Evaluation of Percutaneous Mechanical Thrombectomy via the AngioJet System Combined with Catheter-Directed Thrombolysis for the Treatment of Symptomatic Lower Extremity Deep Venous Thrombosis

Catheter-Directed Thrombolysis Protocols for Deep Venous Thrombosis of the Lower Extremities-A Systematic Review and Meta-analysis

OBJECTIVE

 To summarize characteristics, complications, and success rates of different catheter-directed thrombolysis (CDT) protocols for the treatment of lower extremity deep venous thrombosis (LE-DVT).

METHODS

 A systematic review using electronic databases (MEDLINE, Scopus, and Web of Science) was performed to identify randomized controlled trials and observational studies related to LE-DVT treated with CDT. A random-effects model meta-analysis was performed to obtain the pooled proportions of early complications, postthrombotic syndrome (PTS), and venous patency.

RESULTS

 Forty-six studies met the inclusion criteria reporting 49 protocols (n = 3,028 participants). In studies that addressed the thrombus location (n = 37), LE-DVT had iliofemoral involvement in 90 ± 23% of the cases. Only four series described CDT as the sole intervention for LE-DVT, while 47% received additional thrombectomy (manual, surgical, aspiration, or pharmacomechanical), and 89% used stenting.Definition of venogram success was highly variable, being the Venous Registry Index the most used method (n = 19). Among those, the minimal thrombolysis rate (<50% lysed thrombus) was 0 to 53%, partial thrombolysis (50-90% lysis) was 10 to 71%, and complete thrombolysis (90-100%) was 0 to 88%. Pooled outcomes were 8.7% (95% confidence interval [CI]: 6.6-10.7) for minor bleeding, 1.2% (95% CI: 0.8-1.7%) for major bleeding, 1.1% (95% CI: 0.6-1.6) for pulmonary embolism, and 0.6% (95% CI: 0.3-0.9) for death. Pooled incidences of PTS and of venous patency at up to 1 year of follow-up were 17.6% (95% CI: 11.8-23.4) and 77.5% (95% CI: 68.1-86.9), respectively.

CONCLUSION

 Assessment of the evidence is hampered by the heterogeneity of protocols, which may be reflected in the variation of PTS rates. Despite this, CDT is a low-risk treatment for LE-DVT.

Central Venous Catheter as a Novel Approach to Postoperative Thrombolysis in Patients with Acute Iliofemoral Deep Venous Thrombosis

BACKGROUND AND AIMS

Percutaneous mechanical thrombectomy (PMT) along with postoperative thrombolysis (POT) has been the standard treatment for acute iliofemoral deep venous thrombosis (IFDVT). However, commonly used catheter directed thrombolysis (CDT) approaches for POT carry certain disadvantages, including the need for a sheath, inferior comfortability, and catheter-related complications. Therefore, we propose a new simplified method of POT using a central venous catheter (CVC).

METHODS

The retrospective study analyzed patients with IFDVT who underwent POT using CVC from January 2020 to August 2021. The treatment modalities included filter placement, thrombus removal, iliac vein obstruction release, postoperative CVC thrombolysis, filter retrieval, and adequate full course anticoagulation.

RESULTS

A total of 39 patients were included in this retrospective study. All patients underwent PMT surgery with a procedure success rate of 100%. In the post-PMT CVC thrombolysis, the puncture sites were located in the below-knee vein, including 58.97% in the peroneal vein. The mean duration of CVC-directed thrombolysis was 3.69 ± 1.08 days, and the total urokinase dose was 2.27 ± 0.71 MIU. A total of 37 patients (94.87%) had successful thrombolysis with a length of hospital stay of 5.82 ± 2.21 days. During CVC-directed thrombolysis, only four minor bleeding complications occurred, two of which were indwelling catheter-related. During the 12-month follow-up period, the patency rate and post-thrombotic syndrome incidences were 97.44% and 2.56%, respectively.

CONCLUSION

Thrombolysis through a CVC is a feasible, safe, and effective POT method, and could be an alternative to the conventional CDT approach for patients with IFDVT.

LINC00659 exacerbates endothelial progenitor cell dysfunction in deep vein thrombosis of the lower extremities by activating DNMT3A-mediated FGF1 promoter methylation

It has been shown that long non-coding RNA (lncRNA) LINC00659 was markedly upregulated in the peripheral blood of patients with deep venous thrombosis (DVT). However, the function of LINC00659 in lower extremity DVT (LEDVT) remains to be largely unrevealed. A total of 30 inferior vena cava (IVC) tissue samples and peripheral blood (60 ml per subject) were obtained from LEDVT patients (n = 15) and healthy donors (n = 15), and then LINC00659 expression was detected by RT-qPCR. The results displayed that LINC00659 is upregulated in IVC tissues and isolated endothelial group cells (EPCs) of patients with LEDVT. LINC00659 knock-down promoted the proliferation, migration, and angiogenesis ability of EPCs, while an pcDNA-eukaryotic translation initiation factor 4A3 (EIF4A3), a EIF4A3 overexpression vector, or fibroblast growth factor 1 (FGF1) small interfering RNA (siRNA) combined with LINC00659 siRNA could not enhance this effect. Mechanistically, LINC00659 bound with EIF4A3 promoter to upregulated EIF4A3 expression. Besides, EIF4A3 could facilitate FGF1 methylation and its downregulated expression by recruiting DNA methyltransferases 3A (DNMT3A) to the FGF1 promoter region. Additionally, LINC00659 inhibition could alleviate LEDVT in mice. In summary, the data indicated the roles of LINC00659 in the pathogenesis of LEDVT, and the LINC00659/EIF4A3/FGF1 axis could be a novel therapeutic target for the treatment of LEDVT.

Discussion on operation: To compare the curative effect of PMT and CDT in the treatment of middle and high risk stratified APE and the clinical application value of serum BNP, TnI and plasma DFR levelse

Objective

To compare the efficacy of Percutaneous mechanical thrombectomy (PMT) and Catheter directed thrombolysis (CDT) in the treatment of patients with moderate and high-risk ape and explore the clinical application value of biomarkers in the treatment of moderate and high-risk ape.

Method

A total of 84 patients with ape were selected from the Department of vascular surgery of the Second Affiliated Hospital of Shandong First Medical University and the Department of vascular surgery of Shanghai Ninth People's Hospital Affiliated with Shanghai Jiao Tong University School of Medicine. According to the relevant guidelines, they were divided into high-risk and medium-risk groups, including PMT groups (35 cases) and CDT groups (49 cases). To detect the changes of serum B-type brain natriuretic peptide (BNP),Troponin I (TnI) and plasma D-dimer/fibrinogen ratio (DFR) levels in different risk stratification before and after PMT and CDT, the correlation and diagnostic value of each index, and compare the thrombus clearance rate, pulmonary artery pressure, average dosage of urokinase, effective thrombolytic time, average hospitalization time and complications of PMT and CDT.

Result

Under different treatment methods and risk stratification, there was no statistically significant difference in the clinical data of patients at general baseline;The preoperative BNP, TnI and DFR levels of PMT and CDT in the middle and high risk stratification were significantly lower than those in the other groups (P < 0.005),Compared with the CDT group, PMT has significantly better therapeutic effect on ape than the CDT group in terms of thrombus clearance rate, pulmonary artery pressure, average dosage of urokinase, effective thrombolytic time and average hospitalization time (P < 0.05),meanwhile,there was no significant difference in postoperative complications between the two groups (P < 0.05). After half a year of follow-up, the levels of BNP, TnI and DFR in the cured group were significantly lower than those in the effective group and the ineffective group. The areas under the curve of serum BNP, TnI and plasma DFR were 0.91, 0.87 and 0.93 and the area under the curve DFR has higher diagnostic efficiency than BNP and TnI, while the sensitivity and specificity of TnI are significantly higher than BNP and DFR.

Conclusion

Serum BNP, TnI and plasma DFR levels can reflect the risk stratification and better clinical diagnostic value of ape,PMT and CDT are used to treat high-risk ape. For hospitals with medical conditions, PMT is more worthy of clinical recommendation.

Combined pharmacomechanical thrombectomy with selective catheter-directed thrombolysis in patients with acute proximal deep vein thrombosis

Background

The aim of this study was to evaluate the characteristics and the outcomes of combined percutaneous pharmacomechanical thrombectomy with selective catheter-directed thrombolysis for acute iliofemoral deep vein thrombosis.

Methods

Between March 2018 and February 2020, a total of 37 patients (21 males, 16 females; mean age: 55±13.8 years; range, 21 to 79 years) with symptomatic acute iliofemoral vein thrombosis who underwent combined percutaneous pharmacomechanical thrombectomy and catheter-directed thrombolysis were retrospectively analyzed. All patients received a three-step therapy: (i) insertion of a temporary inferior vena cava filter, (ii) percutaneous pharmacomechanical thrombectomy via rotational mechanical thrombectomy device with an adjuvant 0.15 mg/kg recombinant tissue-type plasminogen activator alteplase, and (iii) catheter-directed thrombolysis with continuous 1 mg/h tissue-type plasminogen activator alteplase. Data including demographic characteristics of the patients, bleeding complications, technical success, and adjuvant angioplasty rates were analyzed. The Kaplan-Meier analysis was used to evaluate freedom from re-thrombosis at 3, 6, and 12 months of follow-up was calculated.

Results

The majority of the patients had left-sided (n=22, 59.4%) proximal deep vein thrombosis. Successful insertion of the inferior vena cava filter was achieved in 97.2% (n=36) of patients. The technical success rate was 89.1% (n=33). Adjuvant venous angioplasty was performed in four patients (10.8%) and no venous stents were used. No major bleeding was occurred, while minor bleeding was observed mostly in the form of hematuria (n=12, 32.4%). No mortality was observed. The 3, 6, and 12-month freedom from re-thrombosis rates were 96.3%, 92.6%, and 86.0%, respectively.

Conclusion

Combined percutaneous pharmacomechanical thrombectomy and catheter-directed thrombolysis seems to be an effective and safe treatment of the iliofemoral acute deep vein thrombosis with acceptable minor bleeding complications post-interventionally.

Current Status and Prospect of Stent Placement for May-Thurner Syndrome

Stent implantation has been proven to be safe and has become the first-line intervention for May-Thurner syndrome (MTS), with satisfactory mid-term patency rates and clinical outcomes. Recent research has demonstrated that catheter-directed thrombolysis is the preferred strategy when MTS is combined with deep vein thrombosis after self-expanding stent placement. However, the stent used for the venous system was developed based on the experience obtained in the treatment of arterial disease. Consequently, relatively common corresponding complications may come along later, which include stent displacement, deformation, and obstruction. Different measures such as adopting a stent with a larger diameter, improving stent flexibility, and increasing stent strength have been employed in order to prevent these complications. The ideal venous stent is presently being evaluated and will be introduced in detail in this review.

Cost-effectiveness Analysis of AngioJet and CDT for Lower Extremity Deep Vein Thrombosis Among Chinese Population

AngioJet has sufficient safety and efficacy in the treatment of acute and subacute lower extremity deep vein thrombosis (LEDVT). But the price of consumables used by AngioJet is relatively high and there is a lack of relevant research on health economics to measure the benefits to patients. Objective of this study is to estimate the cost effectiveness of AngioJet compared with catheter-directed thrombolysis (CDT) among Chinese population. Using a Markov decision model, we compared the 2 treatment strategies in patients with LEDVT. The model captured the development of post-thrombotic syndrome (PTS), recurrent venous thromboembolism, and treatment-related adverse events within a lifetime horizon and the perspective of a third-party payer. Model uncertainty was assessed with one-way and Monte Carl sensitivity analyses. The clinical inputs were obtained from the literature. Costs obtained from the hospital accounts and the literature are expressed in US dollars ($). Utilities were defined as quality adjusted life years (QALY). In cost-effectiveness analysis, AngioJet accumulated $1064.6445/QALY compared with $2080.1561/QALY after CDT treatment alone. AngioJet has higher long-term cost-effectiveness than CDT at a willingness to pay threshold of $11 233.52. One-way sensitivity analysis showed that the utilities of PTS and post-LEDVT state had significant influence on the results and the model maintained a strong stability under  ± 10% fluctuation of utilities. Monte Carl sensitivity analysis shows that AngioJet model has strong stability and AngioJet has higher long-term cost-effectiveness than CDT. AngioJet is likely to be a cost-effective alternative to the CDT for patients with LEDVT.