Catheter-directed thrombolysis of lower limb thrombosis

The Below-the-Knee Approach to Percutaneous Mechanical Thrombectomy for Lower Extremity Deep Venous Thrombosis: A Retrospective Single-Centre, Single-Arm Study

PURPOSE

The objective of this study was to evaluate the safety, efficacy, and feasibility of percutaneous mechanical thrombectomy (PMT) through a below-the-knee (BTK) approach for acute lower extremity deep venous thrombosis (DVT).

METHODS

A retrospective review of DVT patients treated with PMT by the BTK approach at our center from April 2022 to August 2023 was performed. Their preoperative demographics, intraoperative data, and postoperative outpatient outcomes were analyzed.

RESULTS

A total of 12 patients (67% men; mean age, 63 years) met the inclusion criteria. The BTK approach was successfully achieved in all patients through the posterior tibial vein (n = 1), anterior tibial vein (n = 2), and peroneal vein (n = 9). PMTs were achieved in 11 (92%) patients. Successful lysis (grade II and grade III lysis) was achieved in all patients with PMT. Four (33%) patients had residual venous occlusion over the popliteal vein. No intraoperative complications or bleeding events occurred in any of the patients.

CONCLUSION

PMT via BTK puncture seems to be a safe and effective approach for treating lower extremity DVT. It is reserved for highly select patients with a low risk of bleeding and is performed at centers that have experience with this procedure.

The perplexity of catheter-directed thrombolysis for deep venous thrombosis: the approaches play an important role

The recent adjunctive catheter-directed thrombolysis (ATTRACT) trial rose a controversy about the treatment effect of catheter-directed thrombolysis (CDT) in deep venous thrombosis (DVT). In fact, most studies including the ATTRACT trial did not perform subgroup analysis of catheterization approaches. Different approaches would confound the conclusions. Therefore, a single-center retrospective analysis was performed to compare the differences between the antegrade (AGA) and retrograde (RGA) approaches. Total 217 DVT patients treated with CDT were enrolled from January 2010 to December 2017, with mean age of 55.3 years (67 received antegrade approach, 150 received retrograde approach). The clot burden reduction by segment was evaluated. The mean access establishment time and thrombolytic time were compared. The patency of the iliofemoral vein at 6 months was evaluated. The rate of PTS, quality of life and venous insufficiency were assessed at 1 year. AGA group showed better thrombolytic effect in popliteal and femoral vein than RGA group. The rate of iliofemoral clot burden reduction in RGA group was mostly at Grade II, while most were at Grade III in AGA group. The retrograde approach showed better thrombolysis effect in iliofemoral DVT than popliteal to iliac DVT. The RGA group reported longer mean access establishment time (5.4 ± 1.8 vs 27.0 ± 7.5 min, p < 0.001) and thrombolytic time (6.9 ± 1.5 days vs 6.8 ± 1.5 days, p = 0.586). At 6 months, RGA group had a lower rate of femoral vein patency (52.0% vs 89.6%, p < 0.001) and a higher rate of venous insufficiency (52.0% vs 29.9%, p < 0.001), compared with AGA group. Although there was no difference in the rate of PTS, the RGA group showed higher Villalta scores in the free and mild PTS. The antegrade approach was preferably recommended over the retrograde approach for CDT treatment.

Percutaneous thrombectomy using a novel single-session device for acute ilio-caval deep vein thrombosis

A 53-year-old man developed acute left leg pain and edema 2 weeks after lumbar interbody fusion. A computed tomography venogram demonstrated acute thrombosis extending from the deep veins of the calf all the way to and including the common iliac vein owing to external compression of common iliac vein secondary to extruded bone graft material. Endovascular intervention without the use of thrombolysis was performed using a novel percutaneous mechanical thrombectomy system (ClotTriever, Inari Medical, Irvine, Calif), allowing clot removal in single session. Clot removal and stenting were performed with resolution of symptoms and only mild swelling with prolonged standing at the 6-month follow-up.

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

Endovascular thrombolysis to salvage central venous access in children with catheter-associated upper extremity deep vein thrombosis: technique and initial results

Nine patients (average age 8.3 years, range 20 days to 17 years; average weight 31 kg, range 2.7-79 kg) with catheter-associated UE-DVT underwent upper extremity venous thrombolysis with the goal of access salvage. Catheter directed therapy with alteplase (tPA), balloon angioplasty, and mechanical thrombectomy was used in all cases. The mean total dose of TPA was 15 mg (range 1-40 mg). Venous access was ultimately preserved in all patients. No stents or superior vena cava filters were used. There was one episode of symptomatic clinically suspected pulmonary embolism managed by systemic tPA and heparin without long term sequaele. Mean imaging and clinical follow-up was 351 ± 208 and 613 ± 498 days respectively. Endovenous thrombolysis for catheter-associated upper-extremity DVT in children may be safe and effective and could be considered particularly in patients in whom long-term venous access is needed.

Randomized study of different approaches for catheter-directed thrombolysis for lower-extremity acute deep venous thrombosis

BACKGROUND/PURPOSE

To investigate the feasibility, effectiveness, and complications of catheter-directed thrombolysis (CDT) using three different approaches for acute lower-extremity deep venous thrombosis (DVT).

METHODS

A total of 106 patients with acute DVT were enrolled in this study. Forty-one patients received CDT through the small saphenous vein (Group A), 35 through the great saphenous vein (Group B), and 30 through the popliteal vein (Group C). Iliac vein balloon dilation and stenting was performed in 65 cases.

RESULTS

The vascular approach route was not statistically related to limb edema reduction rates (Groups A, B, and C: 82.3 ± 7.6% vs. 81.6 ± 6.0% vs. 83.9 ± 6.1%), nor to thrombolysis rates (63.5 ± 7.7% vs. 66.9 ± 8.4% vs. 66.1 ± 2.7%). The procedure was significantly shorter for Groups B and C. No significant difference was found between Groups B and C. Most complications occurred in Group A. The complication rate in Group B was the lowest. Eighty-eight patients were followed up for 7-24 months. Of these, 78 were pain-free and without limb edema; six showed rethrombosis.

CONCLUSION

CDT is an effective method to manage acute DVT. Of the three routes tested, the small saphenous vein route was associated with more frequent complications. Great saphenous vein catheterization was more effective because of its lower complication rate.

Outcomes in children with deep vein thrombosis managed with percutaneous endovascular thrombolysis

BACKGROUND

Our center has developed a multidisciplinary approach to percutaneous endovascular thrombolysis with the goal of improving outcomes in children with thrombosis. There is little data describing the safety and efficacy of endovascular thrombolysis and the frequency of post-thrombotic syndrome after thrombolysis in children.

OBJECTIVE

Retrospective analysis of children undergoing percutaneous endovascular thrombolysis to determine (1) the safety and efficacy of this procedure and (2) the frequency of the diagnosis of post-thrombotic syndrome after thrombolysis.

MATERIALS AND METHODS

We reviewed the medical and imaging databases for children who underwent percutaneous endovascular thrombolysis for deep venous thrombosis (DVT) between November 2008 and June 2013 at our institution. Demographic data were reviewed for the technical success and complications of thrombolysis and the last assigned post-thrombotic syndrome score using standardized scoring tools.

RESULTS

Forty-one children ages 3 months to 21 years (median age: 15 years; 44% male) underwent percutaneous endovascular thrombolysis between November 2008 and June 2013. Upper extremity DVT occurred in 13 patients (32%); lower extremity DVT occurred in 28 patients (68%). All 41 patients received thrombolysis grading; 90% of those patients achieved greater than 50% thrombus lysis. Twenty-eight patients received formal post-thrombotic syndrome scoring and 4 (14%) met diagnostic criteria for post-thrombotic syndrome. One major bleeding episode and one pulmonary embolism occurred with no long-term sequelae.

CONCLUSION

Endovascular thrombolysis for DVT in children is safe, effective at thrombus removal and may reduce the incidence of post-thrombotic syndrome. Randomized or larger clinical trials would be needed to determine the long-term benefits of endovascular thrombolysis.

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

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

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

BACKGROUND

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

METHODOLOGY

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

RESULTS

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

CONCLUSION

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

Basic data related to thrombolytic therapy for acute venous thrombosis

BACKGROUND

Treatment guidelines for thrombolysis in iliofemoral deep venous thrombosis (DVT) are based on a limited number of observational and prospective studies. The acute venous thrombosis: thrombus removal with adjunctive catheter-directed thrombolysis (ATTRACT) trial will be the first large, multicenter randomized control trial to evaluate the relative advantages of several current treatment strategies. The objective of this study was to summarize the existing data that inform the use of catheter-directed thrombolysis (CDT) or pharmacomechanical thrombectomy in the management of acute iliofemoral DVT.

METHODS

A search of the current literature was done using PubMed, Ovid, and Cochrane databases for all available articles published up to December 2013.

RESULTS

Of those studies, which included at least 25 patients, 19 case series were identified from 1996 to 2012. Treatment groups included anticoagulation, surgical thrombectomy, pharmacomechanical thrombectomy, and CDT. Cases observed in each ranged from 26 to 101. Three studies were identified which derived data from national multicenter registries. Only 2 randomized control trials were identified from 2002 to 2012. Both support the use of CDT over anticoagulation alone for treatment of iliofemoral DVT.

CONCLUSIONS

Present treatment guidelines for acute iliofemoral DVT have been in flux and are derived from a relatively small amount of clinical data. They are summarized here in anticipation of results from the ongoing ATTRACT trial.

Management of proximal deep vein thrombosis

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