Effective single-session percutaneous nonpharmacologic mechanical thrombectomy for phlegmasia cerulea dolens

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.

ClotTriever system for mechanical thrombectomy of deep vein thrombosis

There is increasing evidence that early and comprehensive removal of thrombus in deep vein thrombosis is associated with improved outcomes, including decreased incidence of post-thrombotic syndrome and debilitating long-term symptoms. Catheter-directed thrombolysis is effective for the rapid removal of clot, but it is associated with high bleeding risk. Percutaneous mechanical thrombectomy is a highly effective method for the removal of clot without the use of systemic or catheter-directed thrombolytic therapy. The Inari ClotTriever system (Inari Medical Inc., CA, USA) is a thrombectomy device, which is approved for deep vein thrombosis by the US FDA in 2017. Herein we review the current treatment strategies using the ClotTriever system, its specifications, indications and current state of literature.

Chronic venous ulcer resolution and post-thrombotic syndrome improvement after percutaneous mechanical thrombectomy of a 42-year-old deep vein thrombosis

Post-thrombotic syndrome (PTS) is a chronic disease affecting up to one half of patients with deep vein thrombosis. PTS symptoms range in severity, with the worst form involving the development of venous ulcers. In the present report, we have described a patient with PTS with ulceration for >40 years. A percutaneous approach with a mechanical thrombectomy extirpation device was used to remove the chronic thrombus in a single session. At >3 months of follow-up, the PTS symptoms had improved dramatically, and the ulcer had completely healed. We have demonstrated successful removal of long-standing chronic thrombus using the ClotTriever system (Inari Medical, Irvine, CA) and the management of venous ulcers resulting from debilitating PTS.

Surgical Intervention for Phlegmasia Cerulea Dolens in a 61-Year-Old Cancer Patient

Phlegmasia cerulea dolens, a rare and potentially fatal complication of acute deep vein thrombosis, is characterized by substantial edema, intense pain, and cyanosis. Phlegmasia cerulea dolens may compromise limb perfusion and lead to acute ischemia, gangrene, amputation, and death. We present the case of a 61-year-old woman with a history of breast cancer who had signs and symptoms of phlegmasia cerulea dolens in her left leg. She was treated promptly with open surgical thrombectomy and sequential distal compression with use of an Esmarch bandage to ensure complete thrombus extraction. These techniques restored venous flow and saved her leg. Open surgical thrombectomy should be considered in the presence of limb-threatening acute deep vein thrombosis presenting as phlegmasia cerulea dolens.

Blue Leg: Phlegmasia Cerulea Dolens Secondary to May Thurner Syndrome

Phlegmasia cerulea dolens (PCD) can present as leg pain accompanied by bluish discoloration. It is a limb-threatening emergency that needs to be promptly addressed with anticoagulation with consideration of thrombolytics. We present a case of PCD in an 83-year-old female without obvious risk factor for thrombosis, found to have May Thurner Syndrome (MTS) requiring a chemical and mechanical approach to prevent catastrophic outcomes.

Phlegmasia Cerulea Dolens: A New Perspective on Management

This is a case of phlegmasia cerulea dolens (PCD) with unexpected but complete resolution of symptoms with short-term administration of heparin products, despite falling into category IIb according to the Rutherford limb ischemia scale, which regularly requires aggressive surgical intervention.

We present a case of a 58-year-old Hispanic female with a past medical history of gastritis who arrived at the emergency room (ER) with acute onset severe pain on the left leg associated with discoloration of the leg. The patient was quickly diagnosed with PCD affecting the left lower extremity, which quickly resolved after administration of heparin infusion for one hour, despite the degree of limb ischemia.

There is no consensus for the treatment of this condition. The most interesting feature of this case is the prompt resolution of symptoms with short-term administration of anticoagulation with total resolution without the need for thrombolysis or thrombectomy. This may suggest that prompt pharmacologic treatment in patients eligible for anticoagulation may successfully restore venous flow negating the need for further intervention.

Severe Acute Respiratory Syndrome Coronavirus 2 Infection and Thrombosis: Phlegmasia Cerulea Dolens Presenting with Venous Gangrene in a Child

A 12-year-old girl with severe acute respiratory syndrome coronavirus 2 infection presented as phlegmasia cerulea dolens with venous gangrene. Emergent mechanical thrombectomy was complicated by a massive pulmonary embolism and cardiac arrest, for which extracorporeal cardiopulmonary resuscitation and therapeutic hypothermia were used. Staged ultrasound-assisted catheter-directed thrombolysis was used for treatment of bilateral pulmonary emboli and the extensive lower extremity deep vein thrombosis while the patient received extracorporeal membrane oxygenation support. We highlight the need for heightened suspicion for occult severe acute respiratory syndrome coronavirus 2 infection among children presenting with unusual thrombotic complications.

Upper limb phlegmasia cerulea dolens treated with single-session suction thrombectomy: a case report

Phlegmasia cerulea dolens (PCD) of the lower limbs is a rare condition. PCD of the upper limbs is extremely uncommon, with only a select few cases documented in the literature. A complication of severe deep venous thrombosis, PCD, is characterized by the clinical triad of oedema, pain and limb cyanosis. Delays in treatment are associated with high rates of morbidity and mortality. We present a case of sudden-onset upper limb PCD in a 68-year-old man following haemodialysis through a long-term arteriovenous fistula. Prompt diagnosis and rapid initiation of intravenous anticoagulation followed by urgent single-session suction thrombectomy resulted in the successful restoration of vessel patency without any significant adverse sequelae on 3-month follow-up.

Management of Phlegmasia Cerulea Dolens with Percutaneous Mechanical Thrombectomy

Advanced cases of phlegmasia cerulea dolens (PCD) with absent pedal pulses, sensory/motor deficits, and/or venous gangrene likely require more rapid restoration of flow compared to cases without these factors to prevent progression and associated morbidity/mortality. We present a case of PCD with absent pedal pulses and sensory deficit managed successfully with emergent percutaneous mechanical thrombectomy using Inari ClotTriever (Inari Medical, Irvine, CA) with immediate clinical resolution, including restoration of pedal pulses ~ 45 min after thrombectomy. Percutaneous mechanical thrombectomy with the ClotTriever device has the ability to immediately restore venous flow reversing the pathophysiology of PCD in a short time period similar to surgical embolectomy and may be an alternative treatment strategy in patients with phlegmasia cerulea dolens of high severity.