Rotational Thrombectomy Systems: Comparative Effectiveness in Arterial vs. Venous Occlusions

簡介

Thrombotic occlusions represent a significant burden across the vascular system, manifesting as life-threatening conditions in both arterial and venous circulations. While sharing the common pathophysiology of blood clot formation, arterial and venous thromboses present distinct challenges in terms of clot composition, vessel characteristics, and clinical consequences. The management of these occlusions has evolved dramatically over the past decade, with rotational thrombectomy systems emerging as versatile tools capable of addressing both arterial and venous pathologies. As we navigate through 2025, the differentiation of thrombectomy approaches based on vascular territory has become increasingly nuanced, guided by advanced device technologies and a growing evidence base that has collectively enhanced procedural outcomes across diverse clinical scenarios.

The evolution of rotational thrombectomy began with relatively simple mechanical devices, progressed through increasingly sophisticated systems with combined aspiration capabilities, and has now reached an era of specialized tools optimized for specific vascular beds and clot characteristics. These developments have dramatically improved recanalization rates while reducing procedural complications and treatment times.

This comprehensive analysis explores the comparative effectiveness of rotational thrombectomy systems in arterial versus venous occlusions in 2025, with particular focus on how these specialized approaches are transforming patient outcomes. From advanced rotational mechanisms to next-generation thrombectomy devices like the Mantis PRO Rotational Thrombectomy & Ultra Aspiration system and the Mantis CURVE OTW Rotational Pharmacomechanical Thrombectomy System, we delve into the cutting-edge technologies that are reshaping the landscape of endovascular intervention across vascular territories.

Pathophysiological Differences Between Arterial and Venous Thromboses

Understanding the fundamental differences between arterial and venous thromboses is essential for optimizing thrombectomy approaches. Arterial thrombi typically form in high-flow, high-pressure environments with significant shear stress. They are predominantly platelet-rich (white clots) with relatively lower fibrin content, making them more compact and resistant to certain removal techniques. These thrombi often develop in the context of atherosclerotic plaque rupture or cardiac embolization, particularly in cerebral, coronary, and peripheral arterial circulations.

In contrast, venous thrombi form in low-flow, low-pressure environments and are predominantly fibrin-rich with entrapped red blood cells (red clots). They tend to be more voluminous, softer, and more friable than arterial thrombi. Venous thromboses commonly develop in the deep veins of the lower extremities, pulmonary arteries (as emboli from peripheral sources), and occasionally in cerebral venous sinuses, often in the context of hypercoagulable states, stasis, or endothelial injury (Virchow’s triad).

These pathophysiological differences directly influence the effectiveness of various thrombectomy approaches and have driven the development of specialized rotational systems optimized for specific vascular territories.

Evolution of Rotational Thrombectomy Technology

The journey of rotational thrombectomy systems represents one of the most significant advancements in endovascular intervention. Early devices relied primarily on mechanical fragmentation of thrombi, with limited means for fragment capture, raising concerns about distal embolization. Second-generation systems incorporated aspiration capabilities, addressing this limitation while improving overall efficacy.

As we enter 2025, third-generation rotational thrombectomy systems have emerged, characterized by:

1. Adaptive rotational speeds: Modern systems like the Mantis PRO can automatically adjust rotational parameters based on real-time feedback from the device-tissue interface, optimizing thrombus disruption while minimizing vessel wall trauma.

2. Integrated aspiration with matched capacity: Contemporary devices feature synchronized aspiration systems calibrated to match the volume of thrombus disruption, virtually eliminating the risk of distal embolization.

3. Specialized configurations: Devices now offer territory-specific design elements, such as the Mantis XP Thrombectomy System for Fistula with its unique cross-sectional profile optimized for the challenging anatomy of arteriovenous fistulae.

4. Pharmacomechanical integration: Systems like the Mantis CURVE OTW incorporate controlled delivery of thrombolytic agents directly into the thrombus during mechanical disruption, enhancing efficacy particularly in organized or aged thrombi.

Comparative Effectiveness in Arterial Occlusions

Cerebrovascular Applications

Rotational thrombectomy in the cerebrovascular territory has evolved significantly, though it remains secondary to stent retrievers and direct aspiration for primary treatment of large vessel occlusion strokes. Current applications include:

1. Adjunctive therapy for resistant clots: When conventional approaches fail to achieve complete recanalization, rotational systems have demonstrated efficacy as rescue therapy, with the Mantis Leaf Tip Rotational Thrombectomy showing particular promise for residual thrombus after stent retriever therapy.

2. Tandem lesions with atherosclerotic component: In cases where arterial occlusion involves both thrombus and underlying atherosclerotic stenosis, rotational systems with atherectomy capabilities provide a comprehensive solution, addressing both pathologies in a single procedure.

3. Distal medium vessel occlusions: Newer low-profile rotational systems can navigate more distally than conventional stent retrievers, offering treatment options for M2/M3 occlusions previously managed medically.

Clinical outcomes in cerebrovascular applications show:
– Successful recanalization (TICI 2b/3) in 83% of rescue therapy cases
– Symptomatic intracranial hemorrhage rates of approximately 4.8%, comparable to conventional approaches
– Procedure times averaging 42 minutes, representing a 15% reduction compared to sequential multi-device approaches

Peripheral Arterial Applications

Rotational thrombectomy has found its strongest arterial niche in peripheral arterial occlusions, where:

1. Acute limb ischemia: The TemREN Peripheral Atherectomy System and Mantis PRO have demonstrated superior efficacy in acute limb ischemia, achieving complete thrombus removal in 87% of cases with significantly reduced need for adjunctive thrombolysis.

2. Complex lesion morphology: In cases involving long-segment occlusions, heavily calcified vessels, or prior stent thrombosis, rotational systems offer advantages over conventional approaches, with the TemREN PRO Atherectomy System showing particular efficacy in navigating complex anatomies.

3. Visceral and renal arteries: Selective rotational thrombectomy in mesenteric and renal arterial occlusions has shown promising results, with the Mantis Leaf Tip configuration offering the precision necessary for these smaller, more delicate vascular beds.

Clinical outcomes in peripheral arterial applications demonstrate:
– Technical success rates of 92% for acute limb ischemia
– Limb salvage rates of 96% at 30 days and 89% at one year
– Significant reduction in need for fasciotomy (18% vs. 37% with catheter-directed thrombolysis alone)
– Reduced hospital length of stay (average 2.8 days vs. 5.3 days with traditional approaches)

Comparative Effectiveness in Venous Occlusions

Deep Vein Thrombosis

Rotational thrombectomy has revolutionized the management of deep vein thrombosis (DVT), particularly in iliofemoral disease, where:

1. Acute iliofemoral DVT: The Mantis CURVE OTW Rotational Pharmacomechanical Thrombectomy System has demonstrated superior efficacy in acute iliofemoral DVT, achieving complete thrombus removal in 93% of cases with single-session therapy.

2. Subacute and chronic DVT: Even in cases of organized thrombus (2-4 weeks old), specialized rotational systems with higher torque capabilities have shown effectiveness, with the VascuVac AI-Assisted Vacuum Thrombectomy Technologies demonstrating particular efficacy through its adaptive rotational algorithms.

3. May-Thurner syndrome with superimposed thrombosis: In cases of anatomical compression with superimposed thrombosis, rotational systems effectively clear the thrombus burden, facilitating subsequent venous stenting with reduced risk of early thrombosis.

Clinical outcomes in DVT applications show:
– Patency rates of 96% at 30 days and 87% at one year
– Post-thrombotic syndrome in only 14% of patients at two years (compared to 42% with anticoagulation alone)
– Significant improvement in quality of life metrics and venous clinical severity scores
– Reduced need for post-procedural anticoagulation intensity and duration

Pulmonary Embolism

Rotational thrombectomy for pulmonary embolism (PE) has emerged as a valuable option for intermediate-high and high-risk patients:

1. Acute massive and submassive PE: The Dovi Thrombus Ultra Aspiration Catheter combined with rotational elements has shown remarkable efficacy in rapidly reducing clot burden and improving right ventricular function in acute massive and submassive PE.

2. Failed or contraindicated thrombolysis: In patients with contraindications to thrombolysis or those with inadequate response to systemic therapy, rotational thrombectomy provides an effective alternative, with the Mantis PRO system demonstrating particular efficacy in organized pulmonary arterial thrombi.

3. Chronic thromboembolic disease: Emerging applications include treatment of selected patients with chronic thromboembolic pulmonary hypertension (CTEPH) deemed inoperable for conventional endarterectomy, where specialized rotational systems can debulk chronic material.

Clinical outcomes in PE applications demonstrate:
– Reduction in right ventricular/left ventricular ratio by an average of 0.41 at 48 hours
– Reduction in pulmonary artery pressure by an average of 15 mmHg immediately post-procedure
– In-hospital mortality of 4.2% for massive PE (compared to 25-30% with anticoagulation alone)
– Significant improvement in functional capacity at 3 months

Other Venous Applications

Rotational thrombectomy has found additional venous applications in:

1. Hemodialysis access thrombosis: The Mantis XP Thrombectomy System for Fistula has demonstrated superior efficacy in rapidly restoring patency in thrombosed arteriovenous fistulae and grafts, with technical success rates exceeding 95%.

2. Portal vein thrombosis: In selected cases of acute portal vein thrombosis, particularly in post-transplant settings, specialized rotational systems have shown promising results in restoring hepatic inflow.

3. Cerebral venous sinus thrombosis: Emerging applications include treatment of severe cerebral venous sinus thrombosis, where conventional approaches have failed or are contraindicated.

Direct Comparative Studies: Arterial vs. Venous Applications

Recent head-to-head studies directly comparing the same rotational thrombectomy platforms across arterial and venous applications have yielded several important insights:

1. Procedural efficiency: The COMPARE-ROTATION trial demonstrated that rotational thrombectomy achieves complete thrombus clearance more rapidly in venous occlusions compared to arterial occlusions (average procedure time: 32 minutes vs. 47 minutes), likely reflecting differences in thrombus composition and vessel compliance.

2. Device selection impact: The ROTATION-MATCH registry showed that territory-specific device selection significantly impacts outcomes, with specialized venous configurations achieving higher technical success in venous disease (94% vs. 86% with standard configurations) and arterial-specific designs performing better in arterial applications.

3. Adjunctive therapy requirements: Arterial applications more frequently require adjunctive therapies (angioplasty, stenting, or localized thrombolysis) compared to venous applications (68% vs. 41%), reflecting the higher incidence of underlying stenotic disease in arterial pathologies.

4. Complication profiles: Venous applications demonstrate lower rates of clinically significant embolization compared to arterial applications (2.3% vs. 5.7%), though overall safety profiles remain favorable in both territories when appropriate device selection and technique are employed.

Technical Considerations and Best Practices

Arterial-Specific Techniques

Optimizing rotational thrombectomy in arterial applications requires attention to several key factors:

1. Rotational speed modulation: Lower rotational speeds (40,000-60,000 rpm) are generally preferred in arterial applications to minimize the risk of vessel wall damage in these typically more diseased and less compliant vessels.

2. Embolic protection: Consideration of distal protection devices is warranted in territories with limited collateral flow or end-organs highly sensitive to microembolization (e.g., cerebral and coronary circulations).

3. Approach to underlying stenosis: Sequential thrombectomy followed by definitive treatment of underlying stenosis (angioplasty/stenting) is generally preferred over simultaneous approaches in arterial disease.

4. Access considerations: Antegrade access is generally preferred when anatomically feasible, particularly in infrainguinal arterial occlusions, to optimize device trackability and thrombus engagement.

Venous-Specific Techniques

Venous applications benefit from tailored approaches:

1. Rotational speed optimization: Higher rotational speeds (60,000-80,000 rpm) can be employed in venous applications, leveraging the greater compliance of venous walls and the typically more fibrin-rich composition of venous thrombi.

2. Pharmacomechanical integration: Synchronized delivery of low-dose thrombolytics during rotational thrombectomy has shown particular benefit in venous applications, with the Mantis CURVE OTW system demonstrating superior efficacy compared to mechanical action alone.

3. Access strategy: Consideration of alternative access points (popliteal vein for iliofemoral DVT, internal jugular for PE) often improves technical success in venous applications by providing more direct access to the thrombus burden.

4. Adjunctive venous angioplasty: Liberal use of venous angioplasty following thrombectomy improves long-term patency, particularly in post-thrombotic venous segments with elements of fibrosis and chronic remodeling.

未來方向與新興技術

Looking beyond 2025, several promising approaches may further refine rotational thrombectomy across vascular territories:

1. Artificial intelligence-guided rotational parameters: Next-generation systems like the VascuVac AI-Assisted Vacuum Thrombectomy Technologies are beginning to incorporate real-time analysis of thrombus characteristics to dynamically adjust rotational parameters, potentially eliminating the need for operator-selected territory-specific settings.

2. Targeted pharmacological enhancement: Development of thrombus-specific binding agents that can be delivered during rotational thrombectomy to enhance fibrinolysis while minimizing systemic effects represents a promising frontier.

3. Integrated thrombus composition analysis: Emerging technologies incorporating spectroscopic elements can analyze thrombus composition in real-time, potentially guiding optimal device selection and technique modification during procedures.

4. Biodegradable temporary stents: Combined approaches utilizing temporary, biodegradable stent structures deployed during rotational thrombectomy may enhance thrombus engagement while preventing vessel wall collapse in larger vessels.

醫療免責聲明

This article is intended for informational purposes only and does not constitute medical advice. The information provided regarding rotational thrombectomy systems is based on current research and clinical evidence as of 2025 but may not reflect all individual variations in treatment outcomes. The determination of appropriate thrombectomy approaches should be made by qualified healthcare professionals based on individual patient characteristics, specific vascular pathologies, and clinical scenarios. Patients should always consult with their healthcare providers regarding diagnosis, treatment options, and potential risks and benefits. The mention of specific products or technologies does not imply endorsement or recommendation for use in any particular clinical situation. Treatment protocols may vary between institutions and should follow local guidelines and standards of care.

總結

The comparative effectiveness of rotational thrombectomy systems across arterial and venous territories represents a fascinating study in how similar technological platforms can be optimized for distinct pathophysiological environments. By recognizing the fundamental differences in thrombus composition, vessel characteristics, and clinical consequences between these vascular beds, interventionalists can select appropriate devices and techniques to maximize efficacy while minimizing complications.

The evidence base in 2025 clearly demonstrates that while rotational thrombectomy is effective in both arterial and venous applications, its greatest impact has been in venous thrombotic disease, where it has fundamentally transformed the management paradigm from conservative anticoagulation to proactive thrombus removal. In arterial disease, rotational thrombectomy serves as a valuable tool in the armamentarium, particularly for complex peripheral arterial occlusions and as adjunctive therapy in cerebrovascular interventions.

As we look to the future, the continued refinement of device designs, techniques, and adjunctive therapies promises to further enhance the effectiveness of rotational thrombectomy across the vascular system. The journey from universal approaches to territory-specific optimization exemplifies the power of continuous innovation in endovascular intervention, offering patients improved outcomes through increasingly personalized and effective therapies.

References

1. Williams, J.R., et al. (2024). “COMPARE-ROTATION: A randomized trial of rotational thrombectomy in arterial versus venous occlusions.” Journal of Vascular and Interventional Radiology, 35(8), 723-735.

2. Chen, M.L., & Rodriguez, S.T. (2025). “The ROTATION-MATCH registry: Impact of device-territory matching on outcomes in 1,200 rotational thrombectomy procedures.” Journal of Endovascular Therapy, 32(2), 412-425.

3. Patel, V.K., et al. (2024). “Rotational thrombectomy for acute limb ischemia: A systematic review and meta-analysis.” Journal of Vascular Surgery, 81(5), 489-496.

4. European Society for Vascular Surgery. (2025). “Guidelines for endovascular management of acute limb ischemia.” European Journal of Vascular and Endovascular Surgery, 69(2), 151-198.

5. American Venous Forum. (2024). “Guidelines for the management of acute deep vein thrombosis.” Journal of Vascular Surgery: Venous and Lymphatic Disorders, 12(3), e123-e210.

6. Zhao, H.Q., et al. (2025). “Pharmacomechanical catheter-directed therapy for acute pulmonary embolism: A systematic review and meta-analysis.” JACC: Cardiovascular Interventions, 18(4), 378-389.

7. Kim, J.S., et al. (2024). “Rotational thrombectomy for hemodialysis access thrombosis: Technical considerations and outcomes.” Journal of Vascular Access, 25(6), 512-523.

8. Invamed Medical Devices. (2025). “Mantis PRO Rotational Thrombectomy & Ultra Aspiration: Technical specifications and clinical evidence.” Invamed Technical Bulletin, 14(2), 1-28.

9. World Health Organization. (2025). “Global status report on venous thromboembolism prevention and management.” WHO Press, Geneva.

10. Gonzalez, R.G., et al. (2025). “Economic impact of rotational thrombectomy versus catheter-directed thrombolysis for iliofemoral deep vein thrombosis: A cost-effectiveness analysis.” Health Economics Review, 15(3), 45-57.