Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal

Venous Interventions: Controversies in the Management of Acute Deep Venous Thrombosis and the Role of the Interventional Radiologist

Lower extremity deep venous thrombosis (DVT) is estimated to occur in 1 in 1000 persons annually in adult populations, with prevalence predicted to double by the year 2050. While acute DVT and pulmonary embolism are a major cause of cardiovascular morbidity and mortality, the long-term prognosis for patients with venous thromboembolism is in part determined by the development of post-thrombotic syndrome (PTS), which occurs in up to 50% of patients. PTS refers to a chronic syndrome complex, invariably characterized by intractable edema, pain, stasis dermatitis, and venous stasis ulceration when severe.

AngioJet rheolytic thrombectomy coupled with dose-reduced rt-PA for massive inferior vena cava filter-related thrombosis: A single-center retrospective study

OBJECTIVE

To evaluate the efficacy and safety of AngioJet rheolytic thrombectomy (ART) coupled with dose-reduced rt-PA, compared to catheter-directed thrombolysis (CDT) alone, for the treatment of massive inferior vena cava filter (IVCF)-related thrombosis.

METHODS

We conducted a retrospective analysis of 40 patients who received either ART or CDT alone as the first-line endovascular therapy (ET) between January, 2016 and September, 2022. The data on demographics, clinical characteristics, technical success, clinical success, complications, and early follow-up were reviewed.

RESULTS

Of the 40 included patients, 24 received ART and 16 received CDT alone. The demographics, presentation, lesion characteristics, comorbidities and risk factors were comparable (all p > .05). Technical success rates were 100% in both groups. The total CDT time and infusion agent dosage were lower in the ART group than those in the CDT group (both p < .05). At the end of CDT, clinical success was 81.8% in the ART group, which was slightly higher than that of 70.8% in the CDT group (p > .05). At the 6-month follow-up, the incidences of recurrent thrombosis in the two groups were 6.9% and 15.8%, respectively, and the incidence of post-thrombotic syndrome was 10.3% and 21.1%, respectively. However, these differences were not statistically significant (p > .05). No major complications were noted in either group, ART seemed to have slightly higher risk of transient macroscopic hemoglobinuria and recoverable acute kidney injury, but with a lower minor bleeding incidence when compared with CDT alone (4.2 vs. 31.3%, p < .05).

CONCLUSIONS

ART or CDT alone as the first-line ET for IVCF-related thrombosis has comparable outcomes but with different adverse event profiles. Both modalities are safe and effective in patients with massive IVCF-related thrombosis.

Catheter-based therapies and short-term outcomes in the oncological patients with acute inferior vena cava thrombosis: a single centre experience

OBJECTIVE

To investigate the safety and effectiveness of catheter-based therapy (CBT) using AngioJet rheolytic thrombectomy (ART) device or large lumen catheter (LLC) in the oncological patients with inferior vena cava thrombosis (IVCT).

METHODS

This was a retrospective study including eligible patients with IVCT treated with CBT coupled with dose-reduced thrombolysis as the first-line treatment from February 1, 2015 to January 1, 2022. The baseline demographics, comorbidities, clinical characteristics, treatment details, course data were all reviewed.

RESULTS

A total of 33 patients (mean age 58.8 years, 57.6% male) was included, of whom 17 patients underwent ART and 16 underwent LLC aspiration, the technical success rates were 100%. All patients subsequently underwent catheter-directed thrombolysis relative to reduced-dose thrombolysis. At the end of catheter-directed thrombolysis, clinical success was achieved in 26 (78.8%) patients. In the subgroup analysis, ART seemed to receive a slightly higher rate of thrombus removal Grade III (47.1% vs 12.5%, p = .057). The symptoms of leg pain and swelling post-treatment were significantly improved in both groups (p < .001). Except for transient macroscopic hemoglobinuria occurring in patients with ART, none of all patients suffered from procedure-related adverse events and major complications. Minor complications such as bleeding events occurred in 6.1% (2/33) of patients. At the 6 month follow-up, the incidence of recurrent thrombosis and mild post-thrombotic syndrome (PTS) were 9.7% (3/31) and 6.5% (2/31).

CONCLUSION

CBT is a safe and effective modality for the management of IVCT in the oncological patients, leading to high levels of technical and clinical success, symptoms alleviation, as well as a low incidence of minor complication, mild PTS and recurrence.

ADVANCES IN KNOWLEDGE STATEMENT

The available data and evidence of endovascular therapy (ET) on oncologic patients with IVCT remains insufficient. The purpose of present single center retrospective study including 33 oncological patients is to investigate the preliminary safety and efficacy of CBT using ART device or LLC. The results demonstrated that CBTs are safe and effective as an ET modality in majority of eligible patients with symptomatic acute cancer-associated IVCT, indicating high levels of technical and clinical success, symptoms alleviation, as well as a low prevalence of minor complication, mild post-thrombotic syndrome and recurrence. Furthermore, they have the advantages of accelerated reduction of thrombus burden in a moderate time, speedy restoration of blood flow, but at the risk of potentially increased economic cost. Notably, in the condition of parallel time and dosages of lytic agents, ART tends to achieve a slightly higher thrombus removal Grade III than LLCA.

Prevention, Diagnostics and Treatment of Deep Vein Thrombosis. Russian Experts Consensus

The guidelines are developed in accordance with the requirements of the Ministry of Health of the Russian Federation by the all-Russian public organization «Association of Phlebologists of Russia» with participation of the Association of Cardiovascular Surgeons of Russia, the Russian Society of Surgeons, the Russian Society of Angiologists and Vascular Surgeons, the Association of Traumatologists and Orthopedists of Russia, the Association of Oncologists of Russia, the Russian Society of Clinical Oncology, Russian Society of Oncohematologists, Russian Society of Cardiology, Russian Society of Obstetricians and Gynecologists.

Rheolytic thrombectomy using an AngioJet ZelanteDVT catheter or a Solent Omni catheter for patients with proximal vein thrombosis

PURPOSE

The present study aimed to investigate the preliminary safety and efficacy of rheolytic thrombectomy (RT) using an AngioJet Zelante DVT catheter or a Solent Omni catheter for acute proximal deep vein thrombosis (DVT).

MATERIAL AND METHODS

We conducted a retrospective review of 40 patients who were treated with an AngioJet RT between January 2019 and January 2021, and then the patients were divided into the ZelanteDVT group (n = 17) and the Solent group (n = 23). Data on demographics, clinical characteristics, technical success, clinical success, complications, and early follow-up were analysed.

RESULTS

No significant differences regarding demographics were detected (all p > .05). The technical success rates were both 100%. The ZelanteDVT group had a shorter duration of RT and a higher primary RT success than the Solent group (all p < .05), and the percentage of adjunctive catheter-directed thrombolysis (CDT) was 29.4% in the ZelanteDVT group, which was significantly lower than the 73.9% in the Solent group (p = .010). The clinical success rates for the ZelanteDVT group and Solent group were 100% (17/17) and 95.7% (22/23), respectively, and these values were high in the two groups (p > .05). Apart from transient macroscopic haemoglobinuria occurring in all the patients during the first 24 hours post-RT, none of the patients in either group suffered other procedure-related adverse events or major complications. Minor complications included bleeding events in 21.7% (5/23) of the patients in the Solent group and one (5.9%) patient in the ZelanteDVT group (p > .05). At 6 months, the frequency of PTS was 5.9% (1/17) in the ZelanteDVT group and 17.4% (4/23) in the Solent group (p > .05).

CONCLUSION

Both catheters are safe and effective in managing patients with proximal DVT, thus leading to improved clinical outcomes with few complications. The ZelanteDVT catheter was more effective than the Solent catheter in thrombectomy, thus allowing for faster extraction of the DVT with a shorter run time and lower proportions of patients with adjunctive CDT.

Angiojet pharmacomechanical thrombectomy versus anticoagulant therapy alone in massive cancer-associated thrombosis: a single centre retrospective cohort study

The therapeutic regimen option for the cancer-associated thrombosis (CAT) patients is still a major clinical challenge. The present study aimed to investigate the safety and efficacy of pharmacomechanical catheter-directed thrombolysis (PCDT) with AngioJet treatment compared with the conventional anticoagulation alone therapy in the patients with CAT. We retrospectively reviewed the patients who underwent PCDT and/or anticoagulation for the treatment of CAT between August 1, 2016 and March 1, 2022. Each patient was divided into the PCDT group or the anticoagulation alone group. The baseline demographics, comorbidities, clinical characteristics, treatment details, course data were reviewed. A total of 51 eligible patients were included, of whom 21 were in PCDT group (mean age, 60.1 ± 13.0 years; 52.4% male) and 30 in anticoagulation alone group (mean age, 66.6 ± 11.1 years; 50.0% male). No significant differences regarding age, sex, onset time, limb characteristics, cancer conditions or risk factors were detected (p > .05). After PCDT, grade III lysis was achieved in 8 and grade II lysis in 11 patients. Clinical success was achieved in 90.5% (19/21) patients. The symptoms of leg pain and swelling were significantly improved in both groups. Except for transient macroscopic hemoglobinuria occurring in PCDT group, none of all patients suffered from procedure-related and major complications. Minor complications such as bleeding events occurred in 23.8% (5/21) of patients in PCDT group compared with 10.0% (3/30) in anticoagulation alone group (p > .05). At the 6-month follow-up, iliofemoral patency was found an absolute risk reduction of 37.9% (70.0 vs. 32.1%) (95% CI: 1.183-4.008%; P = 0.010). The incidence of mild PTS was 5.0% (1/20) in PCDT group compared with 10.7% (3/28) in anticoagulation alone group (p > .05). The PCDT is a safe and effective modality in managing patients with CAT, leading to improved clinical outcomes with a low complication. The PCDT was more effective than anticoagulation alone in massive symptom relief and venous patency.

Society of Interventional Radiology Position Statement on the Endovascular Management of Acute Iliofemoral Deep Vein Thrombosis

PURPOSE

To establish the updated position of the Society of Interventional Radiology (SIR) on the endovascular management of acute iliofemoral deep vein thrombosis (DVT).

MATERIALS AND METHODS

A multidisciplinary writing group with expertise in treating venous diseases was convened by SIR. A comprehensive literature search was conducted to identify studies on the topic of interest. Recommendations were drafted and graded according to the updated SIR evidence grading system. A modified Delphi technique was used to achieve consensus agreement on the recommendation statements.

RESULTS

A total of 84 studies, including randomized trials, systematic reviews and meta-analyses, prospective single-arm studies, and retrospective studies were identified and included in the review. The expert writing group developed 17 recommendations that pertain to the care of patients with acute iliofemoral DVT with the use of endovascular venous interventions.

CONCLUSIONS

SIR considers endovascular thrombus removal to be an acceptable treatment option in selected patients with acute iliofemoral DVT. Careful individualized risk assessment, high-quality general DVT care, and close monitoring during and after procedures should be provided.

Endovascular Management of Acute Iliofemoral Deep Vein Thrombosis

Lower extremity deep vein thrombosis (DVT) is frequently encountered in clinical practice. Postthrombotic syndrome (PTS) is a common sequela of DVT and encompasses a wide variety of symptoms, including severe pain, edema, and ulceration, all of which may contribute to a negative impact on quality of life. Studies have demonstrated that acute thrombosis of the iliofemoral venous segment is correlated with high rates of PTS, increased severity of symptoms, and high rates of thrombus recurrence, despite patients receiving treatment with standard-of-care anticoagulation therapy. Endovascular interventions, including catheter-directed thrombolysis, pharmacomechanical thrombectomy, and mechanical thrombectomy, have generated significant interest as a method for reduction of short-term symptom severity and potential reduction of downstream PTS severity. While there is high-quality evidence evaluating the role of catheter-directed and pharmacomechanical thrombectomy for acute iliofemoral DVT, newer mechanical-only devices that utilize thrombectomy without fibrinolytic medication are less studied. Currently, there are limited data evaluating the efficacy and safety of these treatment modalities, although investigations are ongoing.

Suppression of long intergenic non-protein coding RNA 1123 constrains lower extremity deep vein thrombosis via microRNA-125a-3p to target interleukin 1 receptor type 1

Lower extremity deep vein thrombosis (LEDVT) is a disorder of venous return caused by abnormal blood clotting. LEDVT can obstruct the lumen and is the third most common vascular disease after cerebrovascular disease and coronary artery disease. LncRNAs are associated with thrombosis and potentially affect the pathogenesis of DVT. However, no studies have reported the effect of LINC01123 on LEDVT. The aim of this study was to investigate the effect of LINC01123 on LEDVT in rats via the miR-125a-3p/interleukin 1 receptor type 1 (IL1R1) axis. Lentiviral vectors that altering LINC01123, miR-125a-3p and IL1R1 expression were pre-injected into the tail vein of rats, and an LEDVT model was established 1 day later. Detection of LINC01123, miR-125a-3p and IL1R1 expression was performed. Inflammatory factors in femoral venous blood, the length and weight of the thrombus, the histomorphological changes were determined in the rat model. The targeting relation of miR-125a-3p with LINC01123 or IL1R1 was verified. The results presented that LEDVT rats expressed high LINC01123 and IL1R1 and low miR-125a-3p expression levels. After silencing LINC01123 or elevating miR-125a-3p, the rate of thrombosis, length and weight of thrombus, and levels of inflammatory factors were reduced. The targeting relation was presented between miR-125a-3p with LINC01123 or IL1R1. Elevating IL1R1 was available to turn around the action of silence of LINC01123 on LEDVT rats. All in all, suppression of LINC01123 restrains LEDVT via miR-125a-3p to target IL1R1.

Invasive and Pharmacological Treatment of Deep Vein Thrombosis: A Scoping Review

The annual occurrence of venous thromboembolism (VTE) is 300,000-600,000 cases in the United States and 700,000 in Europe. VTE includes deep venous thrombosis (DVT) of upper or lower extremities, superior and inferior vena cava thrombosis, and pulmonary embolism (PE) as well. The primary treatment of DVT includes oral anticoagulation to prevent the progression of the thrombus and decrease the risk of pulmonary embolism. Depending on the symptoms, more invasive treatments can be applied to target the iliofemoral thrombus and its removal. However, less emphasis is given to acute symptomatology, early recovery of function, quality of life improvement, and the individualized likelihood of developing post-thrombotic syndrome. While invasive therapy has been used to enhance the acute management of iliofemoral DVT, our knowledge about the overall outcomes associated with the invasive treatment of VTE is still limited. In this review, we illustrate the available data on pharmacological and endovascular management of iliofemoral VTE, including therapies such as catheter-directed thrombolysis (CDT), mechanical thrombectomy (PMT), and pharmacomechanical catheter-directed thrombolysis (PCDT).

Anticoagulation Treatment in Venous Thromboembolism: Options and Optimal Duration

Venous thromboembolism (VTE), clinically presenting as deep-vein thrombosis (DVT) or pulmonary embolism (PE), constitutes a major global healthcare concern with severe complications, long-term morbidity and mortality. Although several clinical, genetic and acquired risk factors for VTE have been identified, the molecular pathophysiology and mechanisms of disease progression remain poorly understood. Anticoagulation has been the cornerstone of therapy for decades, but there still are uncertainties regarding primary and secondary VTE prevention, as well as optimal therapy duration. In this review we discuss the role of factor Xa in coagulation cascade and the different choices of anticoagulation therapy based on patients' predisposing risk factors and risk of event recurrence. Further, we compare newer agents to traditional anticoagulation treatment, based on most recent studies and guidelines.

Comparison of ultrasound-accelerated versus conventional catheter-directed thrombolysis for deep vein thrombosis: A systematic review and meta-analysis

BACKGROUND

Recent in vitro and clinical studies have shown that ultrasound-accelerated catheter-directed thrombolysis (USACDT) can accelerate thrombolysis. Therefore, in this meta-analysis, we aimed to compare the efficacy and safety of USACDT with conventional catheter-directed thrombolysis in patients with deep vein thrombosis.

METHODS

A systematic search of the following electronic databases was performed from their dates of inception to 20 June 2020: MEDLINE, Scopus, Google Scholar, CINAHL, Cochrane Library, and EMBASE. All randomized controlled trials that directly compared the complications and efficacy of USACDT and conventional catheter-directed thrombolysis in patients with deep vein thrombosis were identified. The statistical analysis was performed using comprehensive meta-analysis software.

RESULTS

Finally, 18 studies with a total of 597 participants were included in our meta-analysis according to the eligibility criteria. Pooled proportion of USACDT success in patients with deep vein thrombosis was 87.8% (18 studies; 95% CI: 83.1-91.3). Success rate was significantly higher in USACDT treatment than in conventional catheter-directed thrombolysis treatment (seven studies; OR: 2.96; 95% CI: 1.69-5.16; P < 0.01)). Although the mean infusion time was higher in catheter-directed thrombolysis treatment compared to USACDT treatment, this difference was not statistically significant (three studies; MD: -1.46; 95% CI: -3.25-0.32; P = 0.10). Moreover, pooled rate of complications was lower in USACDT than catheter-directed thrombolysis which was not statistically significant (seven studies; OR: 0.49; 95% CI: 0.13-1.76; P = 0.27).

CONCLUSION

This meta-analysis revealed that USACDT significantly increased the success rate of thrombolysis compared to conventional catheter-directed thrombolysis. Furthermore, USACDT was associated with lower rate of complication and infusion time. Taken together, these findings confirm the superiority of this novel intervention over conventional catheter-directed thrombolysis in treatment of patients with deep vein thrombosis.

Endovascular Treatment for Lower Extremity Deep Vein Thrombosis: An Overview

Lower extremity deep vein thrombosis (DVT) is a serious medical condition that can result in local pain and gait disturbance. DVT progression can also lead to death or major disability as a result of pulmonary embolism, postthrombotic syndrome, or limb amputation. However, early thrombus removal can rapidly relieve symptoms and prevent disease progression. Various endovascular procedures have been developed in the recent years to treat DVT, and endovascular treatment has been established as one of the major therapeutic methods to treat lower extremity DVT. However, the treatment of lower extremity DVT varies according to the disease duration, location of affected vessels, and the presence of symptoms. This article reviews and discusses effective endovascular treatment methods for lower extremity DVT.

Thrombolytic strategies versus standard anticoagulation for acute deep vein thrombosis of the lower limb

BACKGROUND

Standard treatment for deep vein thrombosis (DVT) aims to reduce immediate complications. Use of thrombolytic clot removal strategies (i.e. thrombolysis (clot dissolving drugs), with or without additional endovascular techniques), could reduce the long-term complications of post-thrombotic syndrome (PTS) including pain, swelling, skin discolouration, or venous ulceration in the affected leg. This is the fourth update of a Cochrane Review first published in 2004.

OBJECTIVES

To assess the effects of thrombolytic clot removal strategies and anticoagulation compared to anticoagulation alone for the management of people with acute deep vein thrombosis (DVT) of the lower limb.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries to 21 April 2020. We also checked the references of relevant articles to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) examining thrombolysis (with or without adjunctive clot removal strategies) and anticoagulation versus anticoagulation alone for acute DVT.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane. We assessed the risk of bias in included trials with the Cochrane 'Risk of bias' tool. Certainty of the evidence was evaluated using GRADE. For dichotomous outcomes, we calculated the risk ratio (RR) with the corresponding 95% confidence interval (CI). We pooled data using a fixed-effect model, unless we identified heterogeneity, in which case we used a random-effects model. The primary outcomes of interest were clot lysis, bleeding and post thrombotic syndrome.

MAIN RESULTS

Two new studies were added for this update. Therefore, the review now includes a total of 19 RCTs, with 1943 participants. These studies differed with respect to the thrombolytic agent, the doses of the agent and the techniques used to deliver the agent. Systemic, loco-regional and catheter-directed thrombolysis (CDT) strategies were all included. For this update, CDT interventions also included those involving pharmacomechanical thrombolysis. Three of the 19 included studies reported one or more domain at high risk of bias. We combined the results as any (all) thrombolysis interventions compared to standard anticoagulation. Complete clot lysis occurred more frequently in the thrombolysis group at early follow-up (RR 4.75; 95% CI 1.83 to 12.33; 592 participants; eight studies) and at intermediate follow-up (RR 2.42; 95% CI 1.42 to 4.12; 654 participants; seven studies; moderate-certainty evidence). Two studies reported on clot lysis at late follow-up with no clear benefit from thrombolysis seen at this time point (RR 3.25, 95% CI 0.17 to 62.63; two studies). No differences between strategies (e.g. systemic, loco-regional and CDT) were detected by subgroup analysis at any of these time points (tests for subgroup differences: P = 0.41, P = 0.37 and P = 0.06 respectively). Those receiving thrombolysis had increased bleeding complications (6.7% versus 2.2%) (RR 2.45, 95% CI 1.58 to 3.78; 1943 participants, 19 studies; moderate-certainty evidence). No differences between strategies were detected by subgroup analysis (P = 0.25). Up to five years after treatment, slightly fewer cases of PTS occurred in those receiving thrombolysis; 50% compared with 53% in the standard anticoagulation (RR 0.78, 95% CI 0.66 to 0.93; 1393 participants, six studies; moderate-certainty evidence). This was still observed at late follow-up (beyond five years) in two studies (RR 0.56, 95% CI 0.43 to 0.73; 211 participants; moderate-certainty evidence). We used subgroup analysis to investigate if the level of DVT (iliofemoral, femoropopliteal or non-specified) had an effect on the incidence of PTS. No benefit of thrombolysis was seen for either iliofemoral or femoropopliteal DVT (six studies; test for subgroup differences: P = 0.29). Systemic thrombolysis and CDT had similar levels of effectiveness. Studies of CDT included four trials in femoral and iliofemoral DVT, and results from these are consistent with those from trials of systemic thrombolysis in DVT at other levels of occlusion.

AUTHORS' CONCLUSIONS

Complete clot lysis occurred more frequently after thrombolysis (with or without additional clot removal strategies) and PTS incidence was slightly reduced. Bleeding complications also increased with thrombolysis, but this risk has decreased over time with the use of stricter exclusion criteria of studies. Evidence suggests that systemic administration of thrombolytics and CDT have similar effectiveness. Using GRADE, we judged the evidence to be of moderate-certainty, due to many trials having small numbers of participants or events, or both. Future studies are needed to investigate treatment regimes in terms of agent, dose and adjunctive clot removal methods; prioritising patient-important outcomes, including PTS and quality of life, to aid clinical decision making.

Outcomes with catheter-directed thrombolysis compared with anticoagulation alone in patients with acute deep venous thrombosis

OBJECTIVE

The authors aimed to investigate the benefits and risks of catheter-directed thrombolysis (CDT) in acute deep venous thrombosis (DVT).

BACKGROUND

The role of CDT in the management of DVT is evolving. Data on CDT versus anticoagulation alone in acute DVT is sparse.

METHODS

We performed a systematic review and meta-analysis of published studies that compared CDT to anticoagulation alone in patients with acute DVT.

RESULTS

We included 11 studies (four randomized control trials [RCTs] and seven observational studies) with a total of 8,737 patients. During hospital stay, patients who received CDT had higher odds of major bleeding (2.5% vs. 1.6%; OR 1.46, 95% CI [1.07, 1.98], p = .02), blood transfusion (10.8% vs. 6.2%; OR 1.8, 95% CI [1.52, 2.13], p < .001), and thromboembolism (15.5% vs. 10%; OR 1.67, 95% CI [1.47, 1.91], p < .001) compared with anticoagulation alone. At 6-month follow-up, patients who received CDT had higher venous patency (71.1% vs. 37.7%; OR 5.49, 95% CI [2.63, 11.5], p < .001) and lower postthrombotic syndrome (PTS; 27% vs. 40.7%; OR 0.44, 95% CI [0.22, 0.86], p = .02). During a mean follow-up duration of 30.5 ± 28 months, CDT group continued to have higher venous patency (79.6% vs. 71.8%; OR 3.79, 95% CI [1.54, 9.32], p = .004) and lower PTS (44.7% vs. 50.5%; OR 0.43, 95% CI [0.23, 0.78], p = .006), but no difference in thromboembolism.

CONCLUSION

Compared with anticoagulation alone, CDT for patients with acute DVT was associated with a higher risk of complications, but a higher rate of venous patency and lower risk of postthrombotic syndrome at 2.5 years follow-up.

Prevalence of venous obstructions in (recurrent) venous thromboembolism: a case-control study

Background

The role of venous obstructions as a risk factor for recurrent venous thromboembolism has never been evaluated. This study aimed to determine whether there is a difference in prevalence of venous obstructions between patients with and without recurrent venous thromboembolism. Furthermore, its influence on the development of post-thrombotic syndrome and patient-reported quality of life was assessed.

Methods

This matched nested case-control study included 32 patients with recurrent venous thromboembolism (26 recurrent deep-vein thrombosis and 6 pulmonary embolism) from an existing prospective cohort of deep-vein thrombosis patients and compared them to 24 age and sex matched deep-vein thrombosis patients without recurrent venous thromboembolism. All participants received standard post-thrombotic management and underwent an additional extensive duplex ultrasonography. Post-thrombotic syndrome was assessed by the Villalta-scale and quality of life was measured using the SF36v2 and VEINES-QOL/Sym-questionnaires.

Results

Venous obstruction was found in 6 patients (18.8%) with recurrent venous thromboembolism compared to 5 patients (20.8%) without recurrent venous thromboembolism (Odds ratio 0.88, 95%CI 0.23–3.30, p = 1.000). After a median follow-up of 60.0 months (IQR 41.3–103.5) the mean Villalta-score was 5.55 ± 3.02 versus 5.26 ± 2.63 (p = 0.909) and post-thrombotic syndrome developed in 20 (62.5%) versus 14 (58.3%) patients, respectively (Odds ratio 1.19, 95%CI 0.40–3.51, p = 0.752). If venous obstruction was present, it was mainly located in the common iliac vein (n = 7, 63.6%). In patients with an objectified venous obstruction the mean Villalta-score was 5.11 ± 2.80 versus 5.49 ± 2.87 in patients without venous obstruction (p = 0.639). Post-thrombotic syndrome developed in 6 (54.5%) versus 28 (62.2%) patients, respectively (Odds ratio 1.37, 95%CI 0.36–5.20, p = 0.736). No significant differences were seen regarding patient-reported quality of life between either groups.

Conclusions

In this exploratory case-control study patients with recurrent venous thromboembolism did not have a higher prevalence of venous obstruction compared to patients without recurrent venous thromboembolism. The presence of recurrent venous thromboembolism or venous obstruction had no impact on the development of post-thrombotic syndrome or the patient-reported quality of life.

Modified one-session endovascular treatment for deep venous thrombosis with high risk of pulmonary embolism: Short-term outcomes

OBJECTIVES

To evaluate the safety and short-term outcomes of the modified one-session endovascular treatment with inferior vena cava filter placement and retrieval in one stage for the treatment of acute lower extremity deep vein thrombosis.

METHOD

Twenty-three patients with unilateral acute lower extremity deep vein thrombosis underwent modified one-session endovascular treatments, which were performed in one stage. Inferior vena cava filter placement without detachment, thrombectomy, and inferior vena cava filter retrieval were performed in one stage. Angioplasty and stent implantation were performed for patients with iliac vein stenosis. Venography was performed to identify the clearance of the thrombus. Color Doppler ultrasound and/or venography were conducted during the follow-up.

RESULTS

A total of 20/23 (87%) patients with thrombus removal rate >90% successfully underwent modified one-session endovascular treatment. inferior vena cava filters were detached in 3/23 (13%) patients achieving 50%-90% thrombus removal rate. Twenty-one iliac vein stents were implanted in 21/23 (91%) patients with iliac vein stenosis. After treatment, the differences in the circumferences of the affected limb and the healthy limb both significantly decreased. No procedure-related death, symptomatic pulmonary embolism, or major bleeding occurred. During the 12-25 months of follow-up, iliac vein stents and lower extremity veins maintained patent.

CONCLUSIONS

The modified one-session endovascular treatment with one-stage inferior vena cava filter placement and retrieval might be safe for the treatment of acute lower extremity deep vein thrombosis, and the early clinical outcomes are satisfactory. Placing and retrieving an inferior vena cava filter in one session could safeguard the endovascular interventions as well as reduce the filter-related complications associated with long dwelling times.

In-hospital outcomes of catheter-directed thrombolysis versus anticoagulation in cancer patients with proximal deep venous thrombosis

OBJECTIVE

The objective of this study was to determine the rate of complications of catheter-directed thrombolysis (CDT) in cancer patients with deep venous thrombosis (DVT) compared with anticoagulation therapy alone.

METHODS

This observational study used the National Inpatient Sample database to screen for any cancer patients who were admitted with a principal discharge diagnosis of proximal lower extremity or caval DVT between January 2005 and December 2013. Patients treated with CDT plus anticoagulation were compared with those treated with anticoagulation alone using propensity score matching for comorbidities and demographic characteristics. The primary end point was in-hospital mortality. Secondary end points were acute intracranial hemorrhage, inferior vena cava filter placement, acute renal failure, blood transfusion rates, length of stay, and hospital charges.

RESULTS

We identified 31,124 cancer patients with lower extremity proximal or caval DVT, and 1290 (4%) patients were treated with CDT. Comparative outcomes as assessed in the two matched groups of 1297 patients showed that there was no significant difference in in-hospital mortality of patients undergoing CDT plus anticoagulation compared with those treated with anticoagulation alone (2.6% vs 1.9%; P = .23). However, CDT was associated with increased risk of intracranial hemorrhage (1.3% vs 0.4%; P = .017), greater blood transfusion rates (18.6% vs 13.1 %; P < .001), and higher rates of procedure-related hematoma (2.4% vs 0.4%; P < .001). The length of stay (6.0 [4.0-10.0] days vs 4.0 [2.0-7.0] days; P < .001) and hospital charges ($81,535 [$50,968-$127,045] vs $22,320 [$11,482-$41,005]; P < .001) were also higher in the CDT group compared with the control group.

CONCLUSIONS

There was no significant difference in in-hospital mortality of cancer patients who underwent CDT plus anticoagulation compared with anticoagulation alone. CDT was associated with increased in-hospital morbidity and resource utilization compared with anticoagulation alone. Further studies are needed to examine the effect of CDT on the development of PTS in this population.

Pharmacomechanical catheter thrombolysis for pregnancy-related proximal deep venous thrombosis: prevention of post-thrombotic syndrome

OBJECTIVE

The efficacy of pharmacomechanical catheter-directed thrombolysis (PCDT) in preventing post thrombotic syndrome (PTS) for pregnancy related deep vein thrombosis (DVT) is unknown.

STUDY DESIGN

An observational cross section study of women with pregnancy related proximal (femoral/iliofemoral) DVT who underwent PCDT followed by anticoagulation (study group), and women who were treated with anticoagulation alone (control group). Women were evaluated for PTS using the Villalta scale (primary outcome) and VEINES-QOL/Sym questionnaires.

RESULTS

Eleven women with iliofemoral DVT underwent PCDT, two during their first trimester and nine postpartum; 18 women were treated with anticoagulation only. There were no significant differences in age, number of previous pregnancies, and duration of anticoagulation or thrombophilia between the groups. The time between DVT diagnosis and study inclusion was longer in the study group [median 50.5 (range 16-120) months] compared to the control group [median 27 (range 11-64) months], p = .4. None of the women in the PCDT group developed PTS, compared to six (33.3%, p = .03) in the control group, four of whom developed severe PTS. One patient in each group developed recurrent DVT, and one patient in the study group developed a calf hematoma. A reduced frequency of lower extremity symptoms was observed in the PCDT group (VEINES-Sym questionnaire), but no differences in quality of life (VEINES-QOL questionnaire) were reported.

CONCLUSION

This study suggests that PCDT may reduce the incidence of PTS in women with pregnancy related proximal DVT.Bullet pointsDVT involving the iliofemoral veins and development of post thrombotic syndrome is frequent among pregnant or postpartum womenStudies of pharmacomechanical catheter-directed thrombolysis (PCDT) for deep vein thrombosis did not include pregnant or postpartum womenIn our observational cross section study women who underwent PCDT (mainly in the postpartum period) had reduced frequency of post-thrombotic syndrome compared to women who received anticoagulation onlyLarger studies are required to confirm the use of PCDT for prevention of PTS in this population.

Lower extremity endovenous reconstruction for symptomatic occlusive disease in pediatric patients: techniques, clinical outcomes, and long-term stent patencies

BACKGROUND

Endovascular stent reconstruction is the standard of care for chronic venous occlusive disease in adults, but it has not been reported in pediatric patients.

OBJECTIVE

This study reports the technical success, complications, clinical outcomes, and stent patency of iliocaval stent reconstruction for chronic iliocaval thrombosis in pediatric patients.

MATERIALS AND METHODS

Fourteen patients, 13 (93%) male with a mean age of 16.4 years (range: 8-20 years), underwent iliocaval stent reconstruction for chronic iliocaval thrombosis. The mean number of prothrombotic risk factors was 2.5 (range: 0-4), including 7 (50%) patients with inferior vena cava atresia. At initial presentation, the Clinical, Etiology, Anatomy, and Pathophysiology classification (CEAP) score was C3 in 2 (14%) patients, C4 in 11 (79%) patients, and C6 in 1 (7.1%) patient. Time course of presenting symptoms included chronic (>4 weeks) (n=7; 50%) and acute worsening of chronic symptoms (2-4 weeks) (n=7; 50%). Aspects of recanalization and reconstruction, stenting technical success, complications, clinical outcomes and stent patency were recorded. Clinical success was defined as a 1-point decrease in the CEAP. Primary, primary-assisted, and secondary patency were defined by Cardiovascular and Interventional Radiological Society of Europe guidelines.

RESULTS

Most procedures employed three access sites (range: 2-4). Intravascular ultrasound was employed in 11 (79%) procedures. Blunt and sharp recanalization techniques were used in 12 (86%) and 2 (14%) patients, respectively. Stenting technical success was 100%. Two (14%) minor adverse events occurred and mean post-procedure hospitalization was 2.8 days (range: 1-8 days). Clinical success rates at 2 weeks, 6 months and 12 months were 85%, 82%, and 83%, respectively. At a mean final clinical follow-up of 88 months (range: 16-231 months), clinical success was 93%. Estimated 6- and 12-month primary stent patencies were 86% and 64%, respectively. Six- and 12-month primary-assisted and secondary stent patency rates were both 100%.

CONCLUSION

Iliocaval stent reconstruction is an effective treatment for symptomatic chronic iliocaval thrombosis in pediatric patients with high rates of technical success, 6- and 12-month clinical success, and 6- and 12-month primary-assisted and secondary patency rates.

Effect of miR-495 on lower extremity deep vein thrombosis through the TLR4 signaling pathway by regulation of IL1R1

Lower extremity deep vein thrombosis (LEDVT), a common peripheral vascular disease caused by a blood clot in a deep vein is usually accompanied by swelling of the lower limbs. MicroRNAs (miRs) have been reported to play roles in LEDVT. We aimed to investigate the effect of miR-495 on LEDVT via toll-like receptor 4 (TLR4) signaling pathway through interleukin 1 receptor type 1 (IL1R1). LEDVT mouse model was established, and the femoral vein (FV) tissues were collected to detect expressions of miR-495, IL1R1, and TLR4 signaling-related genes. The expressions of both CD31 and CD34 (markers for endothelial progenitor cells) in the FV endothelial cells as well as the proportion of CD31⁺/CD34⁺ cells in peripheral blood were measured in order to evaluate thrombosis. The effect of miR-495 on cell viability, cell cycle, and apoptosis was analyzed. IL1R1 was confirmed as the target gene of miR-495. Besides, inhibiting the miR-495 expression could increase IL1R1 expression along with activating the TLR4 signaling pathway. The total number of the leukocytes along with the ratio of weight to length of thrombus in the FV tissue showed an increase. The overexpression of miR-495 could promote FV endothelial cell viability. By injecting agomiR-495 and antagomiR-495 in vivo, the number of leukocytes in the FV tissues and the ratio of weight to length of thrombus were significantly decreased in the mice injected with the overexpressed miR-495, and the IL1R1/TLR4 signaling pathway was inhibited. Collectively, overexpressed miR-495 directly promotes proliferation while simultaneously inhibiting apoptosis of FV endothelial cells, alleviating FV thrombosis by inhibiting IL1R1 via suppression of TLR4 signaling pathway.

Is there a role for intervention radiology for the treatment of lower limb deep vein thrombosis in the era of direct oral anticoagulants? A comprehensive review

Despite recent advances in the treatment of Deep Vein Thrombosis (DVT) provided by Direct Oral Anticoagulants (DOAC), a substantial proportion of lower limb DVT patients will develop some degree of post-thrombotic syndrome (PTS) within 2 years. Systemic thrombolysis, although effective in reducing the risk of PTS and leg ulceration, is associated with a high risk of major bleeding, making it unsuitable for the vast majority of patients. A local approach, aimed at delivering the fibrinolytic drug directly into, or near to, the thrombus surface, is attractive because of the possibility of lowering of the administered drug dose, thus reducing the bleeding risks. However, even after the recent publication of the ATTRACT trial, only weak evidence is available about the efficacy and safety of Catheter Directed Thrombolysis (CDT), either alone (pharmacological technique) or in combination with additional endovascular approaches (pharmacomechanical technique, PMT) including percutaneous mechanical thrombectomy, angioplasty with or without stenting and ultrasound-assisted CDT. The present review is aimed at providing the physicians with a comprehensive evaluation of the current evidence about this relevant topic, in order to build a reliable conceptual framework for a more appropriate use of this resource.

Endovascular Iliocaval Stent Reconstruction for Iliocaval Thrombosis: A Multi-Institutional International Practice Pattern Survey

BACKGROUND

Limited guidelines for the treatment and management of acute and chronic iliocaval thrombosis are published in the literature. The purpose of this report is to present global iliocaval stent reconstruction practices by interventionalists.

METHODS

A 45-question survey focusing on iliocaval stent reconstruction evaluation was distributed through the Open Forum and Venous Disease Service Line of the Society of Interventional Radiology Connect website from June 20, 2017 until September 7, 2017 and the Cardiovascular and Interventional Radiological Society of Europe electronic newsletter on August 11, 2017.

RESULTS

One hundred seven complete responses were received from interventional radiologists in the United States, 2 from South America, and 2 from Central America. 92.5% performed iliocaval reconstruction, and 79.8% performed the procedure for both acute and chronic iliocaval thrombosis. 82.8% completed a standardized physician assessment tool, and 91.9% obtained computed tomography (CT) venography before the procedure. 64.6% used intravascular ultrasound to guide reconstruction. 41.4% found blunt recanalization successful for >75% of patients. 63.6% used sharp recanalization for <25% of patients. 97.0% and 90.9% used uncovered and self-expanding stents, respectively. Wallstents were used most commonly. Most common stent diameters were 24-mm in the inferior vena cava, 14-mm in the common iliac vein, and 12-mm in the external iliac vein. 48.5% and 21.2% prescribed 2 and 3 anticoagulants after stent placement, respectively. 62.6% found iliocaval reconstruction provided symptomatic clinical improvement for iliocaval thrombosis in >75% of patients. 72.7% estimated their 1-year primary stent patency to be >75%.

CONCLUSIONS

Iliocaval reconstruction is performed by many interventionalists; however, there are global inconsistencies in practices, suggesting a need for further research and guideline development.

Percutaneous Endovenous Intervention Plus Anticoagulation versus Anticoagulation Alone for Treating Patients with Proximal Deep Vein Thrombosis: A Meta-analysis and Systematic Review

BACKGROUND

Combination treatment with percutaneous endovenous intervention (PEVI) and anticoagulation has been proposed for treating lower-extremity proximal deep vein thrombosis (DVT). We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the effect of PEVI plus anticoagulation versus anticoagulation alone in patients with lower-extremity proximal DVT.

METHODS

We systematically searched PubMed, Embase, and the Cochrane Library from inception to May 2016. All RCTs comparing clinical outcomes between additional PEVI and anticoagulation alone were included. The main end points were postthrombotic syndrome (PTS) and major bleeding complications. Secondary outcomes included the iliofemoral patency rate, venous obstruction, and recurrent DVT. We assessed pooled data using a random-effects model.

RESULTS

Four RCTs were included. PEVI plus standard anticoagulation compared with anticoagulation alone was associated with a lower rate of PTS (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.18-0.63), significantly higher iliofemoral patency rate at 6 months and 12 months (OR 8.49, 95% CI 1.32-54.60), a lower rate of venous obstruction (OR 0.42, 95% CI 0.20-0.924), and a lower rate of recurrent DVT (OR 0.42, 95% CI 0.20-0.92). However, more major bleeding episodes occurred in the group with catheter-directed thrombolysis (Peto OR 5.86, 95% CI 1.76-19.48).

CONCLUSIONS

PEVI plus anticoagulation reduced the occurrence of PTS, recurrent DVT, and venous obstruction. Another advantage is an increased patency rate at 6 and 12 months. The disadvantage is an increased occurrence of major bleeding events.

Effects of Inhalation Anesthesia vs. Total Intravenous Anesthesia (TIVA) vs. Spinal-Epidural Anesthesia on Deep Vein Thrombosis After Total Knee Arthroplasty

Background

The objective of the present study was to evaluate the varying efficacy of general anesthesia (GA), combined spinal-epidural anesthesia (CSEA), and total intravenous anesthesia (TIVA) on the occurrence of deep vein thrombosis (DVT) following total knee arthroplasty (TKA).

Material/Methods

From July 2013 to May 2015, a total of 197 cases of patients who had undergone TKA treatment at either the Drum Tower Hospital or Nanjing General Hospital of Nanjing Military Command were recruited to participate in the study. The patients in the study were separated into 3 groups depending on the anesthesia approach received: the GA group, the CSEA group, and the TIVA group. The baseline characteristics and relative parameters of patients were monitored before and after surgery for analytic purposes. A 3-month follow-up after surgery was conducted to observe the rate of DVT occurrence and any DVT-related complications.

Results

The TIVA group exhibited significant decreases in relation to the swallowing time reflex, extubation, and consciousness recovery in comparison to other groups in the study. Additionally, platelet count was significantly decreased and there was drastic extension of the activated partial thromboplastin time (APTT) in the CSEA group and the TIVA group. There were clear differences in the incidence of DVT and its complications among the 3 groups. The TIVA group displayed the lowest incidences of DVT and DVT-related complication during the study. Based on logistic regression analysis, the type of anesthesia was utilized as an independent correlative factor for the occurrence of DVT after surgery.

Conclusions

The results obtained during the study established a clinical basis for comparative analysis of various anesthesia methods. We found that, compared with GA and CSEA, patients undergoing TIVA had a reduced rate of risk in relation to the occurrence of DVT following TKA.

Management of Cavoatrial Deep Venous Thrombosis: Incorporating New Strategies

Cavoatrial deep venous thrombosis (DVT) is diagnosed with increasing prevalence. It can be managed medically with anticoagulation or with directed interventions aimed to efficiently reduce the thrombus burden within the target venous segment. The type of management chosen depends greatly on the etiology and chronicity of the thrombosis, existing patient comorbidities, and the patient's tolerance to anticoagulants and thrombolytic agents. In addition to traditional percutaneous catheter-based pharmacomechanical thrombolysis, other catheter-based suction thrombectomy techniques have emerged in recent years. Each therapeutic modality requires operator expertise and a coordinated care paradigm to facilitate successful outcomes. Open surgical thrombectomy is alternatively reserved for specific patient conditions, including intolerance of anticoagulation, failed catheter-based interventions, or acute emergencies.

Incidence and Outcomes of Inferior Vena Cava Filter Thrombus during Catheter-directed Thrombolysis for Proximal Deep Venous Thrombosis

BACKGROUND

The aim of the study was to retrospectively evaluate the incidence and outcomes of inferior vena cava (IVC) filter thrombus during catheter-directed thrombolysis (CDT) for acute proximal deep venous thrombosis (DVT).

METHODS

From October 2006 to June 2015, patients diagnosed with acute proximal DVT and received CDT after a retrievable IVC filter was placed were included. The incidence, treatment, and outcomes of IVC filter thrombus during CDT were recorded and analyzed.

RESULTS

A total of 189 patients (91 women, 98 men; mean age, 57.6 ± 9.8 years; range, 24-85 years) were included in this study. Among the 189 cases, the DVTs involved popliteal iliofemoral veins in 54 patients, iliofemoral veins in 113 patients, and iliac veins in 22 patients, of which 18 patients had thrombus extended into the IVC. Of the 189 patients, a total of 8 (4.2%, 8 of 189) patients were identified with IVC filter thrombus during CDT. The IVC filter thrombus was detected on a median of 2 days (range, 2-4 days) of CDT therapy, including small-size (n = 6) and large-size (n = 2) filter thrombus. Of the 8 patients, CDTs were performed with a mean 7.6 ± 1.1 days (range, 6-11 days) after the presence of symptoms for the treatment of proximal DVT, and all the IVC filter thrombi were lysed during CDT for the proximal DVT. All the IVC filters were removed successfully with a mean of 12.8 ± 0.93 days from placement. There were no procedure- or thrombolysis-related major complications, and no symptomatic pulmonary embolism breakthrough was seen in any of the patients after the filter placement.

CONCLUSIONS

IVC filter thrombus during CDT for the acute proximal DVT is uncommon, and all of them did not need any additional treatment.

Mid-term outcome of endovascular treatment for acute lower extremity deep venous thrombosis

Purposes of the study

To evaluate the benefit of stenting the iliac vein in patients with residual iliac vein stenosis treated with catheter-directed thrombolysis for acute iliofemoral deep venous thrombosis.

Procedures

In this randomized prospective study, patients with a first-time acute lower extremity deep venous thrombosis that had persisted <14 days were treated with catheter-directed thrombolysis. After catheter-directed thrombolysis, patients with >50% residual iliac vein stenosis were randomly divided into two groups: catheter-directed thrombolysis + Stent Group and catheter-directed thrombolysis Alone Group. Patients received urokinase thrombolysis and low-molecular-weight heparin/oral warfarin during the hospitalization period and were administrated oral warfarin after discharge. Cumulative deep vein patency, the Clinical Etiology Anatomic Pathophysiologic classification system, the Venous Clinical Severity Score and the Chronic Venous Insufficiency Questionnaire score were evaluated.

Findings

The cumulative deep vein patency rate was 74.07% in the catheter-directed thrombolysis + Stent Group and 46.59% in the catheter-directed thrombolysis Alone Group. The mean postoperative Clinical Etiology Anatomic Pathophysiologic classification and Venous Clinical Severity Score was significantly lower in the catheter-directed thrombolysis + Stent Group than in the catheter-directed thrombolysis Alone Group. The mean postoperative Chronic Venous Insufficiency Questionnaire score was significantly higher in the catheter-directed thrombolysis + Stent Group than the catheter-directed thrombolysis Alone Group.

Conclusions

Placement of an iliac vein stent in patients with residual iliac vein stenosis after catheter-directed thrombolysis for acute lower extremity deep venous thrombosis increases iliac vein patency and improves clinical symptoms and health-related quality of life at mid-term follow-up compared to patients treated with catheter-directed thrombolysis alone.

Single-Session Endovascular Treatment of Symptomatic Lower Extremity Deep Vein Thrombosis: Is it Possible Even for Aged Thrombosis

BACKGROUND

Feasibility of single-session mechanical thrombetomy, without thrombolytics, for the treatment of the subacute deep vein thrombosis (DVT) of the lower extremity remains poorly described.

PURPOSE

To evaluate the feasibility and efficacy of single-session endovascular treatment of DVT of the lower extremity that is more than 10 days old.

MATERIALS AND METHODS

From January 2010 to December 2013, single-session endovascular treatment was performed in 21 limbs of 21 patients (8 men and 13 women) with DVT more than 10 days old at our hospital. The mean age of the thrombosis was 21.5 days (range 11-45 days). Two patients had malignancy-related obstructions. A 14F introducer sheath was inserted through the popliteal vein followed by aspiration thrombectomy with a large bore catheter. Balloon angioplasty and/or maceration of the thrombus were added when needed. Stent insertions were performed for patients with combined iliac vein stenosis. Technical success, clinical success, mean procedure time, and complications were evaluated.

RESULTS

The technical success rate was 90.5% (19 of 21 patients). Among the 19 successful cases, aspiration thrombectomy alone was performed in 16 (84.2%) patients, additional balloon angioplasty of the femoral vein was performed in 2 (10.5%) patients, and both balloon angioplasty of the femoral vein and rotational thrombectomy were performed in 1 (5.3%) patient. Iliac vein stenting was performed due to combined iliac vein narrowing in 13 (68.4%) of the 19 successful cases. The mean procedure time was 86 minutes (26-179 minutes). All of the patients with technical success (19 of 21 patients) showed marked improvement in symptoms at the time of discharge (clinical success). Unexplained gastrointestinal hemorrhage developed in 1 patient.

CONCLUSION

Single-session endovascular treatment is feasible and effective even for patients with aged deep vein thrombosis of the lower extremity more than 10 days old.

Aspiration thrombectomy using a large-size catheter for acute lower extremity deep vein thrombosis

OBJECTIVE

This study retrospectively evaluated the safety and efficacy of aspiration thrombectomy using a large-size catheter for acute lower extremity deep vein thrombosis (DVT).

METHODS

All patients who underwent aspiration thrombectomy using 9F or 10F catheters for acute lower extremity DVT were included and analyzed. Aspiration thrombectomy was performed in all patients. Additional intravenous thrombolysis was performed in patients with residual thrombus, and stent placement was performed in patients with iliac vein compression syndrome.

RESULTS

From October 2010 to September 2013, the study enrolled 68 patients (37 women, 31 men) with a mean age of 61.7 ± 7.8 years (range, 24-86 years). All patients presented with lower extremity swelling and pain, and the duration of symptoms ranged from 1 to 14 days. The DVTs involved popliteal-iliofemoral veins in 29 patients, iliofemoral veins in 31, and iliac veins in 8. Endovascular procedures were performed in all patients with a technical success rate of 100%. Aspiration alone was effective in 47 patients, and additional thrombolysis was required in the remaining 21. An additional stent was required in 32 patients. Significant improvement in presenting symptoms was achieved in all patients after the procedures, with a clinical success rate of 100%. There were no procedure-related or thrombolysis-related complications. The Villalta scores were <5 in 60 patients and from 5 to 9 in four patients. Primary and secondary patency rates were 89.1% (57 of 64) and 96.9% (62 of 64) at 1 year of follow-up.

CONCLUSIONS

Aspiration thrombectomy using a large-size catheter is safe and effective for acute lower extremity DVT.

Catheter-directed thrombolysis for extensive iliofemoral deep vein thrombosis: review of literature and ongoing trials

In patients with extensive lower limb deep vein thrombosis (DVT) that, typically, extends into the iliofemoral veins, catheter-directed thrombolysis (CDT) can achieve faster and more complete thrombus lysis as compared with systemic thrombolysis, while providing an acceptable safety profile through administration of lower doses of thrombolytic agents. Through a reduction in thrombus burden, CDT has the potential to mitigate the risk for post-thrombotic syndrome by restoring venous patency and preserving venous valve function. The efficacy of CDT may be improved by adjunctive approaches that include percutaneous mechanical thrombectomy, angioplasty with or without stenting, and ultrasound-assisted CDT. CDT may also have a specific therapeutic role in the management of iliofemoral DVT involving patients who are pregnant or with May-Thurner syndrome. This article summarizes the literature in this area and discusses recently completed and ongoing randomized trials on the use of CDT in patients with extensive lower limb DVT.

Endovascular treatment of thrombosed inferior vena cava filters: Techniques and short-term outcomes

PURPOSE

To present the techniques for endovascular treatment of thrombosed filter-bearing inferior vena cavae (IVCs), along with short-term clinical and imaging follow-up.

MATERIALS AND METHODS

A total of 45 consecutive patients (17 females and 28 males), aged 19-79 years (mean age of 49 years), who had IVC filter placement complicated by symptomatic acute or chronic iliocaval thrombosis and underwent endovascular therapy were studied. All patients presented with lower extremity swelling and/or pain. One patient also had bilateral lower extremity swelling and chronic gastrointestinal (GI) bleeding which was secondary to chronic systemic to portal venous collaterals. Patients underwent one or more of the following endovascular treatments depending on the chronicity and extent of thrombosis: (a) catheter-directed thrombolysis (CDT) (n = 25), (b) pharmacomechanical thrombolysis (PMT) (n = 15), (c) balloon angioplasty (n = 45), and/or (d) stent placement across the filter (n = 42). In addition, 16 patients underwent groin arteriovenous fistula (AVF) creation (36%) and 3 (7%) had femoral venous thrombectomy to improve flow in the recanalized iliac veins and IVCs.

RESULTS

Anatomical success was achieved in all patients. Follow-up was not available in 10 patients (lost to follow-up, n = 4; expired due to comorbidities, n = 2; lost to follow-up after re-intervention, n = 4). At a mean follow-up time of 13.3 months (range 1-48 months), clinical success was achieved in 27 patients (60%), i.e. in 21 patients without re-intervention and in 6 patients with re-intervention. Clinical success was not achieved despite re-intervention in eight patients. Higher clinical success was noted in patients who did not require repeat interventions (P = 0.03) and the time to re-intervention was significantly shorter in patients who had clinical failure (P = 0.01). AVF creation did not improve the clinical success rate (P = 1). There was no significant difference in clinical success between patients who had acute or subacute thrombosis compared to those who had chronically occluded filter-bearing IVCs (P = 1).

CONCLUSION

This study suggests that endovascular therapy for thrombosed filter-bearing IVCs is safe and technically feasible.

Outcomes in children with deep vein thrombosis managed with percutaneous endovascular thrombolysis

BACKGROUND

Our center has developed a multidisciplinary approach to percutaneous endovascular thrombolysis with the goal of improving outcomes in children with thrombosis. There is little data describing the safety and efficacy of endovascular thrombolysis and the frequency of post-thrombotic syndrome after thrombolysis in children.

OBJECTIVE

Retrospective analysis of children undergoing percutaneous endovascular thrombolysis to determine (1) the safety and efficacy of this procedure and (2) the frequency of the diagnosis of post-thrombotic syndrome after thrombolysis.

MATERIALS AND METHODS

We reviewed the medical and imaging databases for children who underwent percutaneous endovascular thrombolysis for deep venous thrombosis (DVT) between November 2008 and June 2013 at our institution. Demographic data were reviewed for the technical success and complications of thrombolysis and the last assigned post-thrombotic syndrome score using standardized scoring tools.

RESULTS

Forty-one children ages 3 months to 21 years (median age: 15 years; 44% male) underwent percutaneous endovascular thrombolysis between November 2008 and June 2013. Upper extremity DVT occurred in 13 patients (32%); lower extremity DVT occurred in 28 patients (68%). All 41 patients received thrombolysis grading; 90% of those patients achieved greater than 50% thrombus lysis. Twenty-eight patients received formal post-thrombotic syndrome scoring and 4 (14%) met diagnostic criteria for post-thrombotic syndrome. One major bleeding episode and one pulmonary embolism occurred with no long-term sequelae.

CONCLUSION

Endovascular thrombolysis for DVT in children is safe, effective at thrombus removal and may reduce the incidence of post-thrombotic syndrome. Randomized or larger clinical trials would be needed to determine the long-term benefits of endovascular thrombolysis.

Percutaneous manual aspiration thrombectomy followed by stenting for iliac vein compression syndrome with secondary acute isolated iliofemoral deep vein thrombosis: a prospective study of single-session endovascular protocol

OBJECTIVE

To evaluate the feasibility, safety, and effectiveness of single-session endovascular treatment with manual aspiration thrombectomy (MAT) as the first-line method of thrombus removal for iliac vein compression syndrome (IVCS) with secondary acute isolated iliofemoral deep vein thrombosis (DVT).

METHODS

This was a prospective clinical study. Twenty-six patients (19 women, 7 men, mean age 54 years) with left-sided acute iliac-common femoral DVT secondary to IVCS were enrolled. All patients presented with leg swelling or pains. Endovascular treatment, consisting of MAT, balloon angioplasty, and stent placement, was performed in the same setting. Overnight antegrade thrombolysis was performed in patients with residual thrombus after MAT. Patients were followed up by ultrasonography. The mean follow-up period was 17.8 months (12-25 months).

RESULTS

Single-session endovascular procedures were performed successfully in all patients. The mean procedure time was 67 minutes (ranging from 45 to 90 minutes). Complete thrombus removal, including almost 100% of removal in 24 patients and little residual thrombus (<5%) in two, was achieved after repeated MAT. Thrombolysis was used in these two patients. Complete symptomatic relief was achieved in 25 patients (96%) and partial relief in one. The hospital stay ranged from 2 to 4 days (mean 2.7 days). Recurrent thrombosis within the stent was observed in one case and recanalized with thrombolysis. The 1-year primary and secondary patency rate was 96% and 100%, respectively. No symptomatic pulmonary embolization, bleeding, and venous reflux were observed. Five patients complained about transitory low back pains during balloon angioplasty.

CONCLUSION

Single-session endovascular treatment with MAT as the first-line thrombus removal method is feasible, safe, and effective for IVCS with secondary acute isolated iliofemoral DVT. Although limited, our experience suggests that patients thought to be at high risk of bleeding may be candidates for the present single-session endovascular protocol.

Safety and Efficacy of Catheter-directed Thrombolysis

Objective:

To describe the background for – and mechanism of – catheter-directed thrombolysis (CDT) for iliofemoral deep venous thrombosis (DVT) accessed via the popliteal vein. Focus is on safety and efficacy.

Method:

From the Copenhagen experience we have looked into the systematically registrated risk factors, peri- and postprocedure complications for patients consecutively treated from 1999 to 2006. The patients were treated in a clinical ward. The patients were followed yearly with ultrasonography for assessment of patency and valve function. Inclusion and exclusion criteria have been published earlier.

Results

A total of 89 patients with 91 extremities with iliofemoral DVT were included (70 women and 19 men, mean age 29 years [range 14–59]). Only 11% of the patients were without any risk factor for DVT. CDT was performed without mortality and pulmonary embolism. Major bleeding occurred in two patients and minor bleeding in 27 patients, mostly from the puncture site. Stenting was necessary in 54 limbs. Five stents revealed occlusion, three procedural (2 reopened) and two late. The median follow-up was 87 months (range 17–148). At six years, 86% had competent iliofemoral (and popliteal) vein segment.

Conclusion:

CDT of iliofemoral DVT is a safe procedure. The patients can stay in a clinical vascular ward. The long-term efficacy is still durable in producing competent veins as concluded in our earlier published results.