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Hendley SA, Dimov A, Bhargava A, Snoddy E, Mansour D, Afifi RO, Wool GD, Zha Y, Sammet S, Lu ZF, Ahmed O, Paul JD, Bader KB. Assessment of histological characteristics, imaging markers, and rt-PA susceptibility of ex vivo venous thrombi. Sci Rep 2021; 11:22805. [PMID: 34815441 PMCID: PMC8610976 DOI: 10.1038/s41598-021-02030-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/08/2021] [Indexed: 12/27/2022] Open
Abstract
Venous thromboembolism is a significant source of morbidity and mortality worldwide. Catheter-directed thrombolytics is the primary treatment used to relieve critical obstructions, though its efficacy varies based on the thrombus composition. Non-responsive portions of the specimen often remain in situ, which prohibits mechanistic investigation of lytic resistance or the development of diagnostic indicators for treatment outcomes. In this study, thrombus samples extracted from venous thromboembolism patients were analyzed ex vivo to determine their histological properties, susceptibility to lytic therapy, and imaging characteristics. A wide range of thrombus morphologies were observed, with a dependence on age and etymology of the specimen. Fibrinolytic inhibitors including PAI-1, alpha 2-antiplasmin, and TAFI were present in samples, which may contribute to the response venous thrombi to catheter-directed thrombolytics. Finally, a weak but significant correlation was observed between the response of the sample to lytic drug and its magnetic microstructure assessed with a quantitative MRI sequence. These findings highlight the myriad of changes in venous thrombi that may promote lytic resistance, and imaging metrics that correlate with treatment outcomes.
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Affiliation(s)
- Samuel A Hendley
- Committee on Medical Physics, University of Chicago, Chicago, IL, 60637, USA
| | - Alexey Dimov
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10021, USA
| | - Aarushi Bhargava
- Department of Radiology, University of Chicago, Chicago, IL, 60637, USA
| | - Erin Snoddy
- Department of Radiology, University of Chicago, Chicago, IL, 60637, USA
| | - Daniel Mansour
- Department of Radiology, University of Chicago, Chicago, IL, 60637, USA
| | - Rana O Afifi
- Department of Cardiothoracic and Vascular Surgery, University of Texas at Houston, Houston, TX, 77030, USA
| | - Geoffrey D Wool
- Department of Pathology, University of Chicago, Chicago, IL, 60637, USA
| | - Yuanyuan Zha
- The Human Immunological Monitoring Facility, University of Chicago, Chicago, IL, 60637, USA
| | - Steffen Sammet
- Committee on Medical Physics, University of Chicago, Chicago, IL, 60637, USA.,Department of Radiology, University of Chicago, Chicago, IL, 60637, USA
| | - Zheng Feng Lu
- Committee on Medical Physics, University of Chicago, Chicago, IL, 60637, USA.,Department of Radiology, University of Chicago, Chicago, IL, 60637, USA
| | - Osman Ahmed
- Department of Radiology, University of Chicago, Chicago, IL, 60637, USA
| | - Jonathan D Paul
- Department of Medicine, University of Chicago, Chicago, IL, 60637, USA
| | - Kenneth B Bader
- Committee on Medical Physics, University of Chicago, Chicago, IL, 60637, USA. .,Department of Radiology, University of Chicago, Chicago, IL, 60637, USA.
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2
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Fang D, Li T, Wu Z, Wang Q, Wan M, Zhou M, Mao C. Dual drive mode polydopamine nanomotors for continuous treatment of an inferior vena cava thrombus. J Mater Chem B 2021; 9:8659-8666. [PMID: 34608926 DOI: 10.1039/d1tb01202a] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
It is of great significance to find effective thrombolytic treatments due to the harm caused by thrombosis to human health. Based on the formation mechanism and complex microenvironment of a thrombus, polydopamine nanomotors (PDANMs) modified by the peptide of Arg-Gly-Asp (RGD) and loaded with urokinase (UK) were designed and prepared. A polydopamine (PDA) substrate has a good photothermal conversion effect. Under near-infrared (NIR) light irradiation, it can not only perform photothermal therapy (PTT) on thrombus, but also provide the driving force of PDANMs. Thrombolytic drug UK was loaded in the mesoporous structure of the PDA substrate and can be released at the thrombus site for drug therapy. The modified RGD can target the thrombus site, moreover, benefiting from the guanidine group of L-arginine in the peptide chain, and RGD can interact with reactive oxygen species (ROS) in the thrombus microenvironment to produce nitric oxide (NO). NO not only propelled the movement of nanomotors, but also promoted the growth of vascular endothelial cells to repair damaged blood vessels. The experimental results show that NIR and NO can provide dual driving sources for the nanosystem to achieve continuous and deep penetration of the drug-loaded nanomotors at the thrombus site, while realizing the photothermal and drug synergistic therapy to enhance the therapeutic effect and promote the growth of vascular endothelium cells. This kind of thrombus treatment strategy based on nanomotor drug delivery systems will provide good technical support for the clinical treatment of inferior vena cava thrombus.
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Affiliation(s)
- Dan Fang
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, 210023, China.
| | - Ting Li
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, 210023, China.
| | - Ziyu Wu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Qi Wang
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, 210023, China.
| | - Mimi Wan
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, 210023, China.
| | - Min Zhou
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Chun Mao
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, 210023, China.
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Veenstra EB, van der Laan MJ, Zeebregts CJ, de Heide EJ, Kater M, Bokkers RPH. A systematic review and meta-analysis of endovascular and surgical revascularization techniques in acute limb ischemia. J Vasc Surg 2019; 71:654-668.e3. [PMID: 31353270 DOI: 10.1016/j.jvs.2019.05.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The initial treatment of patients with acute limb ischemia (ALI) remains undefined. The aim of this article was to compare the safety and effectiveness of catheter-driven thrombolysis (CDT) with surgical revascularization and evaluate the various fibrinolytic agents, endovascular, and pharmacochemical approaches that aim for thrombectomy. METHODS PubMed, Embase, and the Cochrane Library were searched for studies on the management of ALI by means of surgical or endovascular recanalization, returning 520 studies. All randomized, controlled trials, nonrandomized prospective, and retrospective studies were included comparing treatment of ALI. RESULTS Twenty-five studies, investigating a total of 4689 patients, were included for meta-analysis spread across nine different comparisons. No differences were found in limb salvage between thrombectomy and thrombolysis. More major vascular events were seen in the thrombolysis group (6.5% compared with 4.4% in the surgically treated group; odds ratio [OR], 0.33; 95% confidence interval [CI], 0.13-0.87; P = .02; I2 = 20%). Comparable limb salvage was found for high- and low-dose recombinant tissue plasminogen activator (r-tPA). No significant differences were found in major vascular event between low r-tPA (14%) and high r-tPA (10.5%; P = .13). The 30-day limb salvage rate was 79.7% for r-tPA treatment and 60.4% for streptokinase (OR, 3.14; 95% CI, 1.26-7.85; P = .01; I2 = 0%). AngioJet showed more limb salvage at 6 months compared with r-tPa (OR, 2.21; 95% CI, 1.17-4.18; P = .01; I2 = 0%). CONCLUSIONS Both CDT and surgery have comparable limb salvage rates in patients with ALI; however, CDT is associated with a higher risk of hemorrhagic complications. No conclusions can be drawn regarding the risk of hemorrhagic complications regarding thrombolytic therapy by means of r-tPA, streptokinase, or urokinase. Insufficient data are available to conclude the preference of using a hybrid approach, ultrasound-accelerated CDT, heated r-tPA. or novel endovascular (rheolytical) thrombectomy systems. Future trials regarding ALI need to be constructed carefully, ensuring comparable study groups, and should follow standardized practices of outcome reporting.
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Affiliation(s)
- Emile B Veenstra
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands; Faculty of Medical Sciences, University of Groningen, Groningen, The Netherlands
| | - Maarten J van der Laan
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Erik-Jan de Heide
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Matthijs Kater
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands.
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Poorthuis MH, Brand EC, Hazenberg CE, Schutgens RE, Westerink J, Moll FL, de Borst GJ. Plasma fibrinogen level as a potential predictor of hemorrhagic complications after catheter-directed thrombolysis for peripheral arterial occlusions. J Vasc Surg 2017; 65:1519-1527.e26. [DOI: 10.1016/j.jvs.2016.11.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 11/10/2016] [Indexed: 10/20/2022]
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5
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Min SK, Kim YH, Joh JH, Kang JM, Park UJ, Kim HK, Chang JH, Park SJ, Kim JY, Bae JI, Choi SY, Kim CW, Park SI, Yim NY, Jeon YS, Yoon HK, Park KH. Diagnosis and Treatment of Lower Extremity Deep Vein Thrombosis: Korean Practice Guidelines. Vasc Specialist Int 2016; 32:77-104. [PMID: 27699156 PMCID: PMC5045251 DOI: 10.5758/vsi.2016.32.3.77] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 08/09/2016] [Indexed: 01/28/2023] Open
Abstract
Lower extremity deep vein thrombosis is a serious medical condition that can result in death or major disability due to pulmonary embolism or post-thrombotic syndrome. Appropriate diagnosis and treatment are required to improve symptoms and salvage the affected limb. Early thrombus clearance rapidly resolves symptoms related to venous obstruction, restores valve function and reduces the incidence of post-thrombotic syndrome. Recently, endovascular treatment has been established as a standard method for early thrombus removal. However, there are a variety of views regarding the indications and procedures among medical institutions and operators. Therefore, we intend to provide evidence-based guidelines for diagnosis and treatment of lower extremity deep vein thrombosis by multidisciplinary consensus. These guidelines are the result of a close collaboration between interventional radiologists and vascular surgeons. The goals of these guidelines are to improve treatment, to serve as a guide to the clinician, and consequently to contribute to public health care.
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Affiliation(s)
- Seung-Kee Min
- Department of Surgery, Seoul National University College of Medicine, Seoul,
Korea
| | - Young Hwan Kim
- Department of Radiology, Keimyung University College of Medicine, Daegu,
Korea
| | - Jin Hyun Joh
- Department of Surgery, Kyung Hee University School of Medicine, Seoul,
Korea
| | - Jin Mo Kang
- Department of Surgery, Gachon University College of Medicine, Incheon,
Korea
| | - Ui Jun Park
- Department of Surgery, Keimyung University College of Medicine, Daegu,
Korea
| | - Hyung-Kee Kim
- Department of Surgery, Kyungpook National University School of Medicine, Daegu,
Korea
| | - Jeong-Hwan Chang
- Department of Surgery, Chosun University College of Medicine, Gwangju,
Korea
| | - Sang Jun Park
- Department of Surgery, University of Ulsan College of Medicine, Seoul,
Korea
| | - Jang Yong Kim
- Department of Surgery, Catholic University College of Medicine,
Korea
| | - Jae Ik Bae
- Mint Intervention Clinic, Seongnam,
Korea
| | - Sun Young Choi
- Department of Radiology, Ewha Womans University College of Medicine, Seoul,
Korea
| | - Chang Won Kim
- Department of Radiology, Pusan National University School of Medicine, Yangsan,
Korea
| | - Sung Il Park
- Department of Radiology, Yonsei University College of Medicine, Seoul,
Korea
| | - Nam Yeol Yim
- Department of Radiology, Chonnam National University College of Medicine, Gwangju,
Korea
| | - Yong Sun Jeon
- Department of Radiology, Inha University College of Medicine, Incheon,
Korea
| | - Hyun-Ki Yoon
- Department of Radiology, University of Ulsan College of Medicine, Seoul,
Korea
| | - Ki Hyuk Park
- Department of Surgery, Daegu Catholic University College of Medicine, Daegu,
Korea
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6
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Sista AK, Vedantham S, Kaufman JA, Madoff DC. Endovascular Interventions for Acute and Chronic Lower Extremity Deep Venous Disease: State of the Art. Radiology 2015; 276:31-53. [PMID: 26101920 DOI: 10.1148/radiol.2015132603] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The societal and individual burden caused by acute and chronic lower extremity venous disease is considerable. In the past several decades, minimally invasive endovascular interventions have been developed to reduce thrombus burden in the setting of acute deep venous thrombosis to prevent both short- and long-term morbidity and to recanalize chronically occluded or stenosed postthrombotic or nonthrombotic veins in symptomatic patients. This state-of-the-art review provides an overview of the techniques and challenges, rationale, patient selection criteria, complications, postinterventional care, and outcomes data for endovascular intervention in the setting of acute and chronic lower extremity deep venous disease. Online supplemental material is available for this article.
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Affiliation(s)
- Akhilesh K Sista
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
| | - Suresh Vedantham
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
| | - John A Kaufman
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
| | - David C Madoff
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
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7
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Szeberin Z, Szabó GV, Sótonyi P, Dósa E. Diffuse leakage through an 8-month-old Dacron graft after thrombolysis with tissue plasminogen activator. J Vasc Surg 2013; 59:245. [PMID: 24370084 DOI: 10.1016/j.jvs.2012.08.099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 08/02/2012] [Accepted: 08/27/2012] [Indexed: 11/20/2022]
Affiliation(s)
- Zoltán Szeberin
- Cardiovascular Center, Semmelweis University, Budapest, Hungary.
| | | | - Péter Sótonyi
- Cardiovascular Center, Semmelweis University, Budapest, Hungary
| | - Edit Dósa
- Cardiovascular Center, Semmelweis University, Budapest, Hungary
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8
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Patel NH, Krishnamurthy VN, Kim S, Saad WE, Ganguli S, Gregory Walker T, Nikolic B. Quality Improvement Guidelines for Percutaneous Management of Acute Lower-extremity Ischemia. J Vasc Interv Radiol 2013; 24:3-15. [DOI: 10.1016/j.jvir.2012.09.026] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 09/15/2012] [Accepted: 09/17/2012] [Indexed: 11/26/2022] Open
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9
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Hynes BG, Margey RJ, Ruggiero N, Kiernan TJ, Rosenfield K, Jaff MR. Endovascular Management of Acute Limb Ischemia. Ann Vasc Surg 2012; 26:110-24. [DOI: 10.1016/j.avsg.2011.05.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Revised: 04/24/2011] [Accepted: 05/15/2011] [Indexed: 10/17/2022]
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10
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Ochoa C, Weaver FA. Basic data related to thrombolytic therapy for acute arterial thrombosis. Ann Vasc Surg 2011; 26:292-7. [PMID: 22188940 DOI: 10.1016/j.avsg.2011.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 08/15/2011] [Indexed: 11/29/2022]
Affiliation(s)
- Christian Ochoa
- Division of Vascular Surgery and Endovascular Therapy, USC Cardiovascular Thoracic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA 90012, USA
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11
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Catheter-Directed Thrombolysis for Acute Iliofemoral Deep Venous Thrombosis. Ann Vasc Surg 2011; 25:707-15. [PMID: 21306867 DOI: 10.1016/j.avsg.2010.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 12/17/2010] [Indexed: 11/23/2022]
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12
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Popuri RK, Vedantham S. The role of thrombolysis in the clinical management of deep vein thrombosis. Arterioscler Thromb Vasc Biol 2011; 31:479-84. [PMID: 21325669 DOI: 10.1161/atvbaha.110.213413] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The cornerstones of current management of deep vein thrombosis (DVT) are the routine use of anticoagulant therapy, graduated elastic compression stockings, and early ambulation. Thrombolytic therapy was previously reserved only for patients with life-, limb-, or organ-threatening complications. However, the postthrombotic syndrome has been increasingly recognized as a frequent and serious long-term complication of DVT. In parallel, endovascular thrombolytic methods have evolved considerably in recent years, prompting discussion and controversy as to whether they should be more liberally used. In some centers, pharmacomechanical catheter-directed thrombolysis is now routinely used in the treatment of acute iliofemoral DVT. Randomized trials are currently under way to determine when the use of pharmacomechanical catheter-directed thrombolysis is appropriate in patients presenting with acute proximal DVT.
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Affiliation(s)
- Radha Krishna Popuri
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
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13
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Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123:1788-830. [PMID: 21422387 DOI: 10.1161/cir.0b013e318214914f] [Citation(s) in RCA: 1447] [Impact Index Per Article: 111.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Venous thromboembolism (VTE) is responsible for the hospitalization of >250 000 Americans annually and represents a significant risk for morbidity and mortality. Despite the publication of evidence-based clinical practice guidelines to aid in the management of VTE in its acute and chronic forms, the clinician is frequently confronted with manifestations of VTE for which data are sparse and optimal management is unclear. In particular, the optimal use of advanced therapies for acute VTE, including thrombolysis and catheter-based therapies, remains uncertain. This report addresses the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT),and chronic thromboembolic pulmonary hypertension (CTEPH). The goal is to provide practical advice to enable the busy clinician to optimize the management of patients with these severe manifestations of VTE. Although this document makes recommendations for management, optimal medical decisions must incorporate other factors, including patient wishes, quality of life, and life expectancy based on age and comorbidities. The appropriateness of these recommendations for a specific patient may vary depending on these factors and will be best judged by the bedside clinician.
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Sebastian AJ, Robinson GJ, Dyet JF, Ettles DF. Long-term Outcomes of Low-dose Catheter-directed Thrombolytic Therapy: A 5-year Single-center Experience. J Vasc Interv Radiol 2010; 21:1004-10. [DOI: 10.1016/j.jvir.2010.03.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Revised: 03/04/2010] [Accepted: 03/30/2010] [Indexed: 11/29/2022] Open
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15
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Agle SC, McNally MM, Powell CS, Bogey WM, Parker FM, Stoner MC. The Association of Periprocedural Hypertension and Adverse Outcomes in Patients Undergoing Catheter-Directed Thrombolysis. Ann Vasc Surg 2010; 24:609-14. [DOI: 10.1016/j.avsg.2009.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2009] [Revised: 10/19/2009] [Accepted: 12/20/2009] [Indexed: 10/19/2022]
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Yamagami T, Yoshimatsu R, Tanaka O, Miura H, Nishimura T. Endovascular thrombolysis using monteplase for non-chronic deep venous thrombosis. Cardiovasc Intervent Radiol 2010; 33:1223-9. [PMID: 20411388 DOI: 10.1007/s00270-010-9856-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Accepted: 03/23/2010] [Indexed: 11/25/2022]
Abstract
This study was designed to evaluate the usefulness of endovascular thrombolysis using monteplase for deep venous thrombosis (DVT). Between December 2005 and October 2009, at our institution nine endovascular thrombolysis treatments with monteplase were performed for symptomatic DVT in eight patients (6 women, 2 men; mean age, 56 (range, 15-80) years). In all, systemic anticoagulation administered by the peripheral intravenous route with heparin and/or thrombolysis with urokinase followed by anticoagulation with orally administered warfarin had been performed, and subsequently six endovascular treatments without monteplase were administered. However, DVT persisted, and endovascular treatments with monteplase were tried. In six (67%) of the nine procedures, DVT completely or almost completely disappeared after endovascular thrombolysis with monteplase. Mean dose of monteplase used was 2,170,000 IU. There was only one procedure-related complication. In one patient, just after thrombolysis with monteplase, bleeding at the puncture site and gingival bleeding occurred. Bleeding was stopped by manual astriction only. Endovascular thrombolysis with monteplase may be an effective treatment for DVT, even in cases resistant to traditional systemic anticoagulation and thrombolysis and endovascular procedures without monteplase.
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Affiliation(s)
- Takuji Yamagami
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-chou, Kawaramachi-Hirokoji, Kamigyo-Ku, Kyoto 602-8566, Japan.
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17
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Endovascular Treatment Options in the Management of Lower Limb Deep Venous Thrombosis. Cardiovasc Intervent Radiol 2009; 32:861-76. [DOI: 10.1007/s00270-009-9662-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2008] [Revised: 06/28/2009] [Accepted: 06/30/2009] [Indexed: 12/17/2022]
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18
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Quality Improvement Guidelines for Percutaneous Management of Acute Limb Ischemia. J Vasc Interv Radiol 2009; 20:S208-18. [DOI: 10.1016/j.jvir.2009.04.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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19
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Vedantham S, Thorpe PE, Cardella JF, Grassi CJ, Patel NH, Ferral H, Hofmann LV, Janne d'Othée BM, Antonaci VP, Brountzos EN, Brown DB, Martin LG, Matsumoto AH, Meranze SG, Miller DL, Millward SF, Min RJ, Neithamer CD, Rajan DK, Rholl KS, Schwartzberg MS, Swan TL, Towbin RB, Wiechmann BN, Sacks D. Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal. J Vasc Interv Radiol 2009; 20:S227-39. [DOI: 10.1016/j.jvir.2009.04.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2005] [Accepted: 11/12/2005] [Indexed: 10/20/2022] Open
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20
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Olvey EL, Skrepnek GH, Nolan PE. Cost-effectiveness of urokinase and alteplase for treatment of acute peripheral artery disease: Comparison in a decision analysis model. Am J Health Syst Pharm 2008; 65:1435-42. [DOI: 10.2146/ajhp070431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Grant H. Skrepnek
- College of Pharmacy, and Investigator, Center of Health Outcomes and Pharmacoeconomic Research, UA
| | - Paul E. Nolan
- College of Pharmacy, and Senior Clinical Scientist, Sarver Heart Center, UA
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Acute venous disease: Venous thrombosis and venous trauma. J Vasc Surg 2007; 46 Suppl S:25S-53S. [DOI: 10.1016/j.jvs.2007.08.037] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2006] [Revised: 08/15/2007] [Accepted: 08/19/2007] [Indexed: 10/22/2022]
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Casella IB, Presti C, Aun R, Benabou JE, Puech-Leão P. Late results of catheter-directed recombinant tissue plasminogen activator fibrinolytic therapy of iliofemoral deep venous thrombosis. Clinics (Sao Paulo) 2007; 62:31-40. [PMID: 17334547 DOI: 10.1590/s1807-59322007000100006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2006] [Accepted: 10/09/2006] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To evaluate the efficacy of catheter-directed low-dose recombinant tissue-type plasminogen activator infusion in the treatment of iliofemoral deep venous thrombosis and prevention of post-thrombotic syndrome. METHOD Eighteen patients (out of 260 evaluated) with acute iliofemoral deep venous thrombosis and no previous evidence of venous insufficiency were prospectively selected for thrombolytic therapy. Catheter-directed low-dose recombinant tissue-type plasminogen activator (1 mg/h) was infused into the thrombotic segments. RESULTS Effective fibrinolysis was achieved in 14 of 18 cases, with correlation between effective fibrinolysis and major/complete resolution of acute signs and symptoms (P <.01). There were no episodes of major complications. Four patients presented with early rethrombosis (1 to 8 weeks). Individuals were followed for a period up to 131 weeks (average, 85.2). The incidence of clinical signs and symptoms of venous insufficiency and duplex-scan findings of valvular reflux was significantly lower in the patients in which lytic therapy succeeded and patency was kept, compared with patients experiencing acute therapeutic failure or rethrombosis (P <.01). CONCLUSIONS Low-dose recombinant tissue-type plasminogen activator fibrinolytic therapy is safe and effective in the treatment of acute iliofemoral venous thrombosis. The late evolution as revealed clinically and by ultrasound was superior in patients for whom lytic therapy was effective.
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Affiliation(s)
- Ivan Benaduce Casella
- Division of Vascular Surgery, Medical School, São Paulo University, São Paulo, SP, Brazil.
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Kim HS, Patra A, Paxton BE, Khan J, Streiff MB. Adjunctive Percutaneous Mechanical Thrombectomy for Lower-extremity Deep Vein Thrombosis: Clinical and Economic Outcomes. J Vasc Interv Radiol 2006; 17:1099-104. [PMID: 16868161 DOI: 10.1097/01.rvi.0000228334.47073.c4] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To assess the clinical and economic benefits of catheter-directed thrombolysis (CDT) alone versus CDT with rheolytic percutaneous mechanical thrombectomy (PMT) for lower-extremity deep vein thrombosis (DVT). MATERIALS AND METHODS Consecutive patients with acute iliofemoral DVT treated with CDT with urokinase between 1997 and 2003 were identified. Demographic characteristics and clinical and economic outcomes were compared between patients treated with CDT alone versus CDT plus PMT. RESULTS Twenty-six limbs in 23 patients received CDT with urokinase, whereas 19 limbs in 14 patients were treated with CDT plus PMT. Mean treatment duration for CDT was 56.5 +/- 27.4 hours, compared with 30.3 +/- 17.8 hours for CDT plus PMT (P = .001). Mean urokinase dose for CDT was 6.70 +/- 5.9 million U compared with 2.95 +/- 1.82 million U for CDT plus PMT (P = .011). Urokinase CDT achieved complete clot lysis in 80.7% of limbs (n = 21) compared with 84.2% of limbs (n = 16) treated with CDT plus PMT (P = .764). The incidences of major bleeding (CDT, 7.7%; CDT plus PMT, 5.3%; P = .749) and pulmonary embolism (CDT, 3.8%; CDT plus PMT, 5.3%; P = .818) were similar. The mean urokinase and PMT device cost for CDT alone was $10,127 compared with $5,128 for CDT plus PMT (P = .026). CONCLUSIONS Percutaneous CDT with rheolytic PMT is as effective as CDT alone for acute iliofemoral DVT but requires significantly shorter treatment and lower lytic agent dose, resulting in lower costs. Randomized studies to confirm the benefits of pharmacomechanical thrombolysis in the treatment of DVT are warranted.
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Affiliation(s)
- Hyun S Kim
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 545, Baltimore, MD 21287-4010, USA.
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Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WRC, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113:e463-654. [PMID: 16549646 DOI: 10.1161/circulationaha.106.174526] [Citation(s) in RCA: 2164] [Impact Index Per Article: 120.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery,⁎Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). J Am Coll Cardiol 2006. [DOI: 10.1016/j.jacc.2006.02.024] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Vedantham S, Thorpe PE, Cardella JF, Grassi CJ, Patel NH, Ferral H, Hofmann LV, Janne d'Othée BM, Antonaci VP, Brountzos EN, Brown DB, Martin LG, Matsumoto AH, Meranze SG, Miller DL, Millward SF, Min RJ, Neithamer CD, Rajan DK, Rholl KS, Schwartzberg MS, Swan TL, Towbin RB, Wiechmann BN, Sacks D. Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal. J Vasc Interv Radiol 2006; 17:435-47; quiz 448. [PMID: 16567668 DOI: 10.1097/01.rvi.0000197348.57762.15] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Suresh Vedantham
- Department of Radiology, Mallinckrodt Institute of Radiology, Saint Louis, Missouri, USA
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Rajan DK, Patel NH, Valji K, Cardella JF, Bakal C, Brown D, Brountzos E, Clark TWI, Grassi C, Meranze S, Miller D, Neithamer C, Rholl K, Roberts A, Schwartzberg M, Swan T, Thorpe P, Towbin R, Sacks D. Quality Improvement Guidelines for Percutaneous Management of Acute Limb Ischemia. J Vasc Interv Radiol 2005; 16:585-95. [PMID: 15872313 DOI: 10.1097/01.rvi.0000156191.83408.b4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Dheeraj K Rajan
- Department of Radiology, University of Health Network, Toronto, Ontario, Canada
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Ouriel K, Kandarpa K. Safety of Thrombolytic Therapy with Urokinase or Recombinant Tissue Plasminogen Activator for Peripheral Arterial Occlusion:A Comprehensive Compilation of Published Work. J Endovasc Ther 2004; 11:436-46. [PMID: 15298504 DOI: 10.1583/04-1226.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To report a comprehensive literature review focused on comparing the risk of complications with urokinase versus recombinant tissue plasminogen activator (rtPA) for thrombolytic treatment of peripheral arterial occlusions. METHODS The English-language literature between 1985 and 2002 was searched for studies that used tissue-derived urokinase or rtPA in the treatment of peripheral arterial occlusions. Forty-eight studies (22 urokinase, 22 rtPA, and 4 that included both treatments) were identified, encompassing 2226 urokinase-treated patients and 1927 rtPA-treated patients. The safety of each thrombolytic agent was assessed based on the incidence of major hemorrhage, intracerebral hemorrhage, major limb amputation, transfusions, and mortality. RESULTS The review revealed a wide range of study protocols, patient conditions, ages of occlusions, dosages/delivery methods of lytic agents, and criteria for reporting complications. The incidence of major hemorrhage varied widely, but the overall rate was lower among urokinase-treated patients (6.2%) than for patients treated with rtPA (8.4%, p=0.007). The overall incidence of intracerebral hemorrhage was also significantly lower for urokinase (0.4% versus 1.1% for rtPA, p=0.020). The major amputation rate was similar for both treatments (urokinase 7.9%, rtPA 7.2%), but the mortality rate was significantly lower for urokinase (3.0% versus 5.6% for rtPA, p<0.001). The need for transfusions was less frequent with urokinase (11.1% versus 16.1%, p=0.002). CONCLUSIONS These results from a large body of published literature suggest that urokinase may be associated with a lower incidence of complications than rtPA in the treatment of peripheral arterial occlusions.
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Affiliation(s)
- Kenneth Ouriel
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Vedantham S, Vesely TM, Sicard GA, Brown D, Rubin B, Sanchez LA, Parti N, Picus D. Pharmacomechanical Thrombolysis and Early Stent Placement for Iliofemoral Deep Vein Thrombosis. J Vasc Interv Radiol 2004; 15:565-74. [PMID: 15178716 DOI: 10.1097/01.rvi.0000127894.00553.02] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To evaluate an approach to the treatment of iliofemoral deep vein thrombosis (DVT) that included pharmacomechanical catheter-directed thrombolysis with reteplase and the Helix mechanical thrombectomy device, followed by early stent placement. MATERIALS AND METHODS During 3-year period, 23 symptomatic limbs in 18 patients with iliofemoral DVT were treated with reteplase catheter-directed thrombolysis. After an initial infusion of 8 to 16 hours, any residual acute thrombus over a long segment (> 10 cm) was treated by maceration with use of the Helix thrombectomy device. Residual short-segment (< 10 cm) iliac vein thrombus and/or stenosis were treated with stent placement. Technical success, clinical success, complications, thrombolytic infusion time, total thrombolytic agent dose, fibrinogen level changes, and late limb status were retrospectively analyzed. RESULTS Technical success was achieved in 23 of 23 limbs (100%). Clinical success was achieved in 22 of 23 limbs (96%). Complete or partial thrombolysis was observed in 19 of 23 limbs (83%). Major bleeding was observed in one patient (6%) and necessitated blood transfusion. Mean per-limb thrombolytic infusion time and total dose were 19.6 hours +/- 8.1 and 13.8 U +/- 5.3 reteplase, respectively. Mean serum fibrinogen nadir and percentage drop in serum fibrinogen were 282 mg/dL +/- 167 and 47% +/- 24%, respectively. Late (mean, 19.8 +/- 11.6 months) modified Venous Disability Scores were 0 (none) for six limbs, 1 (mild) for 10 limbs, 2 (moderate) for two limbs, and 3 (severe) for no limbs. CONCLUSION In a preliminary experience, pharmacomechanical catheter-directed iliofemoral DVT thrombolysis with early stent placement was safe and effective.
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Affiliation(s)
- Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.
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Grunwald MR, Hofmann LV. Comparison of Urokinase, Alteplase, and Reteplase for Catheter-directed Thrombolysis of Deep Venous Thrombosis. J Vasc Interv Radiol 2004; 15:347-52. [PMID: 15064337 DOI: 10.1097/01.rvi.0000121407.46920.15] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To compare the efficacy, safety, and costs associated with catheter-directed thrombolysis with urokinase (UK) and the recombinant agents alteplase (tissue plasminogen activator [TPA]) and reteplase (recombinant plasminogen activator [RPA]) in the treatment of symptomatic deep vein thrombosis (DVT). MATERIALS AND METHODS The authors conducted a retrospective analysis on 74 patients (82 limbs) who underwent treatment for DVT. Thrombosed extremities were treated with either urokinase with therapeutic heparin dosing (UK group; 38 limbs), alteplase with subtherapeutic heparin dosing (TPA group; 32 limbs), or reteplase with subtherapeutic heparin dosing (RPA group; 12 limbs). Infusion times, dosages, drug costs, success rates, and complications were compared among the groups. RESULTS Gender, age, disease location, duration of symptoms, and use of additional interventional therapies did not differ statistically among the three cohorts. Median hourly infused doses, total doses, infusion times, drug costs, and success rates per limb were: UK, 11.3 (10(4)) U/hour, 4.361 million U, 40.6 hours, US dollars 6577, 97.4%; TPA, 0.57 mg/hour, 21.6 mg, 30.8 hours, US dollars 488, 96.9%; RPA, 0.74 U/hour, 21.4 U, 24.3 hours, US dollars 1787, 100.0%. Major and overall complication rates were: UK, 5.3% and 10.5%; TPA, 3.1% and 12.5%; RPA, 8.3% and 16.7%. Infusion times, success rates, and complications were not statistically different among the three groups. Alteplase and reteplase were significantly less expensive than urokinase (P <.001 and P <.01, respectively). CONCLUSION Catheter-directed thrombolysis for the treatment of DVT is safe and effective, regardless of the agent used. However, the new recombinant agents are significantly less expensive than urokinase.
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Affiliation(s)
- Michael R Grunwald
- The Russell H Morgan Department of Radiology and Radiological Science, The Johns Hopkins School of Medicine, Blalock 545, 600 N Wolfe Street, Baltimore, Maryland 21287, USA
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Razavi MK, Lee DS, Hofmann LV. Catheter-directed Thrombolytic Therapy for Limb Ischemia: Current Status and Controversies. J Vasc Interv Radiol 2004; 15:13-23. [PMID: 14709682 DOI: 10.1097/01.rvi.0000112621.22203.12] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Absence of urokinase from the United States market for the past 4 years has resulted in increasing experience with other plasminogen activators in catheter-directed thrombolytic therapy. The differences in the pharmacologic properties and biologic behavior of these agents may translate into clinical outcomes that are distinct. Some of these manifestations can be predicted based on the existing large clinical trials in the acute myocardial infarction literature. However, because of the fundamental differences in techniques and thrombolytic regimens, extrapolation of the coronary data may not always predict the performance of these agents in peripheral catheter-directed fibrinolysis. In this article, the current status of the available lytic agents in the treatment of limb ischemia is reviewed.
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Affiliation(s)
- Mahmood K Razavi
- Department of Vascular and Interventional Radiology, Stanford University Hospital, H3651 Vascular Center, 300 Pasteur Drive, Stanford, California 94305, USA.
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Razavi MK, Lee DS, Hofmann LV. Catheter-directed Thrombolytic Therapy for Limb Ischemia: Current Status and Controversies. J Vasc Interv Radiol 2003; 14:1491-501. [PMID: 14654482 DOI: 10.1097/01.rvi.0000099531.29957.94] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Absence of urokinase from the United States market for the past 4 years has resulted in increasing experience with other plasminogen activators in catheter-directed thrombolytic therapy. The differences in the pharmacologic properties and biologic behavior of these agents may translate into clinical outcomes that are distinct. Some of these manifestations can be predicted based on the existing large clinical trials in the acute myocardial infarction literature. However, because of the fundamental differences in techniques and thrombolytic regimens, extrapolation of the coronary data may not always predict the performance of these agents in peripheral catheter-directed fibrinolysis. In this article, the current status of the available lytic agents in the treatment of limb ischemia is reviewed.
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Affiliation(s)
- Mahmood K Razavi
- Department of Vascular and Interventional Radiology, Stanford University Hospital, H3651 Vascular Center, 300 Pasteur Drive, Stanford, CA 94305, USA.
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