. It is estimated that at least 600,000 symptomatic cases of PE and 300,000 PE-related deaths occur annually in the United States. Epub 2002 Aug 22. Regardless of which device(s) is used earlier, simultaneous administration of low-dose local tPA can be synergistic in treating massive PE. The most recent modification of the Hydrolyser has added a third lumen to allow improved clot aspiration. Percutaneous thrombectomy is a promising approach to declotting the aortoiliac segment. Recanalization is highly effective with a stentriever or using a direct aspiration technique, with the patient awake or under conscious sedation rather than general anesthesia, if it may be performed safely. Find the latest information onCOVID-19,monkeypox, and theflu vaccine. Federal government websites often end in .gov or .mil. Another limitation is the stiff suction catheter which can be difficult to safely navigate into the pulmonary circulation. We use cookies to help provide and enhance our service and tailor content and ads. Before These The latter device must be positioned across the thrombus before withdrawing the sheath and releasing the fragmentation cage. This helps avoid cardiac injury when advancing the large AngioVac cannula into the PA. This site needs JavaScript to work properly. 1 AMA PRA Category 1 Credit 11 It offers various advantages, such as performance under local anaesthesia and early Fig. 8600 Rockville Pike Background: Animal studies indicate promising local success rates, but segmental and subsegmental pulmonary emboli were demonstrated with concomitant increases in mean and systolic pulmonary arterial pressure. The rates of PTS and recurrent DVT were less than 17% and 15%, respectively. government site. The authors declare no conflicts of interest. The tPA can be reconstituted in normal saline solution until there is 0.1mg tPA/mL of solution. The fragmentation process redistributes thrombus into multiple smaller branches further downstream, where the hemodynamic consequence of multiple smaller thrombi in the large volume of the peripheral arterial tree is thought to be less important.78 Additionally, thrombus fragmentation increases the surface area for exposure to a fibrinolytic agent and intrinsic thrombolytic enzymes to facilitate thrombus dissolution.79 Using femoral venous access, CdT involves either rheolytic or rotational techniques to disrupt the thrombus in combination with aspiration of the thrombus fragments. The aim of this study was to review the efficacy and safety of percutaneous mechanical thrombectomy (PMT) against catheter-directed thrombolysis (CDT) in the treatment of acute iliofemoral DVT. For massive PE, the goal of CDT is to remove obstructing PA thrombus to alleviate RV strain, improve cardiac output, and restore hemodynamic stability. Lower injection parameters may be considered depending on the degree of heart failure and pulmonary hypertension, to achieve adequate vessel opacification without endangering the patient. Prior to performing pulmonary angiography, the degree of pulmonary hypertension and underlying cardiopulmonary reserve are important considerations. eCollection 2020. This will stay biochemically stable and active at ambient temperatures for as long as 24 hours when diluted to a concentration as low as 0.01 mg/mL. During suction, rapid blood loss may occur and must be monitored in the collecting chamber as the current system does not allow recycling of aspirated blood. sharing sensitive information, make sure youre on a federal For submassive PE, current data support gentle image-guided infusion catheter placement into thrombosed pulmonary arteries followed by local thrombolytic infusion. Percutaneous interventions, such as percutaneous thrombectomy (PT, including mechanical thrombectomy or pharmomechanical thrombectomy) and ultrasound-accelerated When Not to Perform Percutaneous Thrombectomy of a Clotted Native Fistula, From: Diagnostic Imaging: Interventional Procedures (Second Edition), 2018, Narain Moorjani, Susanna Price, in Cardiac Intensive Care (Third Edition), 2019, Catheter-directed thrombectomy (CdT) is an alternative therapeutic strategy that can be used for the treatment of acute PE. 3 Its mechanical action assists in the disruption of clot within the graft. Objectives: 19 Fig. The venous segments were assessed for endothelial loss, the presence of thrombus, and valvular damage. a) Finally, these are generally rapid and effective methods, thus making them convenient and accessible. government site. Endovascular thrombectomy has become the standard of care in large vessel occlusive stroke management for patients who fit the appropriate criteria for intervention. Access your health information from any device with MyHealth. These devices have been developed in the last two decades with the aim to obtain percutaneous thrombus disruptionextraction. 9 ) which are deployed over a guidewire by unsheathing within the thrombosed target vessel. Valji K. Philadelphia, PA: Saunders; 2012. Bethesda, MD 20894, Web Policies 21. Complications occurred in 15%, including two arterial emboli, one pulmonary embolus, and one hematoma. Mean age was 62.8 years (range, 42-79 years). As these interventions become more commonplace throughout hospitals caring for stroke patients, the role of experienced, efficient, and careful practitioners who may face cases with challenging anatomy and pathology that increase the complication rate is crucial. Online ahead of print. During a mechanical thrombectomy, your surgeon introduces special devices through catheters that can either macerate or suction out Get the Android MyHealth app . Percutaneous thrombectomy (PT) is an established technique for the removal of acute thrombus in occluded arteries, veins and vascular grafts. Would you like email updates of new search results? In all, the authors found both techniques comparable, although the 78% initial success rate is lower than expected for a surgical group.18, The mechanical methods of clearing grafts have several advantages that make them attractive alternatives to pharmacologic thrombolysis. In combination with CdT, local administration of fibrinolytic agents allows lower doses to be used, as it is delivered directly and the mechanical thrombectomy has increased the surface area of the thrombus available to the drug. A guidewire can be inserted through a hole just proximal to the pigtail curve, as this may facilitate rotation of the pigtail. The median duration of primary patency was 14 weeks. Tufts University School of Medicine designates this journal-based CME activity for a maximum of Percutaneous Thrombectomy Submassive PE is defined by right heart strain without hemodynamic shock. The authors acknowledge Rhonda Lee for her assistance in preparing Ideally, the infusion treatment length should extend from the most distal thrombosed PA segment (that can be safely catheterized) to the main PA. Additionally, the proximal side holes can extend into the pulmonary trunk and into the sheath itself, as this allows thrombolytic drug to distribute into other pulmonary branches. Contraindications. ). Comparative efficacy of pulse-spray thrombolysis and angioplasty versus surgical salvage procedures for treatment of recurrent occlusion of PTFE dialysis access grafts. Examine FlowTriever thrombectomy feasibility in highrisk PE patients. Learn more The 24-hour success rate was 82%, but, at the end of 1 week, the clinical success rate had fallen to 59%. 18 Meta-analysis and systematic review of percutaneous mechanical thrombectomy for lower extremity deep vein thrombosis. J Vasc Surg Venous Lymphat Disord. Compared with CDT, PMT was shown to reduce PTS at 1 year (Villalta score: 2.1 3.0 in the PMT group and 5.1 4.1 in the CDT group, P=0.03) and bleeding complications (packed cells transfused: 0.2 0.3 units in the pharmacomechanical thrombectomy group and 1.2 0.7 units in the CDT group, P<0.05). FOIA Piazza G, Hohlfelder B, Jaff M R et al. Examples of infusion catheters include the Unifuse catheter (Angiodynamics, Latham, NY), Fountain catheter (Merit Medical, South Jordan, UT), and EKOS (EKOS, Bothell, WA) catheter. Clipboard, Search History, and several other advanced features are temporarily unavailable. ( The Hydrolyser catheter has been tested in a clinical multicenter study.17 This demonstrated an initial success rate of 89% with early reocclusion in another 17%, yielding an early (1 week) success rate of 72%. On fluoroscopy, the bifurcation is usually inferior, anterior, and to the left of the carina near the fifth thoracic vertebra. Vessel perforation or dissection is reported in 5% to 12% of cases. The patient was still receiving CPR at this point. 2015 May;44(3):195-202. doi: 10.1024/0301-1526/a000430. It may be used in conjunction with the Indigo catheter as the 6-Fr Cleaner fits coaxially within the Penumbra CAT8 lumen ( Catheter-directed thrombolysis can be used as an adjunct to CdT,84 delivering the fibrinolytic agent directly into the PE via a catheter with multiple side holes under fluoroscopic or ultrasound guidance. Treatment Strategies for Proximal Deep Vein Thrombosis: A Network Meta-analysis of Randomised Controlled Trials. Removal of the clot may reduce the incidence of pyrogenic reactions. As the catheter may clog during operation, it is often used with a wire separator (SEP) to attempt declogging during the procedure. All patients with moderate to severe symptoms (National Institutes of Health stroke scale >8) and a treatable occlusion should be considered. Heit J A, Cohen A T, Anderson F A. Often performed in conjunction with thrombolytic therapy. The device comes as either an over-the-wire configuration or the original design whereby the cage is constrained by a sheath. In both devices, the cage rotates at 3000 rpm and is pulled through the thrombus. Laboratory comparison of the catheters indicates that they both perform well and that both cause a moderate amount of hemolysis.14-17. 17 A 6-Fr (135 cm) Argon Cleaner device placed through an 8-Fr CAT8 (110 cm) catheter. In a Existing thrombectomy catheters can be classified by their mechanism of action (Box 2-6).150158 With the exception of one device, mechanical thrombectomy catheters are currently approved by the FDA for use only in hemodialysis grafts (see Chapter 17). Regarding mechanical and aspiration thrombectomy for massive PE, although most devices below are U.S. Food and Drug Administration (FDA)-approved for peripheral thrombectomy, it should be noted that none are currently FDA-approved for use in the pulmonary circulation. To reduce the risk of perforation, only pulmonary artery branches greater than 6mm should be treated and the procedure should be stopped once the hemodynamic status of the patient improves, irrespective of the angiographic result.83. Pharmacomechanical thrombolysis may be prohibitive in select patients with significant bleeding risks. Once the tricuspid is traversed, another forward motion and 180-degree turn will pass it through the outflow tract into the PA. From the internal jugular vein, a C2 catheter (Cook, Bloomington, IN) and a Glidewire with torque control device may be used to select the PA. Ten patients were identified during the study period. Percutaneous mechanical thrombectomy is a safe and effective treatment for acute iliofemoral DVT in terms of restoration of venous patency, prevention of DVT recurrence, and PTS. There is limited published experience with these devices for acute arterial or venous occlusions.150 Technical success ranges from 50% to 90%, with no clear advantage of any particular device. The rate of distal embolization ranges from 5% to 15%. The fibrinolytic agent should be injected directly into the thrombus, as any drug injected proximal to the obstructing thrombus will be washed out by the local eddy currents into the nonobstructed pulmonary arteries, thereby reducing its therapeutic efficacy.85 Results of catheter-directed thrombolysis in patients with acute high-risk (massive) PE were examined in the Pulmonary Embolism Response to Fragmentation, Embolectomy and Catheter Thrombolysis (PERFECT) registry.86 It assessed 101 patients with acute massive (n = 28) and submassive (n = 73) PE who were treated with catheter-directed mechanical or pharmacomechanical thrombectomy and/or catheter-directed thrombolysis (with rtPA or urokinase). A Prospective, Single-arm, Multi-center Trial of EkoSonic Endovascular System and Activase for Treatment of Acute Pulmonary Embolism (PE). 1998 Jul-Aug;21(4):314-8. doi: 10.1007/s002709900267. FOIA The aspiration mechanism can sometimes create a vacuum in the target vessel resulting in low flow, and similar to the Aspirex system, this can be managed with infusion of additional fluids (i.e., saline solution) through the outer sheath.

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