Postthrombotic syndrome and quality of life in patients with iliofemoral venous thrombosis treated with catheter-directed thrombolysis

The role and principles of stenting in acute iliofemoral 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.

The background and role of catheter-directed thrombolysis evolving procedures for acute iliofemoral deep venous thrombosis

Minimal invasive treatment such as early endovenous thrombus removal for iliofemoral deep venous thrombosis (DVT) emerged in the end of last century. The principle is catheter-directed thrombolysis (CDT) using either plasminogen activating agents alone, as ultrasound-assisted CDT, or in combination with mechanical devices as pharmaco-mechanical CDT. The interest for this treatment modality is the high rate of post-thrombotic syndrome (PTS) with anticoagulation (AC) alone, especially after iliofemoral DVT. Recently published randomized controlled trials (RCTs) comparing early thrombus removal with AC alone, as well as non-randomized studies, have demonstrated favorable rates, or at least a decrease of moderate and severe PTS, in favor of these procedures. This article will summarize the background and evolution of the procedures in the last three decades and discuss fundamental criteria for inclusion and exclusion, focusing on the procedures regarding thrombus age and location, technical issues, complications and results including different outcome measures for PTS, for which iliac DVT involvement is a massive risk factor to be prevented.

Randomized controlled trials of interventions for acute iliofemoral deep venous thrombosis

Venous thromboembolism (VTE), notably deep venous thrombosis (DVT), represents a significant cardiovascular disease with high morbidity from post-thrombotic syndrome (PTS). Recent advancements in early thrombus removal technologies have prompted randomized controlled trials (RCT) to assess their efficacy and safety, particularly for iliofemoral DVT (IF-DVT), which carries the greatest risk of developing PTS. This narrative review summarizes these trials and introduces upcoming innovations to evaluate acute intervention for IF-DVT. Specific technologies discussed include catheter-directed thrombolysis, pharmacomechanical catheter-directed thrombolysis, ultrasound-accelerated catheter-directed thrombolysis, and non-lytic mechanical thrombectomy. This review underscores the importance of patient selection, with those presenting with extensive, symptomatic IF-DVT likely to benefit most.

Long-term integrity of 53 iliac vein stents after catheter-directed thrombolysis

BACKGROUND

Long-term surveillance data on venous stent integrity is sparse. There is limited knowledge on whether duplex ultrasound (DUS) can detect potential stent deformities such as kinking, straightening, and fracture, which may impact long-term patency of the stented veins.

PURPOSE

To assess venous stent integrity after at least five years of follow-up and to establish the efficacy of DUS as surveillance in patients with venous stent.

MATERIAL AND METHODS

A total of 45 patients with acute iliac-femoral deep vein thrombosis (DVT) treated with catheter directed thrombolysis (CDT) and stenting >5 years before follow-up. Stents were evaluated with 3D volume low dose non-contrast computed tomography (CT) and DUS for kinking, straightening, stent fracture, and patency. Results from CT scans and DUS were compared to assess the overall agreement between the methods.

RESULTS

Median follow-up was 13.2 years (mean = 11.2 years; range = 5.2-15.8 years). 3D CT reconstructions showed normal stent configuration in 47 stents (89%). All intact stents were identified by DUS. In the remaining six stents, 3D CT reconstructions showed compression, tapering, kinking, and minor fracture. DUS recognized all stent complications except the minor fracture. Overall agreement between CT and DUS was 98% (kappa = 0.90). Two cases of stent occlusion were found.

CONCLUSION

The long-term physical resilience of iliac vein stents evaluated with 3D CT in patients treated with CDT for iliofemoral DVT was high. Stent deformities were mostly compression, whereas fracture was rarely seen. DUS seems to be sufficient to evaluate venous stent integrity.

The effect of balloon-assisted pharmacomechanical catheter-directed thrombolysis on the patency and post-thrombotic syndrome in patients with acute iliofemoral deep vein thrombosis: Is it really necessary or not?

OBJECTIVES

The objective of this study was to describe the contribution and advantage of balloon-dilatation of iliac and femoral veins following pharmacomechanical catheter-directed thrombolysis (PCDT) on the development of post-thrombotic syndrome (PTS).

METHODS

From October 2018 and January 2022, 85 patients with acute total occlusion of the iliac and femoral veins were treated with PCDT. The cohort was divided into two groups depending on the utilization of concomitant balloon dilatation of iliac and femoral veins (Group 1, n=34, 40.0%) or not (Group 2, n=51, 60.0%) during the PCDT. All patients underwent duplex ultrasound scanning for evaluating the patency of iliac veins and recanalization rates at 3, 6, and 12 months postoperatively. the Villalta score was used to score the severity of PTS at 12 months postoperatively.

RESULTS

Patients who underwent balloon-assisted PCDT (group 1) exhibited significantly higher primary patency rates in CIV (recanalization 84.3 ± 14.6%, p = 0.003) , EIV (recanalization 82.8 ± 17.2, p = 0.003) and CFV (recanalization 88.1 ± 12.1%, p = 0.038) compared with the group 2 at the end of 12 months follow-up. Only 2 patients underwent venous stenting in follow-up due to severe venous claudication, however, 13 patients were required iliac vein stenting due to severe PTS proved with a high Villalta score at 12-month follow-up. The d-dimer level at 1-year follow-up had also significantly lower in Group 1 due to higher rates of patency and lower thrombosis burden. The most common bleeding events were hematuria (n =4) or oozing in the puncture site (n = 4).

CONCLUSIONS

This study showed that balloon-assisted PCDT reduces the risk of PTS, is more successful in common iliac vein recanalization, reduces the need for the venous stent, and even lowers the D-dimer levels of the patients compared to routine PCDT alone.

Determinants of Quality of Life in Patients with Post-Thrombotic Syndrome

OBJECTIVES

Chronic post-thrombotic syndrome (PTS) may develop in up to 50% of patients after deep vein thrombosis (DVT) and may reduce patients' quality of life (QoL). We aimed to evaluate the association of PTS severity with QoL in patients with proximal DVT submitted to medical treatment and also to identify modifiable and non-modifiable risk factors related to PTS.

METHODS

Patients with iliac or femoropopliteal DVT observed in Vascular Surgery consultation in our institution from 1 year period with unilateral DVT were selected. Patients with total vein recanalization were excluded. Villalta scale was applied to assess PTS degree and VEINES-QoL/Sym questionnaire was used as a disease-specific QoL measure. Correlation between PTS degree and VEINES-QoL/Sym score and predictors of PTS were determined.

RESULTS

56 patients accepted to enter the study. From those, 66.1% were female, 64.3% (n=36) had iliac and 35.7% (n=20) femoropopliteal DVT. PTS was present in 52.8% of iliac and 65.0% of femoropopliteal DVT patients observed in consultation (P=0.413). There was a significant correlation with PTS degree and both VEINES-QoL and VEINES-Sym scores (P<0.001). Major depression (OR=5.63, P=0.045) and regular wear of compressing stockings (OR=4.69, P=0.041) were the only independent factors associated with PTS. Patients with depression had lower QoL scores, while patients with PTS who wear compression stockings had similar QoL scores compared to patients without PTS. Ultrasound alterations (OR=3.28, P=0.174), age, gender, iliac DVT, multiple DVT and time after DVT (P>0.2) were not associated with PTS syndrome.

CONCLUSIONS

VEINES-QoL/Sym had moderate inverse correlation with PTS degree. Depression was associated with both PTS and lower QoL scores. Patients with PTS criteria compliant to wearing compressing stockings had similar QoL scores to patients without PTS.

Examınatıon of self-care agency and quality of life in individuals with chronic venous disease

AIM

This study aims to investigate self-care agency and quality of life (QoL) in persons with chronic venous disease of the lower extremities.

METHODS

This descriptive study was carried out between December 2014 and September 2016. The study population consisted of patients admitted to Erzurum Regional Training and Research Hospital Clinic of Surgical Cardiovascular Diseases and who had been diagnosed with lower extremity venous disease. The study sample comprised 312 patients who meet the inclusion criteria among this population admitted at the said dates. For data collection, the Patient Information Form, Self-Care Agency Scale, and Venous Insufficiency Epidemiological and Economic Study - Quality of Life/Symptoms Scale (VEINES-QOL/SYM) were used. The data were evaluated using percentage distribution, means, analysis of variance, post-hoc test, t-test, Mann-Whitney U-test and Kruskal-Wallis test.

RESULTS

The mean Self-Care Agency Scale score of the patients with lower extremity venous disease was 102.33±18.20, and their mean VEINES-QOL/Sym score was 74.95±12.86, indicating a moderate level.

CONCLUSION

As a result, this study found the factors that significantly affected mean Self-Care Agency scores and mean QoL scores of the patients in terms of their level of education, employment status, BMI, smoking habits, and conditions about chronic diseases. Positive correlation was found between mean Self-Care Agency scores and QoL scores of the patients.

A Systematic Review and Meta-Analysis of 12-Month Patency After Intervention for Iliofemoral Obstruction Using Dedicated or Non-Dedicated Venous Stents

BACKGROUND

Endovascular stenting of the deep venous system has been proposed as a method to treat patients with symptomatic iliofemoral outflow obstruction. The purpose of this systematic review and meta-analysis was to compare the effectiveness of this treatment at 1-year following the development of dedicated venous stents.

METHOD AND RESULTS

We searched MEDLINE and EMBASE for studies evaluating the effectiveness of venous stent placement. Data were extracted by disease pathogenesis: non-thrombotic iliac vein lesions (NIVL), acute thrombotic (DVT), or post-thrombotic syndrome (PTS). Main outcomes included technical success, stent patency at 1 year and symptom relief. A total of 49 studies reporting outcomes in 5154 patients (NIVL, 1431; DVT, 950; PTS, 2773) were included in the meta-analysis. Technical success rates were comparable among groups (97%-100%). There were no periprocedural deaths. Minor bleeding was reported in up to 5% of patients and major bleeding in 0.5% upon intervention. Transient back pain was noted in 55% of PTS patients following intervention. There was significant heterogeneity between studies reporting outcomes in PTS patients. Primary and cumulative patency at 1 year was: NIVL-96% and 100%; DVT-91% and 97%; PTS (stents above the ligament)-77% and 94%, and; PTS (stents across the ligament)-78% and 94%. There were insufficient data to compare patency outcomes of dedicated and nondedicated venous stents in patients with acute DVT. In NIVL and PTS patients, stent patency was comparable at 1 year. There was inconsistency in the use of validated tools for the measurement of symptoms before and after intervention. When reported, venous claudication, improved in 83% of PTS patients and 90% of NIVL patients, and ulcer healing occurred in 80% of PTS patients and 32% of NIVL patients.

CONCLUSIONS

The first generation of dedicated venous stents perform comparably in terms of patency and clinical outcomes to non-dedicated technologies at 1 year for the treatment of patients with NIVL and PTS. However, significant heterogeneity exists between studies and standardized criteria are urgently needed to report outcomes in patients undergoing deep venous stenting.

Incidence and severity of postthrombotic syndrome after iliofemoral thrombosis – results of the Iliaca-PTS – Registry

Summary: Background: Deep venous thrombosis (DVT) and in particular, iliofemoral thrombosis (IFT) can lead to recurrent thrombosis and postthrombotic syndrome (PTS). Data on the prevalence, predictors and outcome of IFT are scarce. Patients and methods: We retrospectively searched our database of outpatients who had presented with DVT and IFT including the iliac veins from 2014 until 2017. In addition, we performed a prospective registry in a subgroup of patients with IFT. These patients received duplex ultrasound, magnetic resonance venography and measurement of symptom-free walking distance using a standardized treadmill ergometry. The severity of PTS was analyzed using the Villalta-Scale (VS) and quality of life was assessed using the VEINES-QOL/Sym Questionnaire. Results: 847 patients were retrospectively identified with DVT and 19.7% (167/847) of these presented with IFT. 50.9% (85/167) of the IFT-patients agreed to participate in the prospective registry. The majority of these patients (76.5%: 65/85) presented with left-sided IFT. In 53.8% (35/65) May-Thurner syndrome was suspected. 27.1% (23/85) underwent invasive therapy. Moderate or severe PTS (VS ≥ 10) occurred in 10.6% (9/85). The severity of PTS is correlated with a reduced quality of life (ρ (CI 95%) = −0.63 (−0.76; −0.46); p < 0.01). None of the patients presented with a venous ulcer at any time. A high body mass index was a significant predictor (OR (CI 95%) = 1.18 (1.05; 1.33), p = 0.007) for the development of clinically relevant PTS (VS ≥ 10) and venous claudication. Conclusions: Every fifth patient with DVT presented with an IFT. The majority developed left sided IFT. Every 10th patient developed moderate or severe PTS (VS ≥ 10). A high body mass index was predictive for the development of PTS and venous claudication.

Predictors of intracranial hemorrhage in patients treated with catheter-directed thrombolysis for deep vein thrombosis

BACKGROUND

Although acute intracranial hemorrhage (ICH) is a rare complication of catheter-directed thrombolysis (CDT), it remains a major concern associated with the use of CDT. The incidence and clinical predictors of developing ICH in the setting of CDT are not known.

METHODS

The National Inpatient Sample database was used to identify all patients with proximal lower extremity or caval deep vein thrombosis (DVT) from January 2005 to December 2013 in the United States. Multivariate logistic regression was performed to identify the clinical predictors of ICH between patients with DVT who had received anticoagulation therapy alone and those who had been treated with CDT plus anticoagulation therapy.

RESULTS

Of 138,049 patients with proximal lower extremity or caval DVT, 7119 (5.2%) had received anticoagulation therapy and CDT. Of the patients treated with anticoagulation alone, ICH had occurred in 0.2% compared with 0.7% for those treated with CDT (P < .01). The independent predictors of ICH in the CDT cohort were a history of stroke (odds ratio [OR], 19.4; 95% confidence interval [CI], 8.8-42.8; P < .01), chronic kidney disease (OR, 2.2; 95% CI, 1.1-4.7; P = .03), age >74 years (OR, 2.2; 95% CI, 1.2-4.3; P = .02), male sex (OR, 1.8; 95% CI, 1.01-3.3; P = .048). Of those patients treated with anticoagulation alone, the risk factors for the development of ICH were a history of stroke, hospital teaching status, and age >74 years.

CONCLUSIONS

The results from the present nationwide observational study showed that of patients with DVT treated with CDT, the independent predictors for developing ICH were a history of stroke, chronic kidney disease, male sex, and age >74 years.

Same Admission Hybrid Treatment of Primary Upper Extremity Deep Venous Thrombosis with Thrombolysis, Transaxillary Thoracic Outlet Decompression, and Immediate Endovascular Evaluation

BACKGROUND

Multiple algorithms exist for treating acute primary upper extremity deep venous thrombosis (pUEDVT) caused by venous thoracic outlet syndrome (VTOS). In this case series, we present the results of our dedicated same admission treatment algorithm.

METHODS

All patients between January 2015 and December 2019 with an established acute upper extremity deep venous thrombosis (symptoms <14 days) caused by VTOS were treated according to an algorithm consisting of same admission thrombolysis, transaxillary thoracic outlet decompression (TA-TOD) with extensive venolysis, and venography. If a residual stenosis of the subclavian vein was identified on venography, including by means of low-pressure diagnostic balloon inflation, correction by percutaneous transluminal angioplasty (PTA) was performed. The thoracic outlet syndrome disability scale, the Dutch language version of the disabilities of the arm, shoulder, and hand, and the VEINES-quality of life (VEINES-QOL/VEINES-symptoms) questionnaires were collected during follow-up.

RESULTS

In total, 10 patients were treated for acute pUEDVT. After successful thrombolysis (100%) and TA-TOD, immediate venography showed residual stenosis of the subclavian vein in 8 of 10 patients (80%). Low-pressure dilatation of a balloon suited to the geometry of the axillosubclavian vein showed significant tapering in all cases (10/10) after which a formal venous PTA was performed. No stents were used. Mean time to discharge was 6.4 days. All patients were free of symptoms at a mean follow-up period of 34.4 months. Eight of the 10 patients completed follow-up questionnaires and reported a mean thoracic outlet syndrome disability scale of 0.6, mean disabilities of the arm, shoulder, and hand score of 4.2, and a median VEINES-Symptoms of 55.23 (IQR, 12.13), and VEINES-QOL of 55.29 (IQR, 15.42).

CONCLUSIONS

A same admission treatment algorithm for acute pUEDVT in patients with VTOS including thrombolysis, TA-TOD with extensive venolysis, and immediate venography with PTA is effective with promising intermediate results.

Surgical thrombectomy for iliofemoral deep vein thrombosis: Patient outcomes at 8.5 years

Introduction

Deep vein thrombosis (DVT) is a frequent burden and a post-thrombotic syndrome (PTS) can be a serious long-term consequence. Iliofemoral DVT should be associated with severe forms of PTS. Therefore an early thrombus removal has been recommended in specific conditions. The aim of this study was to find out both, the long-term results after surgical thrombectomy of iliofemoral DVT in respect of the development of PTS as well as the venous hemodynamics after surgery concerning venous reflux and venous obstruction.

Methods

Sixty-seven patients who underwent surgical thrombectomy between the years 2000 and 2014 were included in this study; iliofemoral DVT was present in 52 of these patients. 35 patients could be reinvestigated after a mean follow-up of 8.5 years. CEAP (Clinical-Etiological-Anatomical-Pathophysiological) and Villalta scores were recorded in order to describe and assess PTS. Follow-up examinations included a detailed duplex mapping. Venous hemodynamics were measured by digital photoplethysmography and venous occlusion plethysmography.

Results

The primary patency rate of the iliofemoral segment was 88% after 8.5 years. 48% of all patients showed reflux in deep vein segments. Mild or moderate PTS occurred in 57% of all patients. Notably, there was no patient with an active ulcer or severe PTS. The mean venous outflow volume of all patients in the treated legs was 66.1 ml/100ml/min and significantly less than in the controlled contralateral non-treated legs (p<0.05). The mean venous refilling time was 16.3 seconds, while the mean value of the non-treated contralateral legs was 25.6 seconds and therefore significantly higher (p<0.05).

Conclusion

Even though venous hemodynamics are significantly inferior in the treated legs, this study demonstrates excellent patency rates and good clinical outcome after surgical thrombectomy of iliofemoral veins.

Less frequent post-thrombotic syndrome after successful catheter-directed thrombolysis for acute iliofemoral deep vein thrombosis

Post-thrombotic syndrome (PTS) occurs in 20-50% of patients with proximal deep vein thrombosis (DVT). In this study, we aimed to identify potential markers of thrombolysis success at the early stage and to clarify the relationship between early thrombolysis success and subsequent PTS development in patients with acute DVT in the iliac vein. Fifty-two consecutive patients with acute iliofemoral DVT who were treated with catheter-directed thrombolysis (CDT) within 21 days of onset were enrolled. An infusion catheter with multiple side holes was placed to cover the thrombosed vessel entirely. Urokinase solution was administered either continuously or with the pulse-spray method at a dose of 480,000-720,000 IU/day over the course of 2-7 days. During CDT, unfractionated heparin (UFH) was infused simultaneously via the access sheath to prevent thrombus formation. Early success was defined as lysis grade ≥ 50% and restoration of forward flow. PTS was diagnosed based on the Villalta scale. Based on the lysis grading method, complete lysis (grade III) was achieved in 8 of 52 (16%) limbs. Lysis grade II (50-99%) was achieved in 35 of 52 (67%) limbs. Lysis grade I (< 50%) was achieved in 9 of 52 (17%) limbs. Therefore, grade II and grade III lytic outcomes (early success) were observed in 43 patients (83%). One-year clinical follow-up was performed for 43 patients (83%). PTS occurred in seven (16%) patients. Early success was more frequently observed in patients without PTS than in those with PTS (92% vs. 43%; P < 0.01). Early success was only significantly associated with PTS in the multivariate analysis. Patients with acute symptomatic iliofemoral DVT who had early success from CDT treatment during the acute phase less frequently progressed to PTS. Patients with early success tended to undergo the pulse-spray method and had a shorter interval from symptom onset to CDT. The use of pulse-spray method and early initiation of CDT since DVT onset were potential markers of thrombolysis success.

Balloon-assisted catheter-directed thrombolysis: A novel approach for acute deep vein thrombosis in the lower extremities

Background

Methods

Results

Conclusions

Different strategies for pharmacological thromboprophylaxis for lower-limb immobilisation after injury: systematic review and economic evaluation

BACKGROUND

Thromboprophylaxis can reduce the risk of venous thromboembolism (VTE) during lower-limb immobilisation, but it is unclear whether or not this translates into meaningful health benefit, justifies the risk of bleeding or is cost-effective. Risk assessment models (RAMs) could select higher-risk individuals for thromboprophylaxis.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of different strategies for providing thromboprophylaxis to people with lower-limb immobilisation caused by injury and to identify priorities for future research.

DATA SOURCES

Ten electronic databases and research registers (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects, the Cochrane Central Register of Controlled Trials, Health Technology Assessment database, NHS Economic Evaluation Database, Science Citation Index Expanded, ClinicalTrials.gov and the International Clinical Trials Registry Platform) were searched from inception to May 2017, and this was supplemented by hand-searching reference lists and contacting experts in the field.

REVIEW METHODS

Systematic reviews were undertaken to determine the effectiveness of pharmacological thromboprophylaxis in lower-limb immobilisation and to identify any study of risk factors or RAMs for VTE in lower-limb immobilisation. Study quality was assessed using appropriate tools. A network meta-analysis was undertaken for each outcome in the effectiveness review and the results of risk-prediction studies were presented descriptively. A modified Delphi survey was undertaken to identify risk predictors supported by expert consensus. Decision-analytic modelling was used to estimate the incremental cost per quality-adjusted life-year (QALY) gained of different thromboprophylaxis strategies from the perspectives of the NHS and Personal Social Services.

RESULTS

Data from 6857 participants across 13 trials were included in the meta-analysis. Thromboprophylaxis with low-molecular-weight heparin reduced the risk of any VTE [odds ratio (OR) 0.52, 95% credible interval (CrI) 0.37 to 0.71], clinically detected deep-vein thrombosis (DVT) (OR 0.40, 95% CrI 0.12 to 0.99) and pulmonary embolism (PE) (OR 0.17, 95% CrI 0.01 to 0.88). Thromboprophylaxis with fondaparinux (Arixtra®, Aspen Pharma Trading Ltd, Dublin, Ireland) reduced the risk of any VTE (OR 0.13, 95% CrI 0.05 to 0.30) and clinically detected DVT (OR 0.10, 95% CrI 0.01 to 0.94), but the effect on PE was inconclusive (OR 0.47, 95% CrI 0.01 to 9.54). Estimates of the risk of major bleeding with thromboprophylaxis were inconclusive owing to the small numbers of events. Fifteen studies of risk factors were identified, but only age (ORs 1.05 to 3.48), and injury type were consistently associated with VTE. Six studies of RAMs were identified, but only two reported prognostic accuracy data for VTE, based on small numbers of patients. Expert consensus was achieved for 13 risk predictors in lower-limb immobilisation due to injury. Modelling showed that thromboprophylaxis for all is effective (0.015 QALY gain, 95% CrI 0.004 to 0.029 QALYs) with a cost-effectiveness of £13,524 per QALY, compared with thromboprophylaxis for none. If risk-based strategies are included, it is potentially more cost-effective to limit thromboprophylaxis to patients with a Leiden thrombosis risk in plaster (cast) [L-TRiP(cast)] score of ≥ 9 (£20,000 per QALY threshold) or ≥ 8 (£30,000 per QALY threshold). An optimal threshold on the L-TRiP(cast) receiver operating characteristic curve would have sensitivity of 84-89% and specificity of 46-55%.

LIMITATIONS

Estimates of RAM prognostic accuracy are based on weak evidence. People at risk of bleeding were excluded from trials and, by implication, from modelling.

CONCLUSIONS

Thromboprophylaxis for lower-limb immobilisation due to injury is clinically effective and cost-effective compared with no thromboprophylaxis. Risk-based thromboprophylaxis is potentially optimal but the prognostic accuracy of existing RAMs is uncertain.

FUTURE WORK

Research is required to determine whether or not an appropriate RAM can accurately select higher-risk patients for thromboprophylaxis.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017058688.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Clinical outcomes after direct and indirect surgical venous thrombectomy for inferior vena cava thrombosis

OBJECTIVE

Inferior vena cava thrombosis is rare, but patients are at high risk for development of a post-thrombotic syndrome (PTS) in the long term. Surgical approaches include indirect transfemoral venous thrombectomy (iTFVT) and direct open venous thrombectomy (dOVT). This study reports patient outcomes after iTFVT and dOVT for inferior vena cava thrombosis covering a 25-year follow-up period.

METHODS

The study period was from January 1, 1982, to December 31, 2013. Data were retrieved from archived medical records, and patients were invited for a detailed phlebologic follow-up examination (DPFE). Health-related quality of life was assessed with the 36-Item Short Form Health Survey questionnaire. Patient survival, patency rates, and freedom from PTS were calculated using Kaplan-Meier estimation with log-rank testing. The χ² test with Yates continuity correction and logistic regression analysis were applied to identify associations between risk factors or coagulation disorders, mortality, and PTS.

RESULTS

Complete medical records were available for 152 patients. Patients' 5-year survival was 91% ± 3%, and 5-year primary and secondary patency rates were 80% ± 3% and 94% ± 2%. Freedom from PTS after 25 years was 84% ± 6%. No differences for patient survival, patency rates, or freedom from PTS were identified between iTFVT, dOVT, and a combination of both procedures. Antithrombin III deficiency was the most common coagulation disorder, and patients' physical function and social function were impaired compared with those found in German normative data (P < .05). No risk factor or coagulation disorder was associated with survival or PTS.

CONCLUSIONS

Open surgical venous thrombectomy is safe and delivers satisfying short- and long-term outcomes compared with endovascular approaches. It remains valuable for patients who are not eligible for other interventional therapies.

Catheter-directed thrombolysis for patients with acute lower extremity deep vein thrombosis: a meta-analysis

Objectives:

To evaluate case series studies that quantitatively assess the effects of catheter-directed thrombolysis (CDT) and compare the efficacy of CDT and anticoagulation in patients with acute lower extremity deep vein thrombosis (DVT).

Methods:

Relevant databases, including PubMed, Embase, Cochrane, Ovid MEDLINE and Scopus, were searched through January 2017. The inclusion criteria were applied to select patients with acute lower extremity DVT treated with CDT or with anticoagulation. In the case series studies, the pooled estimates of efficacy outcomes for patency rate, complete lysis, rethrombosis and post-thrombotic syndrome (PTS) were calculated across the studies. In studies comparing CDT with anticoagulation, summary odds ratios (ORs) were calculated.

Results:

Twenty-five articles (six comparing CDT with anticoagulation and 19 case series) including 2254 patients met the eligibility criteria. In the case series studies, the pooled results were a patency rate of 0.87 (95% CI: 0.85-0.89), complete lysis 0.58 (95% CI: 0.40-0.75), rethrombosis 0.11 (95% CI: 0.06-0.17) and PTS 0.10 (95% CI: 0.08-0.12). Six studies comparing the efficacy outcomes of CDT and anticoagulation showed that CDT was associated with a reduction of PTS (OR 0.38, 95%CI 0.26-0.55, p<0.0001) and a higher patency rate (OR 4.76, 95%CI 2.14-10.56, p<0.0001).

Conclusion:

Acute lower extremity DVT patients receiving CDT were found to have a lower incidence of PTS and a higher incidence of patency rate. In our meta-analysis, CDT is shown to be an effective treatment for acute lower extremity DVT patients.

The Midterm Effect of Iliac Vein Stenting following Catheter-directed Thrombolysis for the Treatment of Deep Vein Thrombosis

BACKGROUND

When following catheter-directed thrombolysis (CDT) for deep vein thrombosis (DVT), the stenosed iliac veins is controversy. To evaluate the mid-term outcomes of CDT with or without stent implantation for DVT in the presence of iliac vein compression.

METHODS

Seventy-three patients with iliac vein compression following CDT for acute lower extremity DVT from January 2009 to December 2014 were retrospectively analyzed. There were 32 males and 41 females, with average age of 53.57 ± 15.60 years (median: 45 years, range: 20-79 years). After CDT, patients with iliac vein compression were divided into 2 groups: the stenting group (n = 40) and the nonstenting group (n = 33). Patency rate of the deep vein, chronic change of vessels, clinical, etiological, anatomical, and pathological elements (CEAP) classification, venous clinical severity score, and Villalta scale were chosen to evaluate the midterm and long-term outcomes.

RESULTS

Eighty-eight limbs among the patients (58 unilateral and 15 bilateral) were followed with mean time of 38.38 ± 14.91 months. The difference in vein patency between 2 groups (85.17 ± 25.62 vs. 54.61 ± 40.42) was statistically significant (P < 0.05). According to the C in CEAP classification, the difference in clinical manifestations between the 2 groups was statistically significant (P < 0.05). In addition, the Villalta scale scores were also significantly different between the 2 groups (1.73 ± 2.86 vs. 4.39 ± 5.16, P < 0.05).

CONCLUSIONS

Stent implantation in severely stenosed iliac segments following CDT for lower extremity DVT increased the patency of deep veins and improved midterm quality of life compared with that of nonstenting.

Fixed low-dose ultrasound-assisted catheter-directed thrombolysis followed by routine stenting of residual stenosis for acute ilio-femoral deep-vein thrombosis

Patients with ilio-femoral deep-vein thrombosis (DVT) are at high risk of developing the postthrombotic syndrome (PTS). In comparison to anticoagulation therapy alone, extended venography-guided catheter-directed thrombolysis without routine stenting of venous stenosis in patients with ilio-femoral DVT is associated with an increased risk of bleeding and a moderate reduction of PTS. We performed a prospective single-centre study to investigate safety, patency and incidence of PTS in patients with acute iliofemoral DVT treated with fixed-dose ultrasound-assisted catheter-directed thrombolysis (USAT; 20 mg rt-PA during 15 hours) followed by routing stenting of venous stenosis, defined as residual luminal narrowing >50%, absent antegrade flow, or presence of collateral flow at the site of suspected stenosis. A total of 87 patients (age 46 ± 21 years, 60% women) were included. At 15 hours, thrombolysis success ≥50% was achieved in 67 (77%) patients. Venous stenting (mean 1.9 ± 1.3 stents) was performed in 70 (80%) patients, with the common iliac vein as the most frequent stenting site (83%). One major (1%; 95% CI, 0–6%) and 6 minor bleedings (7%; 95%CI, 3–14%) occurred. Primary and secondary patency rates at 1 year were 87% (95% CI, 74–94%) and 96% (95% CI, 88–99%), respectively. At three months, 88% (95% CI, 78–94%) of patients were free from PTS according to the Villalta scale, with a similar rate at one year (94%, 95% CI, 81–99%). In conclusion, a fixed-dose USAT regimen followed by routine stenting of underlying venous stenosis in patients with iliofemoral DVT was associated with a low bleeding rate, high patency rates, and a low incidence of PTS.

Open surgery for iliofemoral deep vein thrombosis with temporary arteriovenous fistula remains valuable

Objective We assessed outcomes of open surgical venous thrombectomy with temporary arteriovenous fistula, and the procedure's effect on health-related quality of life. Method We retrospectively analyzed 48 (26 at long-term) patient medical records. Mortality rates, patency, and risk of post-thrombotic syndrome were analyzed using Kaplan-Meier estimation. The association between risk factors/coagulation disorders and patency/post-thrombotic syndrome along with patient health-related quality of life at long-term was analyzed employing various statistical methods. Results Patient one-year survival rate was 93 ± 4% and primary one-year patency rate was 89 ± 5% (secondary one-year patency rate 97 ± 3%). Freedom from post-thrombotic syndrome after eight years was 80 ± 12% (post-thrombotic syndrome rate 20 ± 12%). Health-related quality of life was impaired vs. normative data in the physical and social subscales, and in the mental component score ( p < .05). Conclusions Open surgical venous thrombectomy appears safe compared with literature-reported outcomes in similar patients using alternative approaches. Iliofemoral deep vein thrombosis impairs physical, social, and mental health-related quality of life.

Ultrasound-assisted versus conventional catheter-directed thrombolysis for acute iliofemoral deep vein thrombosis: 1-year follow-up data of a randomized-controlled trial

Essentials Acute iliofemoral deep vein thrombosis can be treated with catheter-directed thrombolysis (CDT). We performed a randomized trial comparing conventional CDT versus ultrasound-assisted CDT (USAT). Clinical and duplex sonographic outcomes at 12 months were similar in the CDT and USAT groups. In both groups, incidence of postthrombotic syndrome was very low with good quality of life.

SUMMARY

Background In patients with acute iliofemoral deep vein thrombosis (IFDVT), catheter-directed thrombolysis (CDT) aims to prevent the postthrombotic syndrome (PTS). Adding intravascular high-frequency, low-power ultrasound energy to CDT does not seem to improve the immediate thrombolysis results but its impact on clinical outcomes at 12 months is not known. Patients/Methods In this randomized-controlled trial, 48 patients (mean age 50 ± 21 years; 52% women) with acute IFDVT were randomized to conventional CDT (n = 24) or ultrasound-assisted CDT (USAT; n = 24). In both groups, a fixed-dose thrombolysis regimen (20 mg r-tPA over 15 h) was used, followed by routine stenting of residual venous obstruction. At 12 months, PTS and venous disease severity (Villalta score and revised Venous Clinical Severity Score [rVCSS]), disease-specific quality of live (QOL; CIVIQ-20) and duplex-sonographic outcomes were assessed. Results Among the 45 surviving patients, 40 (89%; 95% confidence interval [CI] 76-96%) patients were free from PTS (defined as Villalta score < 5 points; 83%, 95% CI 61-95% in the USAT and 96%, 95% CI 77-100% in the CDT group), with a similar mean total Villalta score of 2.3 ± 2.9 vs. 1.7 ± 1.6, and a mean total rVCSS of 3.0 ± 3.5 vs. 2.7 ± 2.9 in the USAT and the CDT groups, respectively. Both groups had good disease-specific QOL with a CIVIQ-20 score of 29.4 ± 11.8 vs. 26.1 ± 7.8, respectively. Primary (100% vs. 92%) and secondary (100% vs. 96%) iliofemoral patency rates and presence of femoro-popliteal venous reflux (39% vs. 33%) were similar in both groups. Conclusion The addition of intravascular ultrasound energy to conventional CDT for the treatment of acute IFDVT did not have any impact on relevant clinical or duplex sonographic outcomes, which were favorable in both study groups. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier:NCT01482273.

Patency rate and quality of life after ultrasound-accelerated catheter-directed thrombolysis for deep vein thrombosis

Purpose

Studies on ultrasound-accelerated, catheter-directed thrombolysis of acute deep vein thrombosis emphasize good patency rates and low complication rates. Therefore, we analyzed quality of life besides technical success and patency in our patients after ultrasound-accelerated, catheter-directed thrombolysis.

Methods

Between 2009 and 2014, 42 patients suffering from iliofemoral deep vein thrombosis received ultrasound-accelerated, catheter-directed thrombolysis. Follow-up included clinical exanimation and ultrasound. Thirty patients (36 interventions), mean age 41.3 years (range 19–71 years), 56.6% women (17/30), completed the surveys. Five different scores were used to assess the quality of life and symptoms of postthrombotic syndrome: SF36, Euro-QOL 5D, PDI, VEINES-QOL/Sym, and the Villalta score.

Results

Mean therapy duration of ultrasound-accelerated, catheter-directed thrombolysis was 76.4 h and therapeutic success could be reported in 80.5% (29/36). Successful ultrasound-accelerated, catheter-directed thrombolysis was followed by stent angioplasty in 58.3% (21/36) procedures. Overall complication rate was 19.44%, mainly formed by minor bleedings. Mean follow-up was 38.5 months. The primary patency rate was 63.8%, the assisted-primary and the secondary patency rate were 80.5%. We observed an improved quality of life in our patients’ cohort compared to patients suffering from postthrombotic syndrome.

Conclusion

Although ultrasound-accelerated, catheter-directed thrombolysis is feasible with good patency rates, further prospective randomized trials are necessary to evaluate the value of thrombus removal in iliofemoral deep vein thrombosis in comparison to conservative treatment.

Guidance for the prevention and treatment of the post-thrombotic syndrome

The post-thrombotic syndrome (PTS) is a frequent, potentially disabling complication of deep vein thrombosis (DVT) that reduces quality of life and is costly. Clinical manifestations include symptoms and signs such as leg pain and heaviness, edema, redness, telangiectasia, new varicose veins, hyperpigmentation, skin thickening and in severe cases, leg ulcers. The best way to prevent PTS is to prevent DVT with pharmacologic or mechanical thromboprophylaxis used in high risk patients and settings. In patients whose DVT is treated with a vitamin K antagonist, subtherapeutic INRs should be avoided. We do not suggest routine use of elastic compression stockings (ECS) after DVT to prevent PTS, but in patients with acute DVT-related leg swelling that is bothersome, a trial of ECS is reasonable. We suggest that selecting patients for catheter-directed thrombolytic techniques be done on a case-by-case basis, with a focus on patients with extensive thrombosis, recent symptoms onset, and low bleeding risk, who are seen at experienced hospital centers. For patients with established PTS, we suggest prescribing 20–30 mm Hg knee-length ECS to be worn daily. If ineffective, a stronger pressure stocking can be tried. We suggest that intermittent compression devices or pneumatic compression sleeve units be tried in patients with moderate-to-severe PTS whose symptoms are inadequately controlled with ECS alone. We suggest that a supervised exercise training program for 6 months or more is reasonable for PTS patients who can tolerate it. We suggest that management of post-thrombotic ulcers should involve a multidisciplinary approach. We briefly discuss upper extremity PTS and PTS in children.

What is the effect of venous thromboembolism and related complications on patient reported health-related quality of life? A meta-analysis

We conducted a meta-analysis of the literature to 1) assess the health-related quality of life for patients with a minimum follow-up of one year after an episode of pulmonary embolism (PE) or deep-vein thrombosis (DVT), and 2) to assess the HRQOL for patients who develop chronic thromboembolic pulmonary hypertension (CTEPH) and post thrombotic syndrome (PTS). PubMed, EMBASE, and the Cochrane Library were searched from inception to March 30, 2016. Data were pooled using random-effects meta-analysis, and heterogeneity was assessed with I² and Tau² tests. SF-12, SF-36, and VEINES-QOL were evaluated with pooled standardised mean difference (SMD) and 95 % confidence intervals (CI). Fourteen studies were included for meta-analysis. In patients who sustain a PE, physical health becomes impaired (p<0.001, 2 studies) but mental health appears to remain similar to population norms (p=0.069, 2 studies) after at least one year. Patients who develop CTEPH report worse physical (p<0.001, 1 study) and mental health (p=0.009, 1 study). In patients who suffer from a DVT, physical health (p=0.19, 9 studies), mental health (p=0.67, 9 studies), and disease specific quality of life (p=0.61, 8 studies) remain similar to population norms after at least one year. Patients who develop PTS, however, report worse physical health (p<0.001, 7 studies), mental health (p<0.001, 7 studies), and disease specific quality of life (p<0.001, 10 studies). These data can be used to educate patients during the shared decision making process that increasingly governs medical care today.

LEVEL OF EVIDENCE

II.

Risk factors of postthrombotic syndrome before and after deep venous thrombosis treatment

Postthrombotic syndrome is the most common complication after deep venous thrombosis. Postthrombotic syndrome is a debilitating disease and associated with decreased quality of life and high healthcare costs. Postthrombotic syndrome is a chronic disease, and causative treatment options are limited. Prevention of postthrombotic syndrome is therefore very important. Not all patients develop postthrombotic syndrome. Risk factors have been identified to try to predict the risk of developing postthrombotic syndrome. Age, gender, and recurrent deep venous thrombosis are factors that cannot be changed. Deep venous thrombosis location and extent seem to predict severity of postthrombotic syndrome and are potentially suitable as patient selection criteria. Residual thrombosis and reflux are known to increase the incidence of postthrombotic syndrome, but are of limited use. More recently developed treatment options for deep venous thrombosis, such as new oral factor X inhibitors and catheter-directed thrombolysis, are available at the moment. Catheter-directed thrombolysis shows promising results in reducing the incidence of postthrombotic syndrome after deep venous thrombosis. The role of new oral factor X inhibitors in preventing postthrombotic syndrome is still to be determined.

Calcified in-stent restenosis in a venous stent

Stenting of the iliac veins has been an established treatment for improving venous runoff from the legs after thrombolysis of iliofemoral deep venous thrombosis for more than a decade, yet little is known about the long-term fate of stents in the central veins. We describe a case of heavily calcified in-stent restenosis in a 10-year-old venous stent as well as a way of treating this rare condition. With growing numbers of venous stents reaching a significant age, a need for treatment of long-term complications like the one presented here most probably will arise.

Evaluation of pain associated with chronic venous insufficiency in Spanish postmenopausal women

OBJECTIVE

Menopause status has been associated with an increase in venous diseases and lower limb-related symptoms. The purpose of our study was to evaluate pain associated with chronic venous insufficiency and its risk factors in postmenopausal women.

METHODS

A controlled cross-sectional study was performed in 139 postmenopausal women with chronic venous insufficiency and 40 control women. Pain was assessed with a visual analogue scale, the McGill Pain Questionnaire, and the Pain Matcher (Cefar Medical AB, Lund, Sweden). The influence of several demographic and clinical risk factors was analyzed using bivariate and multivariate regression analyses.

RESULTS

Women in the chronic venous insufficiency group had significantly higher pain intensity and significantly lower pain threshold (P = 0.001) than the control group. The level of pain was independently and significantly associated with venous refill time and osteoarthritis index scores. It was not associated with other risk factors or with disease severity according to the clinical, etiological, anatomical, and pathophysiological classification.

CONCLUSIONS

Venous pain is a consistent symptom in postmenopausal women with chronic venous insufficiency, in whom nociceptive thresholds are generally decreased. Reduced physical activity, venous reflux, and osteoarthritis seem to influence pain level in chronic venous insufficiency.

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.

Thrombus age is ideally measured by history or MRV prior to thrombus removal

Many factors are known to be important in order to achieve optimal results after thrombus removal for iliofemoral DVT. Not much is published in the literature about timing the treatment, though many guidelines recommend treatment within 14 days. This time span lies within the phrase of acute DVT according to the definition given in many reporting standards. This article will highlight the value of information acquired from patients directly regarding onset of symptoms versus information acquired from imaging with the purpose of a more precise selection of patients for catheter-directed thrombolysis for iliofemoral DVT. What is the value of clinical information acquired from patients and does the information from imaging have additional value?

Catheter-Directed Thrombolysis Along with Mechanical Thromboaspiration versus Anticoagulation Alone in the Management of Lower Limb Deep Venous Thrombosis-A Comparative Study

Catheter-directed thrombolysis (CDT) with assisted mechanical thrombolysis is now considered as the standard of medical care for deep vein thrombosis (DVT). The study was conducted to describe the immediate and long-term (6 months) safety and effectiveness of CDT in patient with lower limb DVT compared with the routine anticoagulation alone. All 12 to 85 years old patients with recent (0-8 weeks) DVT were included. In CDT group, thrombus was aspirated mechanically and streptokinase (STK) was given along with unfractionated heparin (UFH). After 6 months, deep venous patency and postthrombotic syndrome (PTS) was assessed by using duplex ultrasound and Villalta scale, respectively. Among 51 patients with completed data, 25 patients were allocated additional CDT given for a mean duration of 108 ± 32 hours and 26 patients were allocated standard treatment alone. Grade III (complete) lysis was achieved in 37% patients and grade II (50-90%) lysis in 63% of patients. Patients with partial lysis underwent percutaneous transluminal angioplasty and/or venous stenting. After 6 months, iliofemoral patency was found in 20 (80%) in the CDT group versus 7 (23%) in anticoagulation alone group (p < 0.01). PTS was seen in 5 (20%) in the CDT group versus 19 (77%) in anticoagulation alone group (p < 0.01). We conclude that CDT and conventional manual aspiration thrombectomy are an effective treatment for lower extremity DVT. STK infusion can be safely given up to 6 days. As addition of UFH can cause thrombocytopenia, so daily monitoring of complete blood counts is needed during CDT.

Endovascular management of proximal lower limb deep venous thrombosis - A prospective study with six-month follow-up

BACKGROUND

Catheter-directed thrombolysis with assisted mechanical thrombolysis is the standard of medical care for proximal deep vein thrombosis. We studied the immediate and intermediate (six months) safety and effectiveness of catheter-directed thrombolysis in patients with proximal lower limb deep vein thrombosis.

METHODOLOGY

Thirty consecutive patients aged between 20 and 70 years with proximal lower limb deep vein thrombosis formed the study group. Catheter-directed thrombolysis was done with streptokinase infuse through a catheter kept in the ipsilateral popliteal vein. Unfractionated heparin was given along with streptokinase. Mechanical thromboaspiration using guiding catheter was performed in addition to thrombolytic therapy. After six months, post-thrombotic syndrome and deep venous patency were assessed by using Villalta scale and duplex ultrasound, respectively.

RESULTS

Thirty patients with proximal lower limb deep vein thrombosis were treated with catheter-directed thrombolysis. Mean age of the study patients was 41.7 ± 15 years. Mean duration of illness was 13.3 ± 12 days. The mean duration of thrombolysis was 4.5 ± 1.3 days. Grade III (complete) lysis was achieved in 10 (33%) and Grade II (50-90%) lysis in 20 (67%) of patients. Patients with significant residual lesion in Grade II lysis following catheter-directed thrombolysis underwent percutaneous transluminal angioplasty alone (12/20) or venous stenting (8/20). All patients improved clinically following catheter-directed thrombolysis or assisted catheter-directed thrombolysis. Four patients (13%) developed pulmonary embolism during course of hospital stay and among them two (6.5%) patients died. Eleven patients (37%) had minor bleeding or hematoma at local site, and seven (23%) developed anemia requiring blood transfusion and four (13%) patients had thrombocytopenia. After six months, iliofemoral patency was found in 20 (72%) and post-thrombotic syndrome was seen in six (21%) patients. Two (6.5%) patients died during follow-up due to nephrotic syndrome and carcinoma breast.

CONCLUSION

Catheter-directed thrombolysis and conventional manual aspiration thrombectomy are an effective treatment for proximal lower extremity deep vein thrombosis with good short and intermediate outcome.

Health-related quality of life after catheter-directed thrombolysis for deep vein thrombosis: secondary outcomes of the randomised, non-blinded, parallel-group CaVenT study

OBJECTIVES

To investigate whether additional catheter-directed thrombolysis (CDT) improves long-term quality of life (QOL) compared with standard treatment with anticoagulation and compression stockings alone in patients with proximal deep vein thrombosis (DVT).

DESIGN

Open-label randomised controlled trial.

SETTING

19 Hospitals in the Norwegian southeastern health region.

PARTICIPANTS

Patients (18-75 years) with a high proximal DVT, symptoms <21 days and no increased risk of bleeding were eligible. 189 of 209 recruited patients completed 24 months of follow-up.

INTERVENTIONS

Participants were randomised to additional CDT with alteplase for 1-4 days or to standard treatment only with 6 months of anticoagulation and 24 months of compression stockings.

PRIMARY AND SECONDARY OUTCOME MEASURES

Planned secondary outcome measures included QOL as assessed with the generic instrument EQ-5D and the disease-specific instrument VEINES-QOL/Sym. Primary outcome measure was post-thrombotic syndrome (PTS) after 24 months.

RESULTS

After 24 months there were no differences in QOL between the additional CDT and standard treatment arms; mean difference for the EQ-5D index was 0.04 (95% CI -0.10 to 0.17), for the VEINES-QOL score 0.2 (95% CI -2.8 to 3.0) and for the VEINES-Sym score 0.5 (95% CI -2.4 to 3.4; p values>0.37). Independent of treatment arms, patients with PTS had poorer outcomes than patient without PTS; mean difference for EQ-5D was 0.09 (95% CI 0.03 to 0.15), for VEINES-QOL score 8.6 (95% CI 5.9 to 11.2) and for VEINES-Sym score 9.8 (95% CI 7.3 to 12.3; p values<0.001).

CONCLUSIONS

QOL did not differ between patients treated with additional CDT compared with standard treatment alone. Patients who developed PTS reported poorer QOL and more symptoms than patients without PTS. QOL should be included as an outcome measure in clinical studies on patients at risk of PTS.

TRIAL REGISTRATION

NCT00251771.

Indications for stenting during thrombolysis

The most important vein segment to thrombolyse after deep venous thrombosis (DVT) is the outflow tract meaning the iliofemoral vein. Iliofemoral DVT is defined as DVT in the iliac vein and the common femoral vein. Spontaneous recanalization is less than 50%, particularly on the left side. The compression from adjacent structures, predominantly on the left side is known as the iliac vein compression syndrome. Therefore, it is essential that supplementary endovenous procedures have to be performed in case of persistent obstructive lesions following catheter-directed thrombolysis. Insertion of a stent in this position is the treatment of choice facilitating the venous flow into an unobstructed outflow tract either from the femoral vein or the deep femoral vein or both. The stent, made of stainless steel or nitinol, has to be self-expandable and flexible with radial force to overcome the challenges in this low-pressure system. The characteristics of the anatomy with external compression and often a curved vein segment with diameter difference make stent placement necessary. Ballooning alone has no place in this area. The proportion of inserted stents varies in the published materials with catheter-directed thrombolysis of iliofemoral deep venous thrombosis.

Management of proximal deep vein thrombosis

Iliofemoral DVT constitutes approximately 20-25% of lower limb DVT and represents a specific subgroup of patients at highest risk for post-thrombotic syndrome (PTS). Anticoagulation alone has no significant thrombolytic activity and has not impact on PTS prevention. Early thrombus removal has reduced PTS in uncontrolled reports and reviews but major trials are awaited. The optimal timing for treatment appear to be thrombus <2 weeks old and, methods for thrombus removal include direct open or suction thrombectomy, catheter directed thrombolysis (CDT), with or without percutaneous mechanical thrombectomy (PMT) devices. Three principle types of PMT device are in use (rotational, rheolytic and ultrasound enhanced devices) and are combined with CDT in pharmocomechanical thrombolysis (PhMT) to enhance early thrombus removal. These devices have individual device specific attributes and side effects that are additional to the bleeding complications of thrombolysis. A number of additional interventions may be utilised to the improve results of CDT and PhMT. IVC filter deployment to reduce periprocedural PE, is supported by little evidence unless an indication for its use already exists. However, balloon venoplasty and vein stents undoubtedly vein patency after treatment. Early thrombus removal comes with additional upfront costs derived from devices, imaging and critical care bed usage. However, significant potential savings from reduction in PTS and rethrombosis rates may reduce overall societal costs. This review focuses on iliofemoral thrombosis, however, the less commonly encountered but clinically important subclavian vein thrombosis is also discussed.

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.