Single-Session Treatment of Patients with Symptomatic Iliocaval and Iliofemoral Deep Vein Thrombosis: Technical Results of a Prospective Pilot Study

Current Evidence for Endovascular Therapies in the Management of Acute Deep Vein Thrombosis

Acute lower extremity deep vein thrombosis (DVT), specifically proximal iliofemoral DVT, is a relatively common disorder that can result in a chronic debilitating post-thrombotic syndrome (PTS), with a significant effect on a patient's quality of life. Anticoagulation is first-line therapy; however, percutaneous interventions have emerged as treatment options for patients where there is concern that anticoagulation alone will not resolve the DVT as well as prevent PTS. This paper will discuss the existing data on these interventions and review current endovascular techniques, including catheter-directed thrombolysis, pharmacomechanical thrombectomy, and large-bore mechanical thrombectomy in the management of DVT.

Percutaneous Thrombectomy Using a Computer-Assisted Aspiration Device for Deep Vein Thrombosis

PURPOSE

To demonstrate the safety and effectiveness of a computer-assisted large-bore thrombectomy (CA-LBT) device in aspiration thrombectomy for treatment of deep vein thrombosis (DVT).

MATERIALS AND METHODS

A single-institution retrospective review was performed to include 16 consecutive patients (median age, 51.1 years; range, 19-77 years; 5 men and 11 women) who underwent percutaneous thrombectomy using a 16-F CA-LBT device (Lightning Flash Aspiration System; Penumbra, Alameda, California) for DVT (12 iliofemoral occlusions with or without caval extension [75.0%], 3 axillosubclavian occlusions [18.8%], and 1 caval occlusion [6.3%]) between January 2023 and August 2023.

RESULTS

Thrombectomy was performed via the popliteal (n = 10, 62.5%), femoral (n = 3, 18.8%), saphenous (n = 1, 6.3%), brachial (n = 1, 6.3%), and femoral and brachial (n = 1, 6.3%) veins, with a median fluoroscopy time of 17 minutes (range, 7.2-61 minutes) and contrast agent volume of 110 mL (range, 30-175 mL). Restoration of anterograde flow was achieved in all cases (100%, 16/16). Thirteen patients (81.2%) received venoplasty after thrombectomy for residual stenosis. Stents were placed in 7 patients (43.8%). With a median clinical follow-up of 77 days (range, 3-278 days), symptom improvement was achieved among 13 of 15 patients (86.7%) who initially presented with DVT-associated symptoms. Of 14 patients with imaging follow-up, patency was confirmed in 12 (85.7%). Of the 2 patients (14.3%) with complete thrombosis on follow-up imaging, one patient was successfully treated with repeated thrombectomy using CA-LBT technology and the other was treated with systemic anticoagulation.

CONCLUSIONS

Aspiration thrombectomy with this 16-F CA-LBT device is a feasible option for treatment of proximal or large-volume DVT.

Single-center experience with the JETi Hydrodynamic Thrombectomy System for acute limb ischemia

OBJECTIVE

Acute limb ischemia (ALI) remains a vascular emergency with high morbidity and mortality. While the JETi Hydrodynamic Thrombectomy System (Abbott) offers a percutaneous approach to fragment and aspirate the thrombus in patients with arterial occlusions, data on its efficacy and safety are limited. This study reports our early experience using the JETi device to treat ALI at our institution.

METHODS

This is a single-center, retrospective review of patients with ALI treated with the JETi device between September 2020 and December 2022. Patients were included if the JETi device was used either as a primary intervention or as an adjunct procedure. The primary endpoint was technical success defined as <50% residual thrombus after intervention. Secondary endpoints included achieving complete resolution of the thrombus on angiogram, acute kidney injury (AKI), major bleeding, 30-day major amputation, and 30-day mortality.

RESULTS

A total of 59 JETi procedures for ALI (median age 62 years [interquartile range: 56-71 years]) were performed on 39 male and 20 female patients. The median time from onset of symptoms to hospitalization was 24 hours (interquartile range: 4-168 hours). Rutherford classifications were I (10), IIa (27), IIb (14), and undocumented (8). Etiology of ALI was native vessel thrombosis (27), embolism (16), graft/stent thrombosis (14), and iatrogenic (2). A total of 124 vessels were treated, with an average of 2.1 vessels per procedure. The primary outcome was achieved in 86% (107/124) of the arteries, with 82% (102/124) successfully opened using the JETi device alone without the need for any adjunctive therapy. Complete resolution of the thrombus using JETi was achieved in 81% (101/124) arteries, with or without the use of adjunctive therapy. A total of 6.7% (4/59) patients required a major limb amputation within 30 days despite successful recanalization, and one 30-day mortality was recorded. Complications included distal embolization (5), access site hematoma (2), and AKI (4). No major bleeding, hemolysis-induced AKI, or vessel dissection or perforation was observed.

CONCLUSIONS

The JETi device appears to be a safe and effective percutaneous treatment option in the management of ALI. It provides definitive treatment with a high technical success rate of 86% and a good safety profile.

The role and principles of stenting in acute iliofemoral venous thrombosis

Catheter-directed interventions for acute iliofemoral deep venous thrombosis (DVT) have been increasingly used over the past 15 years to target severe symptomatology and prevention of post-thrombotic syndrome incidence or reduce its severity if it were to develop. Aside from successful thrombus removal, adjunctive stents are frequently required to treat an uncovered lesion or significant residual thrombus to ensure quality of life improvement besides retarding DVT recurrence and post-thrombotic syndrome. As the evidence is mounting, the need and role for stenting, as well as the principles of an optimal technique, in the acute DVT setting are now better understood. Accumulating experience appears to favor stenting in the acute setting. The diameter of the stent, the length, the extent of overlapping, and the landing zones are crucial determinants of a successful durable outcome. This article endeavors to guide the interventionalist on stenting when encountering a patient with acute symptomatic iliofemoral DVT with concerns of quality of life impairment.

Pharmacomechanical thrombectomy of iliofemoral deep vein thrombosis is associated with a low incidence of post-thrombotic syndrome and perioperative complications

BACKGROUND

Iliofemoral deep venous thrombosis (IFDVT) is associated with an incidence of post-thrombotic syndrome (PTS) of up to 50%. PTS is associated with high morbidity, impaired quality of life and a significant economic burden. The aim of the current study was to assess the impact of a single session pharmacomechanical thrombectomy (PMT), dedicated venous stents and a risk mitigation protocol on the rate of PTS.

METHODS

Between 2015 and 2022, patients presenting with acute or subacute IFDVT treated with the same protocol of single session PMT, dedicated venous stents, and risk-mitigation measures were included. Procedural success rate, complications, stent patency and incidence of PTS were determined.

RESULTS

Of 60 patients (58 ± 19 years; 65% male), the procedural success rate was 93%, with 7% of patients experiencing complications but no long-term sequelae or mortality. Most (n = 52; 87%) patients were stented, including 46% across the inguinal ligament. At 3 months post-procedure, primary, assisted primary and secondary stent patency rates were 89%, 93% and 98%, respectively, with no loss of patency or re-interventions after that. At latest follow-up of a median 48 months (n = 32), stent patency rate was 97%, with only three patients (9%) experiencing symptoms of PTS.

CONCLUSION

Single session PMT, dedicated venous stents and a risk-mitigation protocol results in high success rate, excellent long-term stent patency and low incidence of PTS without compromising safety. These results support early intervention for iliofemoral DVT.

The emerging role of mechanical thrombectomy in acute DVT management

Catheter directed thrombolysis (CDT) and pharmacomechanical thrombectomy in various technical combinations have been the main driver of acute deep venous interventions for over a decade. While the majority of high-level evidence was based on it, CDT requires longer procedural care and is associated to a small but not negligible bleeding risk. Contemporary DVT intervention, following the paradigm shift in myocardial infarction and stroke management, has steadily migrated towards minimizing or eliminating thrombolytics due to the introduction of mechanical/aspiration thrombectomy. Mechanical thrombectomy (MT) devices are undoubtedly improving our ability to remove thrombus more efficiently in a single session without the adverse events and complex logistics related to the use of thrombolytics.

Single-Session Percutaneous Mechanical Thrombectomy for Acute and Subacute Deep Vein Thrombosis: Clinical Outcomes and Predictive Factors of Recurrence

Objectives

To evaluate the efficacy and safety of single-session percutaneous mechanical thrombectomy (PMT) for deep vein thrombosis (DVT), to compare clinical outcomes and recurrences between acute and subacute DVT, and to identify factors predicting recurrence.

Materials and Methods

From January 2018 to March 2021, 100 consecutive patients (age: 64.64 ± 17.28 years; male, 42%) with symptomatic DVT who underwent single-session PMT were enrolled for this study. These patients were divided into an acute DVT group (< 14 days, n = 75) and a subacute DVT group (15-28 days, n = 25).

Results

A large-bore aspiration thrombectomy was used in 80 (80%) cases, Angiojet (Boston Scientific, Marlborough, MA, USA) device in one (1%) case, and a combination of both techniques in 19 (19%) cases. The anatomic success rate was 97% and the clinical success rate was 95%. There were no major complications. Clinical outcomes were not different between the two groups. The recurrence-free survival rate in the acute DVT group was significantly (p = 0.015) better than that in the subacute DVT group. The anatomic success (HR, 52.3; 95% CI, 3.82-715.21; p = 0.003) and symptom duration (HR, 17.58; 95% CI, 1.89-163.34; p = 0.012) were predictive factors associated with recurrence.

Conclusions

Single-session PMT is safe and effective for immediate symptom relief in acute and subacute DVT patients. However, recurrence occurred more frequently in patients with subacute DVT than in those with acute DVT. Anatomic success of the procedure and duration of symptoms were independent predictors of DVT recurrence.

Catheter-Directed Interventions for the Treatment of Lower Extremity Deep Vein Thrombosis

Lower extremity deep vein thrombosis (DVT) leads to significant morbidity including pain, swelling, and difficulty walking in the affected limb. If left untreated, DVT increases the risk of pulmonary embolism (PE), recurrent venous thromboembolism (VTE), and post thrombotic syndrome (PTS). The objective of this review was to identify catheter-directed interventions and their success rates for the treatment of lower extremity DVT. A comprehensive search of current and emerging catheter-directed interventions for lower extremity DVT treatment was conducted in PubMed and Google Scholar. Clinical trials, retrospective and prospective observational studies, and case reports were identified to classify percutaneous mechanical thrombectomy (PMT), catheter-directed thrombolysis (CDT), and pharmacomechanical CDT (PCDT) devices based on their mechanism of action and indication of use. Catheter-directed interventions such as PMT, CDT, and PCDT offer an alternative therapeutic strategy for DVT management, particularly in patients with limb-threatening conditions and absolute contraindications to anticoagulants. Currently, there are limited guidelines for the use of mechanical and pharmacomechanical devices because of the lack of clinical evidence available for their use in treatment. Future studies are required to determine the short and long-term effects of using catheter-directed interventions as well as their effectiveness in treating acute versus subacute and chronic DVT.

Catheter-directed thrombectomy with the JETi8 in the treatment of acute superior vena cava syndrome

Superior vena cava syndrome can lead to significant morbidity and mortality, particularly in acute settings. We report a case of an acute Port-a-Cath-associated thrombosis of the superior vena cava. Percutaneous catheter-directed thrombectomy was performed using the JETi8 thrombectomy device with additional angioplasty and stenting, allowing rapid flow restoration and rapid clinical recovery. Postoperative anticoagulation was initiated and pursued lifelong. This report is unique in illustrating how JETi8 thrombectomy seems to be a safe and effective therapy, allowing rapid flow restoration, rapid clinical improvement, and persistent patency at 6 months.