Roper 

et al. J Med Case Reports (2021) 15:459

https://doi.org/10.1186/s13256-021-03062-3

Unclogging the effects of the Angiojet®

CASE REPORT Open Access

thrombectomy system on kidney function:

a case report
Tayeba Roper1*  , Muhammad Amaran1, Prakash Saha2, Cormac Breen1 and David Game1 

Abstract 
Background: AngioJet® is an increasingly used method of percutaneous mechanical thrombectomy for the treat-
ment of patients with arterial and venous thromboses. AngioJet® has been shown to cause intravascular haemoylsis
universally. We report the case of a 29 year old patient who underwent AngioJet® thrombectomy and post-procedure
developed a stage 3 Acute kidney injury (AKI.) requiring renal replacement therapy (RRT), secondary to intravascular
haemolysis. We aim to explore the mechanism and potential risk factors associated with developing AKI in these
patients and suggest steps to optimise patient management.
Case presentation:  A 29 year old Caucasian male who developed a stage 3 AKI, requiring RRT, following AngioJet®
thrombectomy for an occluded femoral vein stent. Urine and laboratory investigations showed evidence of intravas-
cular haemolysis, which was the likely cause of AKI. Following a brief period of RRT he completely recovered renal
function.
Conclusions:  AKI is an increasingly recognised complication following AngioJet® thrombectomy, but remains under-
appreciated in clinical practice. AKI results from intravascular haemolysis caused by the device. Up to 13% of patients
require RRT, but overall short-term prognosis is good. Pre-procedural risk factors for the development of AKI include
recent major surgery. Sodium bicarbonate should be administered to those who develop renal impairment. Renal
biopsy is high risk and does not add to management. Increased clinician awareness and vigilance for AKI post-proce-
dure can allow for early recognition and referral to nephrology services for ongoing management.
Keywords:  Acute kidney injury, Haemolysis, Deep vein thromboses, Arterial thromboses, Angiojet

Background embolisation and post thrombotic syndrome (PTS). Tra-

Arterial and deep venous thromboses (DVT) are com- ditional methods for clot removal with catheter directed
mon and can cause significant morbidity and mortality. thrombolysis (CDT) are now being superseded by Percu-

as the AngioJet® rheolytic thrombectomy device (Pos-

The mainstay of treatment most commonly involves the taneous mechanical thrombectomy (PMT) devices, such
administration of antiplatelet or anticoagulant medi-

AngioJet®). These are an increasingly used form of endo-

cations, respectively. However, for larger burden clots sis Medical, Minneapolis, Minnesota, USA) (henceforth
more invasive treatment options are available, to reduce
the associated risk of complications, including clot vascular treatment for both arterial and deep vein throm-
boses, due to the associated reduction in treatment time,
intensive care admissions, and overall length of hospital
*Correspondence: [email protected]

Angiojet® employs multiple high-pressure saline jets

1
stay compared to CDT techniques [1, 2].
Department of Renal Medicine, Guy’s & St Thomas’ NHS Foundation
Trust,, Great Maze Pond, London SE1 9RT, United Kingdom
Full list of author information is available at the end of the article which cause fragmentation of targeted clots, whilst

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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Roper et al. J Med Case Reports (2021) 15:459 Page 2 of 6

simultaneously delivering thrombolytic agent into the and discolouration secondary to DVT. There was no his-
clot. A Venturi effect is created by the jets, which allows tory of chest pain, shortness of breath or palpitations.
for aspiration of the clot debris, and prevents clot embo- A year prior he had undergone left common-iliac vein
lisation [3]. Although effective, the mechanism of action stenting for a non-thrombotic iliac vein lesion, to redi-
has been shown to cause significant haemolysis and rou- rect venous return away from the VM. As he remained
tinely results in post-procedural haemoglobinuria. This in symptomatic following this procedure, elective surgical

an increasingly recognized complication of Angiojet®,

turn can cause acute kidney injury (AKI), which although excision-and-tie of the main feeder vessel to the VM was
performed three weeks prior to this presentation. Bleed-

ous cases of AKI following Angiojet® have been reported

remains underappreciated in clinical practice. Five previ- ing at the time of this operation led to Apixaban, that he
was previously on, to be stopped. He had no other past
in the literature, one of which was in a child [4–8]. We medical history, including no known history of renal
report the case of a 29 year old male who developed impairment, and no family history of renal disease. At the

therapy (RRT), following AngioJet® thrombectomy of an

a severe Stage 3 AKI [9], requiring renal replacement time of presentation cardiorespiratory examination was
unremarkable. Examination of the abdomen revealed a
occluded iliac vein stent. We aim to expand on the possi- firm, palpable mass in the left abdominal wall, consistent

going AngioJet®, and suggest steps which could be taken

ble risk factors for development of AKI in patients under- with the known VM. The left upper leg was swollen with
mottling of the skin, but otherwise soft and non-tender,
to optimise the management of these patients. and peripheral pulses were intact. 7500 units twice daily
of low molecular weight heparin (LMWH) were com-
Case presentation menced at the time of presentation. Following CT venog-
A 29 year old Caucasian male with a known left flank raphy (Fig. 1) and duplex ultrasonography, that identified
symptomatic venous malformation (VM) (Fig.  1) was an occluded venous stent, Angiojet thrombectomy and
admitted with a 2-day history of left leg pain, swelling venoplasty were performed under general anaesthetic

A D

Fig. 1  A–C Computed tomography with contrast agent showing the vascular malformation (arrow) and placement of venous stent (D, arrow head)
 Roper et al. J Med Case Reports (2021) 15:459 Page 3 of 6

Fig. 2  Venogram demonstrating occluded stent (A), Angiojet thrombectomy (B) and successful recanalization of the stent (C)

by the vascular surgical team (Fig. 2). Pre-operative clot- (Fig.  3). Laboratory investigations demonstrated serum
ting markers were all within normal limits (INR 1.1, lactate dehydrogenase (LDH) to be elevated at 1148 U/L
APTR 1.1). Intraoperatively, 8000 units of unfractionated and haptoglobin level low at 0.3  g/L, haemoglobin fell
heparin were administered, followed by 15000 units of post-procedure from 145 to 86  g/L (Table  1). Direct
LMWH one hour post-procedure. Successful recanalisa- antiglobulin test was negative. Blood tests performed
tion of the thrombosed stent was achieved. In the post- pre-procedure and within 72  hours post-procedure are
operative period he developed bradycardia and vomiting, shown in Table  1. Acute renal screen blood tests and
and was treated with antiemetic and intravenous fluids. virology were all negative. An ultrasound of the kid-
Vomiting settled after 36 hours. He remained haemody- neys and urinary tract demonstrated normal sized (right
namically stable throughout. Following surgical inter- 12.5  cm, left 11.9  cm), unobstructed kidneys bilaterally,
vention a continuous intravenous heparin infusion was with a diffuse increase in renal echogenicity and loss of
commenced, to prevent re-occlusion of the stent. corticomedullary differentiation. Incidentally the spleen
His renal function was noted to decline immediately was noted to be enlarged at 13 cm. A duplex ultrasound
postop, from a baseline serum creatinine of 77 µmol/L to confirmed patent renal vasculature, and good perfusion
168  µmol/L (Fig.  3). The patient passed dark red urine, of both kidneys.
which on urine dipstick tested positive for blood. Renal The patient was transferred to the renal ward 72 h post-
function continued to decline over the coming 48 hours procedure due to an ongoing decline in renal function

Haemodialysis
12 3 4
Discharge
1400

1200
Angiojet
1000
Creanine (µmol/L)

800

600

400

200

0
1-22-20 1-27-20 2-1-20 2-6-20 2-11-20 2-16-20 2-21-20 2-26-20 3-2-20 3-7-20 3-12-20 3-17-20 3-22-20
Fig. 3  Graph of Creatinine over time. Arrows demonstrate timing of Angiojet® thrombectomy, Haemodialysis sessions and discharge
Roper et al. J Med Case Reports (2021) 15:459 Page 4 of 6

Table 1  Laboratory investigations pre- and within 72 hours post-Angiojet® thrombectomy

Laboratory investigation Pre-procedure Within 72 hours post-procedure Reference range

Haemoglobin 145 86 130–170 g/L

White blood cells 9.3 7.1 4–11 × ­109
Platelets 196 191 150–400 × ­109
Creatinine 77 1296 59–104 µmol/L
Estimated glomerular filtration rate 104 4 70–130 mL/min
Urea – 28.8 1.7–8.3 mmol/L
Potassium 4.3 4.9 3.5–5.0 mmol/L
Sodium 138 138 135–145 mmol/L
Bicarbonate – 16 22–30 mmol/L
Albumin 52 38 40–52 g/L
Bilirubin 7 5 0–21 umol/L
Creatinine kinase – 201 0–229 IU/L
C-reactive protein 1 31 0–4 mg/L
International normalised ratio 1.1 1.0 0.8–1.2 Ratio
Activated partial thromboplastin time ratio 1.1 2.4 (on Heparin infusion) 0.8–1.2 Ratio
Haptoglobin – 0.3 0.3–2.0 g/L
Reticulocyte count – 66 10–100 × ­109
Lactate Dehydrogenase – 1148 135–225 U/L
Direct Antiglobulin Test – Negative –
Blood film – Red cell morphology—mild polychromasia, slight –
anisocytosis, rare tear drop poikilocytes

and fall in urine output (Fig.  2). He was initially man- been reported [4–8]. The occurrence of haemolysis in
aged with intravenous 1.26% sodium bicarbonate and the case presented, as evidenced by the passage of dark
0.9% sodium chloride solutions, to maintain a positive red urine post-procedure, fall in haemoglobin and hap-
fluid balance. However urine output continued to fall and toglobin, and rise in serum LDH, was an anticipated con-
he started to develop evidence of fluid overload. After a sequence of the procedure. Given the patients’ young age
further 48 hours, intermittent haemodialysis (HD) was and absence of other risk factors, deterioration in renal
commenced via a right internal jugular vein vascath. Four function to the point of requiring RRT (Fig.  3), was not
sessions of HD were completed in total (Fig. 3). He sub- anticipated. The patient had a small volume of contrast
sequently started to show signs of renal recovery with intra-operatively and significant vomiting post-oper-
polyuria, passing over 3 litre of clear urine per day. A atively, both of which could have contributed to AKI.
decision was made not to perform a renal biopsy in view The severity of AKI with need for RRT, despite aggres-
of the high risk of bleeding given the concomitant hepa- sive fluid replacement, suggests the cause of deteriora-
rin infusion. He was discharged with a falling creatinine tion in renal function was likely haemolysis, as previously
and once loaded on warfarin. At the time of writing the reported.
patient’s renal function had improved to near baseline, Previous reports have demonstrated an increased risk
with a serum creatinine of 90 µmol/L (Fig. 3). of complications following native renal biopsy in hospital
in-patients who develop AKI, compared to outpatients
Discussion and conclusions
our patient was started on post AngioJet®, the decision
[12]. Given this and the concomitant Heparin infusion,
Haemolysis is a well-documented cause of AKI in many
conditions, including autoimmune haemolysis, par- was made not to perform a renal biopsy to further inves-

secondary to prosthetic cardiac valves [10]. AngioJet®

oxysmal nocturnal haemoglobinuria and haemolysis tigate the cause for AKI. It was felt that there was suffi-
cient evidence of haemolysis (as previously discussed)
has previously been shown to universally result in post- as a cause for AKI, and that a biopsy would add little to
procedural gross haematuria, following intravascu- guide further management. One previous study reports

post AngioJet®. This study reported findings including

lar haemolysis caused by the high-pressure saline jets on renal biopsy findings in a patient who developed AKI

AngioJet®-induced intravascular haemolysis have also

[11]. Furthermore, previous cases of AKI secondary to
acute tubular injury, red blood cell debris within tubules,
 Roper et al. J Med Case Reports (2021) 15:459 Page 5 of 6

and tubular epithelial cells and podocytes staining for increased risk of developing AKI. Other than major sur-
ferritin and haemo-oxygenase-1 (HO-1) [7]. These find- gery performed within 3 months of vascular intervention
ings lend support to numerous studies which suggest the [11], none of the studies identified any pre-procedural
mechanism of AKI following haemolysis is likely related risk factors for the development of AKI, including tradi-
to a complex interplay of cytotoxic inflammatory media- tional risk factors for AKI. Both Escobar et al. and Shen
tors, activated in response to the increased iron and et al. reported 2 patients requiring a period of RRT, 11%
haemprotein load from lysed red blood cells. Filtered and 13%, respectively [11, 16].
haemoproteins induce the release of ferritin and HO-1, The case presented appears typical when compared to

Jet® [4–8]. Our patient developed AKI immediately post-

which protect against oxidative-stress by scavenging free other reported cases of significant AKI following Angio-
haem and iron. When these protective mechanisms are
overwhelmed however, haem and iron can have direct procedure with associated haematuria and evidence of
toxic effects on glomeruli and tubular cells, resulting in haemolysis, despite aggressive intravenous rehydration.
renal dysfunction [13]. After a brief period of HD there was evidence of renal
The ‘Peripheral Use of AngioJet Rheolytic Thrombec- recovery with increased urine output and improvement
tomy with a Variety of Catheter Lengths’ (PEARL) reg- in serum creatinine (Fig.  3). It remains unclear as to

AngioJet® and the development of AKI. PEARL made no

istry only briefly mention the association between whether the presence of a VM contributed to the devel-
opment of AKI in our patient. The presence of a VM
comment on the incidence of AKI not requiring RRT, and meant there was a larger burden of thrombus present,
quoted that 5% of patients required RRT at 12 months which in turn would require a more prolonged procedure
post-procedure. They did not however expand on the to clear. It is conceivable that the increased clot burden
indication for RRT, nor resolution and prevention of AKI allowed for a greater degree of haemolysis and therefore

the risk of AKI associated with AngioJet®. Morrow et al.

in this group [14]. Subsequent studies have reported on an increased risk of AKI in this patient. Prevention and
management of AKI associated with haemolysis is an
observed the incidence of AKI in patients with arterial area which remains under investigation. There is some

Jet®. They found the incidence of renal dysfunction to be

and venous thromboses, undergoing PMT with Angio- evidence to suggest the use of sodium bicarbonate may
be beneficial through the effect of alkalinisation, reduc-
significantly higher in the PMT group compared to CDT tion of free radical generation and attenuation of the
controls, 21% and 0% (p = 0.033), respectively. None of effects of oxidative stress on renal tubules [13] (Table 2).

Escobar et al. found AngioJet® to be an independent

the PMT patients however required RRT [15]. Similarly, In some individuals however, these conservative meas-
ures are unsuccessful and the need for RRT may be
risk factor for the development of AKI (odds ratio 8.22, inevitable. Timely referral to nephrology services allows

increased risk of AKI in patients undergoing AngioJet®

p = 0.004) [16]. Shen et al. also reported a significantly for advice regarding fluid resuscitation and commence-
ment of RRT, potentially without the need for admission
for iliofemoral DVT compared to CDT, 22.8% and 9.2% to an intensive care unit. This case, along with previous

patients who develop AKI post AngioJet® is good, with

(p = 0.013), respectively. Furthermore, they demon- reports, would suggest that the short-term prognosis in
strated major surgery within 3 months prior to vascular

AKI post AngioJet® (odds ratio 8.51, p < 0.01) [11]. Our

intervention, to be a risk factor for the development in good recovery of renal function in most. Further studies

implications of AKI following AngioJet®, including the

are needed however to determine the potential long-term

3 months prior to AngioJet®, potentially placing him at

patient underwent excision-and-tie of the VM within
long-term risk of needing RRT.

Table 2  Management pre- and post- AngioJet® for optimization of patient care
Management pre- and post- AngioJet® thrombectomy

Patients should be counselled and consented regarding the potential risk of AKI and need for RRT​
Consider use of alternative therapy in patients who have undergone major surgery within the last 3 months
Renal function should be checked immediately post-procedure
Fluid resuscitation with intravenous sodium bicarbonate, should be initiated immediately in those with renal impairment
An accurate fluid balance chart should be maintained
Timely referral to nephrology services will allow for appropriate commencement of renal replacement therapy and avoidance of ICU admission
Performing a renal biopsy is high risk and does not alter management in those with renal impairment
Roper et al. J Med Case Reports (2021) 15:459 Page 6 of 6

AngioJet® thrombectomy, but remains underappreciated

AKI is an increasingly reported complication following Author details
1
 Department of Renal Medicine, Guy’s & St Thomas’ NHS Foundation Trust,,
Great Maze Pond, London SE1 9RT, United Kingdom. 2 Vascular Surgery Depart-
in day-to-day clinical practice. AKI can be severe and in ment, Guy’s & St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London,
up to 13% of cases require RRT, but short-term outcomes United Kingdom.

in hospital inpatients, are not associated with AngioJet®.

are good. Routine risk factors for the development of AKI Received: 10 February 2021 Accepted: 14 August 2021

Jet® is the only pre-procedural risk factor reported to be

Undergoing major surgery within 3 months of Angio-

over AngioJet® may therefore need to be considered in

associated with the development of AKI. The use of CDT References
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Written informed consent was obtained from the patient for publication of
this case report and any accompanying images. A copy of the written consent
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The authors declare that they have no competing interests.