Endovascular Treatment Options in the Management of Lower Limb Deep Venous Thrombosis

Novel Deep Sea Isoindole Alkaloid FGFC1 Exhibits Its Fibrinolytic Effects by Inhibiting Thrombin-Activatable Fibrinolysis Inhibitor

BACKGROUND

The thrombin-activatable fibrinolysis inhibitor (TAFI) is an important regulator in the balance between blood clot formation (coagulation) and dissolution (fibrinolysis), which is mainly activated by thrombin bonded with thrombomodulin (TM).

METHODS

In this study, the investigation focused on the unique target TAFI of fungi fibrinolytic compound 1 (FGFC1), a novel fibrinolytic compound sourced from the deep sea. In this sense, the regulation of TAFI by FGFC1, in comparison to established TAFI inhibitors such as DS-1040 and PCTI in hPPP, was investigated, which was validated through the molecular docking of FGFC1 to TAFI. The inhibitory effect of FGFC1 on TAFI-mediating coagulation (ex vivo and in vitro) and its fibrinolytic effect (ex vivo) were investigated in hPPP and hCMEC/D3 cells, respectively, followed by SEM.

RESULTS

FGFC1 solutions ranging from 0.023 to 0.736 mM effectively inhibited TAFI activation. Notably, the 0.023 mM concentration demonstrated significant suppression, comparable to DS-1040 and PCTI. These inhibitory effects of FGFC1 (0.023-0.368 mM) were further validated through the enhancement in TAFI (TAFIa) activation by fibrins in the coagulum prior to proteolysis, resulting in the cleavage of TAFIa from 33 kDa to 28 kDa. Furthermore, these regulatory effects of FGFC1 on TAFI were demonstrated to have minimal association with TM-mediated control, as confirmed through a molecular docking analysis. FGFC1 (0.023-0.092 mM) was suggested to have obstructive effects on TAFI-mediated coagulation in the hPPP, which was demonstrated by the inhibition of clot aggregation, protein crystallization, and platelet anchoring, as observed through SEM. Simultaneously, FGFC1 (0.023 to 0.368 mM) significantly enhanced TAFI-mediated fibrinolysis, which was also supported by increased levels of t-PA, u-PA, and plasmin.

CONCLUSIONS

From the above findings, FGFC1 is identified as a novel dual-target bioactive compound participating in blood formation/dissolution that demonstrates anti-coagulation and fibrinolytic effects by regulating TAFI activation, inhibiting TAFIa-fibrin combination, and initiating proteolysis. It also provided convincing evidence that TAFI plays a critical role in thrombolysis as a molecular link between coagulation and fibrinolysis. Furthermore, the application of FGFC1 was indicated as a potential therapeutic strategy in thromboembolic and hemorrhagic diseases.

Predictive factors for iliac vein compression syndrome in patients with varicose veins

OBJECTIVE

This study aimed to identify predictors of iliac vein compression syndrome (IVCS) in patients with varicose veins and to evaluate the necessity of routine lower extremity venography for preoperative assessment of these patients.

METHODS

A retrospective analysis was conducted on data from 1165 patients with lower-limb varicose veins who underwent preoperative venography at Wuhan Union Hospital, Tongji Medical College, China, between January 2019 and September 2023. Logistic regression analyses identified factors associated with concurrent IVCS, and a nomogram was constructed based on these findings.

RESULTS

Out of 1165 patients, 75 (6.4%) had IVCS according to venography and 769 had iliac vein ultrasound and found 2 (0.17%) positives. Multivariate analysis revealed the independent predictive value of left-sided involvement (odds ratio (OR) = 3.22, 95% confidence interval (CI): 1.24-8.33, p = 0.016), history of deep vein thrombosis (DVT) in the affected limb (OR = 3.11, 95% CI: 1.21-8.00, p = 0.018), pain (OR = 2.24, 95% CI: 1.17-4.26, p = 0.014), and positive results on iliac vein ultrasound (OR = 25.56, 95% CI: 2.10-311.26, p = 0.011) for the presence of IVCS in patients with lower-limb varicose veins. A nomogram incorporating these predictors demonstrated moderate predictive ability (AUV = 0.689, 95% CI: 0.607-0.771), with good calibration upon validation.

CONCLUSIONS

Patients with left lower extremity varicose veins, pain symptoms, history of DVT in the affected limb, and positive iliac vein ultrasound findings are at a higher risk of concurrent IVCS. Patients with varicose veins who have the aforementioned risk factors may need to undergo preoperative angiography.

Prevalence and outcomes of heparin-induced thrombocytopenia in hospitalized patients with venous thromboembolic disease: Insight from national inpatient sample

OBJECTIVE

The mainstay of therapy for patients with venous thromboembolic disease (VTE) is anticoagulation. In the inpatient setting, majority of these patients are treated with heparin or low molecular weight heparin. The prevalence and outcomes of heparin-induced thrombocytopenia (HIT) in hospitalized patients with venous thromboembolic disease (VTE) is unknown.

METHODS

This nationwide study identified patients with VTE from the National Inpatient Sample database between January 2009 and December 2013. Among these patients, we compared in-hospital outcomes of patients with and without HIT using a propensity score-matching algorithm. The primary outcome was in-hospital mortality. Secondary outcomes included rates of blood transfusions, intracranial hemorrhage, gastrointestinal bleed, length of hospital stay, and total hospital charges.

RESULTS

Among 791,932 hospitalized patients with VTE, 4948 patients (0.6%) were noted to have HIT (mean age, 62.9 ±16.2 years; 50.1% female). Propensity-matched comparison showed higher rates of in-hospital mortality (11.01% vs 8.97%; P < .001) and blood transfusions (27.20% vs 20.23%; P < .001) in patients with HIT compared with those without HIT. No significant differences were noted in intracranial hemorrhage rates (0.71% vs 0.51%; P > .05), gastrointestinal bleed (2.00% vs 2.22%; P > .05), length of hospital stay (median, 6.0 days; interquartile range [IQR], 3.0-11.0 vs median, 6.0 days; IQR, 3.0-10.0 days; P > .05), and total hospital charges (median, $36,325; IQR, $17,798-$80,907 vs median, $34,808; IQR, $17,654-$75,624; P > .05).

CONCLUSIONS

This nationwide observational study showed that 0.6% of hospitalized patients with VTE in the United States have HIT. The presence of HIT was associated with higher in-hospital mortality and blood transfusion rates compared with those without HIT.

Predictors of long-term outcomes after catheter-directed thrombolysis combined with stent implantation in acute deep vein thrombosis secondary to iliac vein compression

The purpose of this study is to analyze predictive factors for long-term clinical outcomes after catheter-directed thrombolysis (CDT) combined with stent implantation for acute deep vein thrombosis (DVT) secondary to iliac vein compression (IVC). A retrospective analysis was performed to review clinical data and follow-up information on 52 patients who underwent CDT combined with stent implantation for acute DVT secondary to IVC from June 2015 to March 2020. Clinical outcomes including stent patency and incidence of postthrombotic syndrome (PTS) were investigated using Kaplan-Meier analysis. All included patients were categorized into 2 groups according to the presence of PTS. Potential risk factors, including age, gender, degree of iliac vein stenosis, time from onset to treatment, dosage of thrombolytic agent, stent extending below the inguinal ligament, and duration of anticoagulation for PTS were evaluated using multivariate logistic regression analysis. Over a median follow-up of 24 months, 4 individuals underwent reintervention due to in-stent stenosis or stent compression. Primary stent patency was 98.1% at 1 month, 94.2% at 6 months, 90.4% at 12 months, and 88.5% at 24 months. Freedom from PTS was 98.1% at 6 months, 84.6% at 12 months, and 75% at 24 months. No treatment-related mortality or morbidity was observed. Based on the development of PTS, 13 patients with PTS were classified into group A and 39 patients without PTS were regarded as group B. Upon multivariate logistic regression analysis, key prognostic factors for PTS were degree of iliac vein stenosis and time from onset to treatment. CDT combined with stent implantation is safe and effective for acute DVT secondary to IVC in the long-term perspective. Severe iliac vein stenosis and longer period from onset to treatment may be associated with a higher risk of PTS.

Effectiveness of Venous Stenting for the Treatment of Lower Extremity Chronic Thrombotic Venous Obstruction

BACKGROUND

Patients with venous hypertension (HTN) have significant morbidity and poor quality of life. Deep venous thrombosis (DVT) and congenital defects that led to chronic outflow blockage are frequent causes of venous HTN. It is known that the venovenous bypass has been the standard method used in the treatment of chronic iliofemoral vein occlusions. Percutaneous recanalization has earlier been shown to be technically possible. With venoplasty and stenting, we used an aggressive endovascular strategy to treat the iliofemoral venous thrombotic occlusion.

METHODS

From May 2019 to April 2021, the medical records were reviewed for 63 patients diagnosed with symptomatic iliofemoral thrombotic occlusive disease and treated with venous stenting. The procedures' results were analyzed at Al-Azhar University Hospitals.

RESULTS

The medical records of 63 cases (44 women with a median age of 49.52 years), with chronic outflow block of iliofemoral vein segment that were treated with endovascular venous stenting, were reviewed retrospectively. Optimal success was obtained in 56 cases (88.9%). The twelve-month primary, assisted primary, and secondary patency rates were 76.8%, 80.4%, and 87.5%, respectively, while it was 73.2%, 80.4%, and 87.5%, respectively, after 2 years. The procedure-related complication rate was 6.3%. Puncture site hematoma was observed in 2 patients (3.2%). Early (30 days) stent thrombosis occurred in 2 patients (3.2%). Most importantly, there was no procedure-related mortality.

CONCLUSIONS

Endovascular treatment with balloon angioplasty and stenting of chronic venous thrombotic occlusions is an effective and safe procedure associated with a high technical rate of success and excellent patency rates. Accordingly, it should be considered the first line in the treatment of symptomatic iliofemoral vein occlusion.

Post-thrombotic Syndrome: Preventative and Risk Reduction Strategies Following Deep Vein Thrombosis

Venous disease is common in the general population, with chronic venous disorders affecting 50–85% of the western population and consuming 2–3% of healthcare funding. It, therefore, represents a significant socioeconomic, physical and psychological burden. Acute deep vein thrombosis, although a well-recognised cause of death through pulmonary embolism, can more commonly lead to post-thrombotic syndrome (PTS). This article summarises the pathophysiology and risk factor profile of PTS, and highlights various strategies that may reduce the risk of PTS, and the endovenous management of iliofemoral deep vein thrombosis. The authors summarise the advances in PTS risk reduction strategies and present the latest evidence for discussion.

Safety and Efficacy of Aspiration Thrombectomy or Pharmacomechanical Thrombectomy after Catheter-Directed Thrombolysis for the Treatment of Acute Iliofemoral Deep Vein Thrombosis

PURPOSE

To evaluate the safety and efficacy of additional aspiration thrombectomy (AT) or pharmacomechanical thrombectomy (PMT) after catheter-directed thrombolysis (CDT) for the treatment of acute iliofemoral deep vein thrombosis (AIFDVT).

MATERIALS AND METHODS

Between May 2017 and December 2018, 40 patients with AIFDVT were enrolled. Twenty underwent AT after CDT (CDTAT), while the remaining 20 underwent PMT using an AngioJetTM device after CDT (CDTPMT). Thrombus clearance was assessed using computed tomography venography at 1 week after the procedure, as follows: grade I, ≤50%; grade II, 51% to 75%; grade III, >75%. Grade III was considered a successful outcome. Treatment outcomes (thrombus clearance, thrombolytic therapy duration, urokinase dose, major complications, residual filter thrombosis, and Villalta score) were compared between the groups.

RESULTS

Successful thrombus clearance was achieved in 95% of the patients in both groups. Significant decreases in the thrombolytic therapy duration (P=0.018) and urokinase dose (P=0.014) were noted in the CDTPMT group. Major complications were not noted in both groups. Residual filter thrombi >10 mm were found in 6 filters in the CDTAT group and in 1 filter in the CDTPMT group (P=0.038). The Villalta scores at 6 months were 1.47±1.24 and 1.12±0.92 in the CDTAT and CDTPMT groups, respectively (P=0.372).

CONCLUSION

Both methods may be safe and effective management options for patients with AIFDVT. CDTPMT can reduce urokinase dosage, time and remained filter thrombus compared to CDTAT. Studies conducted in the future should compare the effects of overnight CDT followed by PMT with those of single-session PMT on patients with AIFDVT.

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.

Endovenous Intervention of May-Thurner Syndrome with Thrombus beyond Iliac Vein Stenosis

Purpose

With the increase in the incidence of venous thrombosis, interest in May-Thurner syndrome (MTS) accompanying iliac vein compression has increased. Some patients with MTS have inferior vena cava thrombosis or thrombosis beyond iliac vein stenosis (TBIVS). This study aimed to identify the characteristics of MTS with TBIVS including pulmonary embolism (PE) and post-thrombotic syndrome (PTS) compared to those of MTS without TBIVS.

Materials and Methods

Thirty-five patients with deep vein thrombosis associated with MTS were treated between March 2012 and February 2016. Demographic data, medical history, computed tomography findings (iliac vein size of stenosis and stenotic ratio compared with the other side), and clinical outcomes (preoperative PE and PTS) were retrospectively collected and reviewed by dividing into groups with or without TBIVS.

Results

Eight of the 35 patients with MTS had TBIVS. The group with TBIVS had a statistically significantly greater iliac vein size (P<0.001) and ratio (P=0.001). PE was more prevalent in the group with TBIVS (63% vs. 15%, P=0.007). However, no statistically significant intergroup difference in PTS prevalence was found.

Conclusion

The presence of mild iliac vein stenosis in MTS can be used to predict TBIVS and the requirement for more attention to PE.

May-Thurner Syndrome with Large Abdominal Varicosity, Treated Successfully Using Multiple Approaches

May-Thurner syndrome (MTS) is a venous outflow obstruction disorder characterized by compression of the left common iliac vein by an overriding right common iliac artery. MTS primarily affects young to middle-aged women, although many patients remain entirely asymptomatic. Anatomic variations of MTS, while uncommon, have been described. Treatment usually involves endovascular management, including thrombolysis and/or thrombectomy with or without inferior vena cava filter placement, followed by angioplasty and stenting of the left common iliac vein. We report a unique case of a 31-year-old woman who presented with MTS-related deep vein thrombosis accompanied by symptomatic abdominal and pelvic varicosities. The varicosities were treated successfully using multiple procedures, resulting in complete resolution of all symptoms. Our case discusses a treatment approach for an unusual presentation of MTS-related postthrombotic syndrome, and provides a brief literature review of MTS complications and management.

Effects of Inhalation Anesthesia vs. Total Intravenous Anesthesia (TIVA) vs. Spinal-Epidural Anesthesia on Deep Vein Thrombosis After Total Knee Arthroplasty

Background

The objective of the present study was to evaluate the varying efficacy of general anesthesia (GA), combined spinal-epidural anesthesia (CSEA), and total intravenous anesthesia (TIVA) on the occurrence of deep vein thrombosis (DVT) following total knee arthroplasty (TKA).

Material/Methods

From July 2013 to May 2015, a total of 197 cases of patients who had undergone TKA treatment at either the Drum Tower Hospital or Nanjing General Hospital of Nanjing Military Command were recruited to participate in the study. The patients in the study were separated into 3 groups depending on the anesthesia approach received: the GA group, the CSEA group, and the TIVA group. The baseline characteristics and relative parameters of patients were monitored before and after surgery for analytic purposes. A 3-month follow-up after surgery was conducted to observe the rate of DVT occurrence and any DVT-related complications.

Results

The TIVA group exhibited significant decreases in relation to the swallowing time reflex, extubation, and consciousness recovery in comparison to other groups in the study. Additionally, platelet count was significantly decreased and there was drastic extension of the activated partial thromboplastin time (APTT) in the CSEA group and the TIVA group. There were clear differences in the incidence of DVT and its complications among the 3 groups. The TIVA group displayed the lowest incidences of DVT and DVT-related complication during the study. Based on logistic regression analysis, the type of anesthesia was utilized as an independent correlative factor for the occurrence of DVT after surgery.

Conclusions

The results obtained during the study established a clinical basis for comparative analysis of various anesthesia methods. We found that, compared with GA and CSEA, patients undergoing TIVA had a reduced rate of risk in relation to the occurrence of DVT following TKA.

Pharmacomechanical Thrombolysis for Deep Vein Thrombosis in May-Thurner Syndrome

Objective

Patients with May-Thurner syndrome presenting with acute deep vein thrombosis benefit from early lysis of clot and endovascular treatment. We evaluated the outcome of patients with May-Thurner syndrome who presented with deep vein thrombosis, managed with pharmacomechanical thrombolysis as the primary mode of intervention, in combination with angioplasty and stent placement.

Methods

We reviewed all patients with May-Thurner syndrome managed in our institution between January 2009 to December 2015. Patency rate and postthrombotic syndrome were evaluated as primary end points.

Results

A total of seven patients (6 females, 1 male) with a mean ± SD age of 48 ± 17 years and mean ± SD body mass index of 29.64 ± 7.25 kg/m2 were identified. Six patients presented with acute deep vein thrombosis and one presented with chronic venous insufficiency. Five patients underwent pharmacomechanical thrombolysis (TRELLIS and altepase) with concomitant stenting of the common iliac vein, one had only angioplasty with stent placement, and one had only pharmacomechanical thrombolysis. Median time from presentation to pharmacomechanical thrombolysis was 4 days (range = 1–9). Patency rate and postthrombotic syndrome at 12 months were 100% and 0%, respectively. No patient experienced major bleeding or pulmonary embolism. The median length of stay was 3 days (range = 0–4). There was no mortality associated with the procedure. The mean ± SD follow-up was 26 ± 15 months.

Conclusions

In patients with May-Thurner syndrome, pharmacomechanical thrombolysis is an effective approach for the management of acute deep vein thrombosis, decreasing thrombus burden, and long-term postthrombotic syndrome when used in conjunction with stenting.

Iatrogenic IVC Perforation after Successful Catheter-Directed Thrombolysis

Central vein perforation as a rare complication of venous interventions is considered a nightmare if occurring in thoracic cage but behaves benignly in abdominal or pelvic region. This is not a rule, as we unfortunately encountered during the procedure of venous intervention in our patient. Although mechanical control of iatrogenic perforation or rupture is the first and most critical step during interventional procedures, the importance of anticoagulant and thrombolytic agents reversal should not be overlooked.

[Diagnostics and endovascular treatment of venous diseases]

In venous disease, acute thromboses and chronic venous insufficiency have the highest health economics relevance. Duplex sonography is the first line diagnostic assessment tool, while cross-sectional imaging is employed as a supplementary method. Due to the availability and examination times computed tomography is preferred in the emergency setting and is supplemented by magnetic resonance imaging (MRI) for specific questions. Endovascular treatment procedures are increasingly becoming available in addition to classical conservative treatment methods.

A Rare Presentation of an Isolated Internal Iliac Artery Aneurysm: Report of a Case and Literature Review

Isolated internal iliac artery aneurysms (IIIAAs) are extremely rare. We present the case of a 75-year-old white Caucasian male patient admitted for right lower limb deep venous thrombosis and low-risk pulmonary embolism due to the compression of the external iliac vein from an IIIAA. A review of the literature was also performed to identify the epidemiologic, clinical characteristics and diagnostic and operative strategies of this disease. At present, a recommendation for the best operative strategy in the presence of an IIIAA is difficult. Our analysis demonstrated controversial results, but we are confident to recommend the endovascular treatment in an elective setting.

Feasibility of continuous, catheter-directed thrombolysis using low-dose urokinase in combination with low molecular-weight heparin for acute iliofemoral venous thrombosis in patients at risk of bleeding

The present study aimed to examine the feasibility of catheter-directed thrombolysis (CDT) using continuous infusion of low-dose urokinase in combination with low molecular weight heparin (LMWH) for acute iliofemoral venous thrombosis. This retrospective analysis included patients with symptomatic acute iliofemoral venous thrombosis who received CDT using continuous infusion of low-dose urokinase in combination with LMWH within the past four years. Urokinase was administered at 1×10⁴ U/h and 2×10⁴ U/h in patients at high-risk and low-risk of bleeding, respectively. Measurements included urokinase dosage, duration, clinical outcomes and CDT-related complications. A total of 46 patients were included (high-risk, n=17; low-risk, n=29). In the high-risk patients, 64.7% experienced dissolution of ≥50% thrombi after a median CDT duration of 8 days (range, 6-10 days) and median total urokinase dose of 1.92×10⁶ units (range, 1.44-2.4×10⁶ units). In the low-risk patients, 82.8% achieved dissolution of ≥50% thrombi after a median CDT duration of 7 days (range, 4-10 days) and a median total urokinase dose of 3.36×10⁶ units (range, 1.92-4.80×10⁶ units). Remission of clinical symptoms after CDT was achieved in 15 (88.2%) and 28 (96.6%) cases in high-risk and low-risk patients, respectively. No treatment-associated pulmonary embolism or major bleeding was observed. Three (6.5%) subjects (high-risk, n=1; low-risk, n=2) experienced minor bleeding. In conclusion, continuous infusion of low-dose urokinase via CDT in combination with LMWH is effective and safe for acute iliofemoral venous thrombosis in patients with one or more risk factor for bleeding.

Patency and Clinical Outcomes of a Dedicated, Self-Expanding, Hybrid Oblique Stent Used in the Treatment of Common Iliac Vein Compression

Purpose: To investigate the clinical outcomes of a dedicated hybrid oblique nitinol stent that has been specifically designed to treat common iliac vein compression. Methods: The Bern Venous Stent Registry database was interrogated to identify all patients who had at least 6-month follow-up after treatment with the sinus-Obliquus hybrid stent for common iliac vein compression. The search identified 24 patients (mean age 39±18 years; 20 women) who matched the search criteria. Ten patients had postthrombotic syndrome (PTS), another 10 patients had acute iliofemoral thrombosis after catheter-directed therapy, and 4 patients had nonthrombotic iliac vein compression. Primary treatment success was defined as antegrade flow and stenosis <30% on venography and evidence of a spontaneous Doppler signal in the treated segment. Stent patency was assessed using duplex ultrasound. Clinical outcomes were evaluated using a clinical symptom score (Villalta) and the revised venous clinical severity score (rVCSS) at 3, 6, and 12 months in follow-up. Results: Primary treatment success was achieved in all patients. Mean follow-up was 10±3 months. Primary patency estimates by Kaplan-Meier analysis were 92% at 6 months [95% confidence interval (CI) 71% to 98%] and 83% (95% CI 54% to 95%) at 10 months. Three symptomatic patients underwent reintervention for early and late stent thromboses and the third for in-stent restenosis, resulting in secondary patency of 100%. Overall, all patients had clinical improvement at the latest follow-up; 50% reported complete resolution of symptoms. In patients with PTS, the Villalta score decreased by 6±6 points (p=0.02) and the rVCSS score by 3±1 points (p=0.05). Among deep vein thrombosis patients, none developed PTS. Conclusion: In patients with common iliac vein compression, the oblique hybrid nitinol stent appears to provide excellent early patency and clinical outcomes.

Medical management of tumor lysis syndrome, postprocedural pain, and venous thromboembolism following interventional radiology procedures

The rapid expansion of minimally invasive image-guided procedures has led to their extensive use in the interdisciplinary management of patients with vascular, hepatobiliary, genitourinary, and oncologic diseases. Given the increased availability and breadth of these procedures, it is important for physicians to be aware of common complications and their management. In this article, the authors describe management of select common complications from interventional radiology procedures including tumor lysis syndrome, acute on chronic postprocedural pain, and venous thromboembolism. These complications are discussed in detail and their medical management is outlined according to generally accepted practice and evidence from the literature.

Endovascular Treatment of Iliac Vein Compression (May-Thurner) Syndrome: Angioplasty and Stenting with or without Manual Aspiration Thrombectomy and Catheter-Directed Thrombolysis

PURPOSE

May-Thurner syndrome (MTS) is a rare clinical entity featuring venous obstruction of the left lower extremity. The aim of the present study was to report our experience with MTS and to evaluate the utility of treatment using endovascular techniques.

MATERIALS AND METHODS

We retrospectively analyzed data on 23 MTS patients (21 females, two males; mean age 44 ± 15 years). Eighteen patients presented with deep vein thrombosis (DVT) and five with symptoms associated with chronic venous hypertension (CVH). DVT patients were treated via thromboaspiration, catheter-directed thrombolysis, and angioplasty; followed by stent placement. CVH patients were treated with angioplasty and stent placement alone. All patients were followed-up using Doppler ultrasonography and computed tomography venography.

RESULTS

Complete left common iliac vein patency was achieved in 21 of the 23 patients (technical success rate: 91,3%). Complete thrombolysis was attained by 14 of the 18 DVT patients (77.7%). The mean clinical and radiological follow-up time was 15.2 ± 16.1 months. Upon follow-up, complete symptomatic regression was observed in 19 of the 23 patients (82.6%). Stent patency was complete in 19 of the 21 patients (90.4%) who received stents. Restenosis occurred in two patients. No treatment-related mortality or morbidity was observed.

CONCLUSION

Endovascular treatment of MTS is safe and effective and reduces symptoms in most patients, associated with high medium-term patency rates.

Dimerized plasmin fragment D as a potential biomarker to predict successful catheter-directed thrombolysis therapy in acute deep vein thrombosis

Objectives

The value of dimerized plasmin fragment D in the clinical monitoring during the catheter-directed thrombolysis in patients with acute deep vein thrombosis is not known.

Methods

Dimerized plasmin fragment D levels in 24 patients with acute deep vein thrombosis undergoing catheter-directed thrombolysis were prospectively evaluated. The plasma dimerized plasmin fragment D level was measured serially before and at every 12 h during catheter-directed thrombolysis for 24 h. Technical success was defined as restoration of patency and flow with less than 50% residual thrombus by surveillance rotational venography.

Results

Technical success was achieved in 79.2% (19 of 24) of the treated limbs after catheter-directed thrombolysis. In univariate analysis, there was significant elevation of the dimerized plasmin fragment D at 12th h after starting the catheter-directed thrombolysis ( P < 0.05) in patients with less than 50% residual thrombus stenosis. The optimal cut-off value of dimerized plasmin fragment D to predict successful catheter-directed thrombolysis was determined as 18.4 µg/ml at the 12th h after starting the catheter-directed thrombolysis with sensitivity 0.8 and specificity 0.8 ( P = 0.03). It was further validated in multivariate logistic regression analysis (odds ratio: 14.38; 95% CI: 1.22–169.20; P = 0.03).

Conclusions

Catheter-directed thrombolysis is safe and effective for restoration of blood flow in patients with acute deep vein thrombosis. Dimerized plasmin fragment D value greater than 18.4 µg/ml at the 12th h after starting catheter-directed thrombolysis had a high predictive rate of greater than 50% lysis at the end of catheter-directed thrombolysis.

Pulmonary embolism and stroke associated with mechanical thrombectomy

Mechanical thrombectomy offers the advantage of rapid removal of venous thrombi. It allows venous obstructions to be removed and requires shorter duration of infusion of thrombolytic agents. However, aspiration of thrombi can lead to complications, particularly pulmonary embolism and hemolysis. The validity of using vena cava filters during thrombectomy in order to avoid embolism has not yet been established. The authors report a case of massive pulmonary embolism associated with ischemic stroke in a patient with a hitherto undiagnosed patent foramen ovale. The patient developed respiratory failure and neurological deficit after thrombectomy. This case raise questions about the value of the thrombectomy for the treatment of proximal vein thrombosis due to the risks of this procedure. The authors also discuss the need for vena cava filters and ruling out a patent foramen ovale in patients undergoing thrombectomy.

Percutaneous manual aspiration thrombectomy followed by stenting for iliac vein compression syndrome with secondary acute isolated iliofemoral deep vein thrombosis: a prospective study of single-session endovascular protocol

OBJECTIVE

To evaluate the feasibility, safety, and effectiveness of single-session endovascular treatment with manual aspiration thrombectomy (MAT) as the first-line method of thrombus removal for iliac vein compression syndrome (IVCS) with secondary acute isolated iliofemoral deep vein thrombosis (DVT).

METHODS

This was a prospective clinical study. Twenty-six patients (19 women, 7 men, mean age 54 years) with left-sided acute iliac-common femoral DVT secondary to IVCS were enrolled. All patients presented with leg swelling or pains. Endovascular treatment, consisting of MAT, balloon angioplasty, and stent placement, was performed in the same setting. Overnight antegrade thrombolysis was performed in patients with residual thrombus after MAT. Patients were followed up by ultrasonography. The mean follow-up period was 17.8 months (12-25 months).

RESULTS

Single-session endovascular procedures were performed successfully in all patients. The mean procedure time was 67 minutes (ranging from 45 to 90 minutes). Complete thrombus removal, including almost 100% of removal in 24 patients and little residual thrombus (<5%) in two, was achieved after repeated MAT. Thrombolysis was used in these two patients. Complete symptomatic relief was achieved in 25 patients (96%) and partial relief in one. The hospital stay ranged from 2 to 4 days (mean 2.7 days). Recurrent thrombosis within the stent was observed in one case and recanalized with thrombolysis. The 1-year primary and secondary patency rate was 96% and 100%, respectively. No symptomatic pulmonary embolization, bleeding, and venous reflux were observed. Five patients complained about transitory low back pains during balloon angioplasty.

CONCLUSION

Single-session endovascular treatment with MAT as the first-line thrombus removal method is feasible, safe, and effective for IVCS with secondary acute isolated iliofemoral DVT. Although limited, our experience suggests that patients thought to be at high risk of bleeding may be candidates for the present single-session endovascular protocol.

The association of septic thrombophlebitis with septic pulmonary embolism in adults

Background:

There have been an increasing number of pediatric reports of septic pulmonary embolism in the setting of septic thrombophlebitis adjacent to a primary infectious source.

Methods:

Retrospective review at an urban hospital. A total of five adults with a documented primary infectious source, adjacent septic thrombophlebitis and septic pulmonary embolism were identified between 2000 and 2011.

Results:

The predominant symptoms on presentation were fever and pleuritic chest pain, followed by chills and cough. S. aureus was the pathogen in 4 patients. Only one case had echocardiographic evidence of endocarditis. All patients received IV antibiotics and anticoagulation therapy. No new embolic events or central nervous system complications were noted.

Conclusions:

The triad of extrapulmonary infection, contiguous septic thrombophlebitis and septic pulmonary embolism is present in adult as well as pediatric populations. The use of systemic anticoagulation with appropriate antibiotics resulted in clinical and radiologic improvement but no significant complications.

[The role of thrombolysis in the clinical management of deep vein thrombosis]

Acute Deep Venous Thrombosis (DVT) therapies have been judged primarily on their ability to prevent symptomatic pulmonary embolism, early thrombus progression, and recurrent VTE. The cornerstones of current management of DVT, supported by the 2008 American College of Chest Physicians (ACCP) guidelines, are the routine use of anticoagulant therapy, graduated elastic compression stockings, and early ambulation. For selected appropriate patients with extensive acute proximal DVT, while the French recommendations (Afssaps 2009) still consider thrombolysis not indicated, ACCP guidelines now suggest in-situ thrombolysis in addition to anticoagulation to reduce the risk of subsequent postthrombotic syndrome (PTS) and recurrent DVT (Grade 2 B recommendation). Contemporary invasive endovascular treatments, called pharmacomechanical treatment, mitigate the drawbacks (major bleeding) historically associated with systemic thrombolytic approaches, by means of intra-thrombus delivery of drugs, followed by mechanical dispersion to accelerate lysis and then aspiration of remaining drug and clot debris. The proof of concept for the "open vein" hypothesis - that a strategy of early thrombus removal can reduce the incidence of PTS long term - comes incrementally and randomized trials (ATTRACT trial with a 2016 target completion date) are currently under way and might lead to a shift of the paradigms of the management of acute DVT focused on active thrombus removal.

Interventional radiology and the care of the oncology patient

Interventional Radiology (IR) is occupying an increasingly prominent role in the care of patients with cancer, with involvement from initial diagnosis, right through to minimally invasive treatment of the malignancy and its complications. Adequate diagnostic samples can be obtained under image guidance by percutaneous biopsy and needle aspiration in an accurate and minimally invasive manner. IR techniques may be used to place central venous access devices with well-established safety and efficacy. Therapeutic applications of IR in the oncology patient include local tumour treatments such as transarterial chemo-embolisation and radiofrequency ablation, as well as management of complications of malignancy such as pain, organ obstruction, and venous thrombosis.

Emergency Physician Performed Ultrasound for DVT Evaluation

Deep vein thrombosis is a common condition that is often difficult to diagnose and may be lethal when allowed to progress. However, early implementation of treatment substantially improves the disease prognosis. Therefore, care must be taken to both acquire an accurate differential diagnosis for patients with symptoms as well as to screen at-risk asymptomatic individuals. Many diagnostic tools exist to evaluate deep vein thrombosis. Compression ultrasonography is currently the most effective diagnostic tool in the emergency department, shown to be highly accurate at minimal expense. However, limited availability of ultrasound technicians may result in delayed imaging or in a decision not to image low-risk cases. Many studies support emergency physiciansas capable of accurately diagnosing deep vein thrombosis using bedside ultrasound. Further integration of ultrasound into the training of emergency physicians for use in evaluating deep vein thrombosis will improve patient care and cost-effective treatment.

A multimodal therapeutic approach to phlegmasia cerulea dolens in a pediatric patient

Phlegmasia cerulea dolens is a rare but serious complication of deep venous thrombosis, which can lead to arterial compromise, tissue ischemia, and gangrene. It typically presents in an elderly population often with coexistent malignancy. There have been no reported cases in the ambulatory pediatric population. The authors report a case of a 5-year-old girl who presented with acute, extensive left lower extremity deep venous thrombosis resulting in phlegmasia cerulea dolens. Pharmacologic and mechanical interventions as described in the adult population were utilized. This case demonstrates that an aggressive, multimodal approach to phlegmasia cerulea dolens can be employed in the pediatric population and result in successful limb salvage.

Endovascular stent treatment for symptomatic benign iliofemoral venous occlusive disease: long-term results 1987-2009

Venous stenting has been shown to effectively treat iliofemoral venous obstruction with good short- and mid-term results. The aim of this study was to investigate long-term clinical outcome and stent patency. Twenty patients were treated with venous stenting for benign disease at our institution between 1987 and 2005. Fifteen of 20 patients (15 female, mean age at time of stent implantation 38 years [range 18-66]) returned for a clinical visit, a plain X-ray of the stent, and a Duplex ultrasound. Four patients were lost to follow-up, and one patient died 277 months after stent placement although a good clinical result was documented 267 months after stent placement. Mean follow-up after stent placement was 167.8 months (13.9 years) (range 71 (6 years) to 267 months [22 years]). No patient needed an additional venous intervention after stent implantation. No significant difference between the circumference of the thigh on the stented side (mean 55.1 cm [range 47.0-70.0]) compared with the contralateral thigh (mean 54.9 cm [range 47.0-70.0]) (p=0.684) was seen. There was a nonsignificant trend toward higher flow velocities within the stent (mean 30.8 cm/s [range 10.0-48.0]) and the corresponding vein segment on the contralateral side (mean 25.2 cm/s [range 12.0-47.0]) (p=0.065). Stent integrity was confirmed in 14 of 15 cases. Only one stent showed a fracture, as documented on x-ray, without any impairment of flow. Venous stenting using Wallstents showed excellent long-term clinical outcome and primary patency rate.