Multi-factor analysis of failure for modified single-session Angiojet rheolytic thrombectomy in treatment of acute iliofemoral venous thrombosis from iliac vein compression syndrome

PURPOSE

To explore the risk factors of failure for modified single-session Angiojet rheolytic thrombectomy combined with directed iliac vein stenting, directed filter retrieval in the treatment of iliac vein compression with iliofemoral vein thrombosis.

METHODS

During September 2017 to September 2021, 278 patients with DVT were retrospectively analyzed and 203 were eligible for inclusion. All patients were tried to take modified single-session Angiojet rheolytic thrombectomy combined with directed iliac vein stenting, directed filter retrieval treatment. The perioperative factors were analyzed between groups: group 1-modified single-session therapy succeed, and group 2-modified single-session therapy failed. The high risk factors of failure group were evaluated by logistic regression analysis.

RESULTS

48 patients failed in modified single-session therapy, up to 23.64%. Single factor analysis indicated that there were five independent risk factors related with the failure (p < 0.05), including course of disease longer than 7 days, lumbar degeneration-related iliac vein compression syndrome (dIVCS), antegrade vein access, balloon-assisted cracking thrombus, and suction time. Logistic regression analysis indicated that course of disease longer than 7 days (OR = 19.642.95%CI:6.776∼56.933), dIVCS (OR = 11.586.95%CI:4.016∼33.427) were high risk factors for modified single-session therapy failed, antegrade vein access (OR = 0.171.95%CI:0.047∼0.614) and balloon-assisted cracking thrombus (OR = 0.157.95%CI:0.045∼0.542) were protective factors for therapy failure (p < 0.05).

CONCLUSIONS

Long course of disease and dIVCS are the high risk factors for failure of modified single-session Angiojet rheolytic thrombectomy combined with directed iliac vein stenting, directed filter retrieval in the treatment of iliac vein compression syndrome (IVCS). But, antegrade vein access and balloon-assisted cracking thrombus intraoperatively may improve the success rate of modified single-session treatment.

Impact of the Result of Continued Thrombolysis After Stenting Following Pharmacomechanical Thrombectomy for Iliofemoral Deep Vein Thrombosis-A Retrospective Study

Objective

The aim of this study is to compare the procedure and treatment outcomes of using either direct stenting alone following pharmacomechanical thrombectomy or continued catheter-directed thrombolysis after stenting for treatment of acute left iliofemoral deep vein thrombosis while clot removal degree achieved grade III.

Methods

From March 2018 to May 2019, 82 patients who underwent iliac venous stenting for treatment of acute left iliofemoral deep vein thrombosis with iliac vein stenosis after pharmacomechanical thrombectomy therapy using the AngioJet system while Clot removal degree achieved grade III were divided into two groups: Direct stenting alone group (n = 39) and continued catheter-directed thrombolysis after stenting group (n = 43). Comparisons were made regarding the treatment outcomes, stent patency rate, and Villalta scale between these two groups.

Results

No serious perioperative complications occurred. The mean urokinase dose and hospitalization time in the stenting alone group and continued catheter-directed thrombolysis after the stenting group were 0.30 million U versus 1.76 ± 0.54 million U and 4.85 ± 0.93 days versus 6.33 ± 1.02 days, (P < .001). In the first 30 days after the operation, there were 3 recurrent episodes of deep vein thrombosis in the stenting alone group (P = 0.064). Each patient has completed at least one year of follow-up, the mean follow-up was 15.95 ± 3.44 months. Overall cumulative stent patency rates were 87.2% in stenting alone group and 97.7% in continued catheter-directed thrombolysis after stenting group at 12months (P = 0.037). The Villalta scores at 12 months had a significant difference between the two groups. The mean Villalta scores in the stenting alone group and continued catheter-directed thrombolysis after the stenting group were 4.44 ± 1.63 and 1.63 ± 1.29, respectively (P < 0.001).

Conclusion

When the clot removal degree of pharmacomechanical thrombectomy thrombectomy reaches grade III, both stenting alone and continued catheter-directed thrombolysis after stenting are effective treatment modalities. For young patients with low bleeding risk, continued catheter-directed thrombolysis after stenting has a better patency rate and a lower 1-year post-thrombotic syndrome risk and does not increase major bleeding events. However, it may increase the time and costs of hospitalization accordingly.

A retrospective comparison of thrombectomy followed by stenting and thrombectomy alone for the management of deep vein thrombosis with May-Thurner syndrome

OBJECTIVE

To summarize the clinical results of thrombectomy with stenting (TBS) in patients with deep venous thrombosis (DVT) secondary to May-Thurner syndrome (MTS) compared with the outcomes in patients treated with thrombectomy alone (TB).

METHODS

A retrospective observation of patients with proximal DVT secondary to MTS was conducted in our institution. Patients accepted treatment including either catheter-directed TBS or TB. The complications and stent patency rates were recorded after treatments. The clinical results were assessed in both groups. The independent predictors for in-stent restenosis were further calculated in this study.

RESULTS

We included 372 patients with DVT secondary to MTS. Two hundred twenty-one patients received treatment with thrombectomy with TBS and 151 with TB. A longer mean procedure time (65.1 ± 13.9 minutes vs 49.5 ± 15.7 minutes; P < .001) and higher venous perforation rate (23 patients vs 5 patients; P = .011) were observed in the TBS group than in the TB group. The median follow-up time was 34 months. The patency rates in the TBS group at 36 months were as follows: primary patency rate of 74.0% and secondary patency rate of 92.1%. Independent predictors for restenosis included visible remaining collateral vessels (hazard ratio [HR], 1.12-3.29; P = .02), residual thrombus (HR, 1.40-4.38; P = .002), and tapered iliac vein (HR, 1.26-4.06; P = .006). Clinical results, including Venous Clinical Severity Scores (TBS, 8.0 ± 3.0; TB, 11.4 ± 3.2), Chronic Venous Insufficiency Questionnaire score (TBS, 76.4 ± 4.0; TB, 83.1 ± 4.6), Villalta scores (TBS, 3.8 ± 1.7; TB, 6.6 ± 3.2), and edema scores (TBS, 0.7 ± 0.7; TB, 1.6 ± 0.6), improved significantly in the TBS group.

CONCLUSIONS

TBS is effective and feasible for patients with proximal DVT secondary to MTS. Furthermore, compared with TB, additional stenting might be effective in improving the venous clinical results at follow-up observations.

Critical Review of Large Animal Models for Central Deep Venous Thrombosis

OBJECTIVE

To review the existing literature on large animal models of central venous thrombosis (CVT) and to evaluate its relevance in regard to the development and testing of dedicated therapeutics applicable to humans.

METHODS

A systematic literature search was conducted in PubMed and Embase. Articles describing an in vivo experimental protocol of CVT in large animals, involving the iliac vein and/or the vena cava and/or the brachiocephalic vein, were included. The primary aim of the study, animal characteristics, experimental protocol, and thrombus evaluation were recorded.

RESULTS

Thirty-eight papers describing more than 30 different protocols were included. Animals used were pigs (53%), dogs (21%), monkeys (24%), and cattle (3%). The median number of animals per study was 12. Animal sex, strain, and weight were missing in 18 studies (47%), seven studies (18%), and eight studies (21%), respectively. CVT was always induced by venous stasis: solely (55%), or in addition to hypercoagulability (37%) or endothelial damage (10%). The size of the vessel used for thrombus creation was measured in four studies (10%). Unexpected animal death occurred in nine studies (24%), ranging from 3% to 37% of the animals. Twenty-two studies (58%) in the acute phase and 31 studies in the chronic phase (82%) evaluated the presence or absence of the thrombus created, and its occlusive characteristic was reported, respectively, in five and 17 studies. Histological examination was performed in 24 studies (63%) with comparison to human thrombus in one study.

CONCLUSION

This review showed advantages and weaknesses of the existing large animal models of CVT. Future models should insist on more rigour and consistency in reporting animal characteristics, as well as evaluating and comparing the thrombus created to human thrombus.

Diagnosis and Treatment of Nonthrombotic Right Iliac Vein Compression Syndrome

BACKGROUND

The anatomical etiology of right iliac vein compression syndrome (RIVCS) differs from that of left iliac vein compression syndrome. This study aimed to investigate the clinical features and therapeutic characteristics of RIVCS.

METHODS

Sixteen patients with nonthrombotic RIVCS were admitted to our hospital from May 2013 to July 2017. All patients underwent computed tomography venography (CTV) examinations of the right lower limb, which indicated that the right iliac veins were compressed by extrinsic structures. RIVCS was divided into 3 types according to the CTV findings. Stenting was conducted in patients with the appropriate indications. The superficial varicose veins in the lower limbs were simultaneously treated during endovascular treatment in a compound operating room. Antiplatelet therapy was administered after discharge.

RESULTS

Most RIVCS cases were types II and III, and the most frequently compressed segments were the middle and distal parts of the iliac vein. Most stents did not require stretching into the inferior vena cava and therefore seldom affected contralateral blood flow. Fifteen patients required stenting; the diameters of the stents ranged from 10 to 16 mm. All symptoms were alleviated, and the ulcers healed postoperatively. The remaining single patient with superficial varicose veins did not have an indication for endovascular therapy. During follow-up, all patients were symptom free, and the stents showed excellent patency.

CONCLUSIONS

CTV is a simple, accurate, and important method for diagnosing RIVCS. Endovascular therapy is an effective therapeutic method for RIVCS. Compared with the left side, stent implantation for RIVCS is safer and has fewer effects on contralateral blood flow.

Strategies for the diagnosis and treatment of the iliac vein compression syndrome

Aim

To evaluate the diagnosis and treatment strategies for the iliac vein compression syndrome (IVCS) and the factors that affect the treatment outcome.

Methods

In total, 69 patients with IVCS were enrolled in the study. The patients underwent computed tomography (CT) venography before treatment. CT observations included assessment of the iliac venous channel sagittal diameter (IVCD) before the lower lumbar vertebra, causes of oppression, thrombus density, and embolization range. The patients with IVCS were divided into the simple IVCS (sIVCS, n = 22), lumbar degeneration-related type IVCS (dIVCS, n = 33), and IVCS of other causes (oIVCS, n = 14) including lumbar fracture, hematoma of infection, and abscess wraping around and compressing the iliac vein, groups. The treatment methods included target venous catheter-directed thrombolysis (CDT), a mechanical breaking and sucking treatment for the thrombi, followed by balloon dilatation and iliac vein stent implantation. The factors that may possibly affect the treatment outcomes included IVCS type, duration of disease, thrombus hardness, embolization length, and treatment regimen. Logistic regression was used to analyze the factors that affected the therapeutic efficacy.

Results

At the first stage, CDT was only effective in 15 cases (5 dIVCSs and 10 oIVCSs) and was ineffective in the remaining 54 cases, which required further mechanical breaking and sucking of the thrombi and intravenous balloon dilatation. In the second stage, combination of thrombi breaking and suction and balloon dilatation was preliminarily effective in 26 cases (6 sIVCSs, 16 dIVCSs and 4 oIVCSs), but during follow-up from 1 to 6 months, treatment was considered futile for 9 recurrent cases (3 sIVCSs and 6 dIVCSs). So, 28 cases of preliminary ineffective treatment and 9 relapse in the second stage were arranged to the third stage of treatment by iliac vein stent implantation. All 37 cases were treated effectively and achieved a satisfactory iliac vein patency, and were followed-up for 24 months without recurrence. Logistic regression analysis showed that IVCS type (β = 4.14; Wald test, P < 0.01), duration of illness (β = -5.33; Wald test, P = 0.02), thrombus density (β = -6.46; Wald test, P = 0.01), embolization length (β = 2.74; Wald test, P = 0.03), and treatment regimens (β = 11.92; Wald test, P = 0.01) all had a significant effect on the treatment outcomes.

Conclusion

The selection of a suitable intervention treatment regimen for different types of IVCS may aid in improving the curative effect.

Use of Computed Tomography and Magnetic Resonance Imaging in Central Venous Disease

Successful management of acute deep vein thrombosis and post-thrombotic syndrome depends on careful patient selection and detailed investigation of thrombus extent, composition, and anatomy. This article reviews the use of computerized tomography and magnetic resonance imaging in the assessment of central deep veins of the pelvis and addresses new developments within the field. Despite drawbacks of each imaging modality, when contemplating deep venous reconstruction, cross-sectional imaging should be considered for preoperative planning and to compliment intraoperative imaging tools, including intravascular ultrasound and contrast venography.

Re-intervention for occluded iliac vein stents

Iliac vein stenting has become more frequent with improved diagnostic capabilities of intra-vascular ultrasound (IVUS) for recognizing May-Thurner syndrome, chronic venous insufficiency (CVI) and thrombus. In this manuscript, we discuss the reasons for initial stenting, with long-term outcomes and some of the associated pitfalls. The best techniques for re-intervention when iliac stents become occluded will also be discussed.

Underlying Anatomy and Typing Diagnosis of May-Thurner Syndrome and Clinical Significance: An Observation Based on CT

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To explore the underlying anatomy of May-Thurner syndrome (MTS) using computed tomography (CT) and discuss its clinical significance for typing diagnosis.

SUMMARY OF BACKGROUND DATA

Because the anatomical position of the corpse cannot fully illustrate the actual clinical situation in vivo, the diversity of MTS has not been fully elucidated yet.

METHODS

We retrospectively analyzed the data of 69 patients with MTS. By CT showing, patients were categorized to simple MTS (sMTS, 22 patients), lumbar degeneration-related MTS (dMTS, 33 patients) and other causes MTS (oMTS, 14 patients); meanwhile, a healthy control group were set. Evaluated indexes were onset age, course of disease, diameter of the iliac vein tunnel (IVTD), lumbar degeneration-related iliac vein compression (IVC), therapeutic effect, and diagnostic cutoff of risk IVTD prone to MTS.

RESULTS

The onset age of sMTS, dMTS, and oMTS were respectively 42.3 ± 6.5 years, 61.5 ± 10.6 years, and 53.1 ± 16.8 years (P < 0.001); courses were respectively 12.1 ± 9.2 days, 22.5 ± 7.6 days, and 6.8 ± 6.7 days (P = 0.002). IVTDs of sMTS, dMTS, oMTS, and the control were respectively 2.52 ± 0.50 mm, 2.29 ± 0.30 mm, 5.93 ± 2.21 mm, and 4.34 ± 1.61 mm (P < 0.001). Lumbar degeneration-related IVC in dMTS occurred at 41 places, including forward bulging or protruding intervertebral discs (51%,17/33), osteophytes (50%,16/33), and spondylolisthesis (19%, 8/33), but none happened in sMTS, oMTS, and the control. Eighty-six percent of sMTSs, 55% dMTSs, and none oMTSs needed intravenous stent-implanted operation to obtain effective treatment. MTS type (Waldχ = 6.092, P = 0.009), course (Waldχ = 4.618, P = 0.032), and treatment plan (Waldχ = 14.748, P < 0.001) markedly influence the therapeutic result. The cutoff of risk IVTD for sMTS and dMTS was 2.98 mm, which diagnostic sensitivity was 90% and specificity 100%.

CONCLUSION

Owing to the distinct pathoanatomy and causes, diagnosis in classification of MTS by CT is helpful in accurate treatment program.

LEVEL OF EVIDENCE

3.

Contemporary management of acute and chronic deep venous thrombosis

INTRODUCTION

This review aims to provide an update on the management of deep vein thrombosis (DVT).

SOURCES OF DATA

A systematic search of PubMed, Google Scholar and Cochrane databases was carried out.

AREAS OF AGREEMENT

Direct oral anticoagulants (DOACs) are as effective and easier to use than vitamin K antagonists for the treatment of DVT. Catheter-directed thrombolysis can reduce post thrombotic syndrome in patients with iliofemoral DVT. Compression bandaging can help heal a venous ulcer.

AREAS OF CONTROVERSY

Compression hosiery to prevent post thrombotic syndrome. Long-term evidence to show clinical benefit of using endovenous therapies to restore deep vein patency.

GROWING POINTS

Developing imaging methods to identify patients who would benefit from venous thrombolysis. The evolution of dedicated venous stents.

AREAS TIMELY FOR DEVELOPING RESEARCH

Understanding the mechanisms that lead to stent occlusion and investigation into the appropriate treatments that could prevent in-stent thrombosis is required.

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.

Which criteria demand additive stenting during catheter-directed thrombolysis?

Many factors are necessary for obtaining satisfactory results after catheter-directed thrombolysis (CDT) for iliofemoral deep venous thrombosis (DVT). Selections of patients, composition of the thrombolytic fluid, anticoagulation per- and post-procedural, recognition and treatment of persistent obstructive lesions of the iliac veins are the most important contributors. Stenting has been known for 15 to 20 years. The first publication on CDT in 1991 was combined with ballooning the iliac vein, an additive procedure which has been abandoned as an isolated procedure. This chapter will discuss selection, indication, such as an iliac compression syndrome, and outcome of iliac stenting in combination with CDT. The reported frequency of stenting used after CDT is very inconsistent, therefore this will be discussed in details. It is concluded that selection for stenting is of the greatest importance, when CDT is used for iliofemoral DVT, but strict criteria for stenting are not available in the existing literature. The potential value of intravascular ultrasound (IVUS) is also discussed.