The Role of Interventional Radiology in the Management of Deep Venous Thrombosis: Advanced Therapy

Knowledge Mapping of Global Status and Trends for Thromboangiitis Obliterans: A Bibliometrics and Visual Analysis

Objective

Thromboangiitis obliterans (TAO) is a segmental nonatherosclerotic inflammatory vascular disease characterized by recurrent progressive inflammatory reactions and thrombosis in the small and medium-sized arteries and veins of the extremities. However, there are few bibliometric studies on TAO. Therefore, this study was employed to generalize the research status, hotspots and development trends of TAO-related research.

Methods

The data from 1999 to 2022 were collected from the Web of Science core collection database, and analyzed through bibliometrics software. VOSviewer was utilized to carry out academic collaboration between different countries/regions, institutions, and authors, visualization map of co-cited authors, journals, reference, and co-occurring keywords. CiteSpace was used to analyze the dual-map of journals, keyword bursts, and timeline of keywords. Bar and pie charts in this study were statistically analyzed and graphed through Microsoft Excel 2021. Scimago Graphica was applied to map the academic collaboration between different countries/regions.

Results

A total of 553 literatures were involved in this study. Japan at the leading global position not only in the number of publications, but also total citations, average citations and H-index. Institution with the major contribution to TAO research is Mashhad University of Medical Sciences, and Nagoya University. Annals of Vascular Surgery, Angiology, Journal of Vascular Surgery are the main publication channel for articles related to TAO. Fazeli, B., Iwai, T., and Kihara, Y. are major contributors in this field. The studies on TAO keywords could be grouped into four clusters: Etiology, Mechanism, Cell therapy and Clinical therapy.

Conclusion

Although the number of TAO publications has fluctuated over the past 20 years, it has generally shown a steady upward trend. Etiology and treatment research on TAO and some keywords such as trail, therapy, outcome, management, stem cells, angioplasty, and activation will become a hot spot in the future.

Deep venous stenting in females

Deep venous stenting has gained increasing prominence in recent years. This issue focuses on special considerations in female patients. The specific challenge relates to the fact that these patients are often much younger than those in whom arterial stents are placed. The stents have to perform adequately over potentially 60 years- and there is no data of that length available.

Single-Session Percutaneous Mechanical Thrombectomy Using the Aspirex®S Device Plus Stenting for Acute Iliofemoral Deep Vein Thrombosis: Safety, Efficacy, and Mid-Term Outcomes

To assess the safety, efficacy and mid-term outcomes of single-session percutaneous mechanical thrombectomy (PMT) for acute symptomatic iliofemoral deep vein thrombosis (DVT) using the Aspirex^®S device. Retrospective review of 30 patients (women, 23; mean age, 45.5 ± 19.9 years; range, 17-76) who underwent PMT with the 10-French Aspirex^®S device (Straub Medical AG, Wangs, Switzerland) for acute DVT between December 2015 and March 2019. Procedures were performed by popliteal (n = 22) or jugular (n = 7) approach, or both (n = 1). Mean time from diagnosis to PMT was 5.5 ± 4.6 days (range, 2-11). Successful thrombus removal and venous patency restoration were achieved in all patients (100%). Fluid removal was 307.8 ± 66.1 mL (range, 190-410). Additional venous stenting rate was 100%. Mean procedural time was 107.3 ± 33.9 min (range, 70-180). No major complication occurred. The patient's postprocedural course was uneventful in all cases, with hospital discharge within 2 days in 83.3%. Early in-stent rethrombosis occurred within 1 week in 3 patients, successfully managed by endovascular approach. Secondary stent patency rate was 86.7% at a mean follow-up of 22.3 ± 14.2 months (range, 6-48), as assessed by Duplex ultrasound. Single-session of PMT using the Aspirex^®S device is a safe and effective therapeutic option in patients presenting with acute symptomatic iliofemoral DVT.

Just How Attractive is the ATTRACT Trial?

Venous thromboembolism (VTE) is a major public health issue; deep vein thrombosis (DVT) affects about 1/1000 patients. Each year, VTE kills more patients in Western Europe than breast cancer, prostate cancer, acquired immune deficiency syndrome (AIDS) and road traffic accidents combined and is responsible for the deaths of approximately 370,000 European citizens (Cohen et al. in Thromb Haemost 98:756-764, 2007; Bĕlohlávek et al. in Exp Clin Cardiol 18(2):129-138, 2013). The recently published ATTRACT trial (Acute Venous Thrombosis Thrombus Removal with Adjunctive Catheter-directed Thrombolysis) (Vedantham et al. in N Engl J Med 377:2240-2252, 2017) concluded that the addition of catheter-directed thrombolysis to standard therapy with anticoagulation and compression stockings offers no significant clinical benefit over standard therapy in terms of reduction in the rate of post-thrombotic syndrome (PTS) at 2 years. It is the largest, prospective, multi-centre, randomised controlled trial (RCT) and represents the culmination over a decade of planning, execution and analysis. In this opinion article, we analyse why it was needed, what it demonstrated, some limitations, and the directions in which this important publication will take us.

Factors Associated with Contralateral Deep Venous Thrombosis after Iliocaval Venous Stenting

BACKGROUND

The majority of iliac venous obstructions occur on the left side, and endovascular therapy has become the first line treatment for this condition. A left common iliac venous stent will protrude into the inferior vena cava (IVC) to some extent, thereby covering the contralateral common iliac vein (CIV) outflow. This may increase the risk of thrombosis of the contralateral iliac vein. The aim of this paper was to determine the rate of, and factors associated with, contralateral lower limb venous thrombosis after stenting, and to evaluate the results of salvage revascularisation.

METHODS

A total of 376 patients (102 from UCH, Galway, Ireland, 2008-16, and 274 from, CHU Nord, Marseille, France, 2000-15) with symptomatic acute or chronic left iliocaval venous obstruction were retrospectively evaluated. Either duplex ultrasound scanning (DUS) or computed tomographic venography (CTV) was used for pre- and post-operative imaging. Data were collected from the PACS system (IMPAX, Agfa, BE) of the Radiology Department, UCH, Galway, and from the electronic medical records of Vascular Surgery department, CHU Nord, Marseille.

RESULTS

The median age of stented patients was 46 (range 15-86 years), 80% were female (301/376). Following left CIV stent placement, 10 patients later presented with a right (contralateral) iliac deep venous thrombosis (DVT) resulting in a cumulative incidence of contralateral DVT of 4% according to Kaplan-Meier analysis. Acute DVT (p=.001), non-compliance with the prescribed 6 months anticoagulation (p = 0.05), pre-operative contralateral internal iliac vein (IIV) thrombosis (p = 0.001), and pre-existing IVC filter placement (p = 0.003) were all statistically significantly associated with contralateral DVT. All patients with symptomatic contralateral iliac DVT underwent clot removal in the acute phase. The primary patency of these limbs was 100% at 3 years.

CONCLUSION

Stent placement across the iliocaval confluence from the left CIV is associated with a low but definite rate of contralateral iliac vein thrombosis. Acute DVT, pre-operative contralateral IIV thrombosis, pre-existing IVC filters, and anticoagulation non-compliance are significant risk factors.

Management of Cavoatrial Deep Venous Thrombosis: Incorporating New Strategies

Cavoatrial deep venous thrombosis (DVT) is diagnosed with increasing prevalence. It can be managed medically with anticoagulation or with directed interventions aimed to efficiently reduce the thrombus burden within the target venous segment. The type of management chosen depends greatly on the etiology and chronicity of the thrombosis, existing patient comorbidities, and the patient's tolerance to anticoagulants and thrombolytic agents. In addition to traditional percutaneous catheter-based pharmacomechanical thrombolysis, other catheter-based suction thrombectomy techniques have emerged in recent years. Each therapeutic modality requires operator expertise and a coordinated care paradigm to facilitate successful outcomes. Open surgical thrombectomy is alternatively reserved for specific patient conditions, including intolerance of anticoagulation, failed catheter-based interventions, or acute emergencies.

Quantitation of Venous Clot Lysis With D-Dimer Assay During Catheter-Directed Thrombolysis for Lower Extremity Deep Venous Thrombosis

This study evaluated whether D-dimer (DD) concentration analysis is a useful approach for noninvasive monitoring of clot lysis during catheter-directed thrombolysis (CDT) for deep vein thrombosis (DVT). DD levels have been found to be elevated during fibrinolytic therapy for DVT. Therefore, measuring the level of DD is a potential alternative method to assess the effect of fibrinolytic therapy. From January 2013 to March 2014, 32 patients with symptomatic acute DVT involving the iliac or femoral veins were treated using CDT. Urokinase was the thrombolytic agent. Demographics, procedural details, DD concentration, and thrombus score were recorded before and after the thrombolytic therapy. The peak DD concentration was 35.35 ± 11.18 μg/mL during CDT therapy, and the time-integrated DD concentration was 157.95 ± 69.46 μg·d/mL. The peak DD concentrations were higher in patients with substantial lysis compared with those in patients with minimal or no lysis (40 ± 0 versus 30.7 ± 14.57 μg/mL; P = 0.016). The time-integrated DD concentrations were also higher in patients with substantial lysis compared with those in patients with minimal or no lysis (194.14 ± 37.57 units versus 121.75 ± 75.93 units, P = 0.002). There was a moderate correlation (r = 0.57) between the peak DD level and the lysed clot volume. There was also a correlation between the time-integrated DD and clot lysis (r = 0.65). DD concentration analysis offers an alternative approach to noninvasive monitoring of venous clot lysis during CDT for DVT.

Endovascular stent placement for chronic post-thrombotic symptomatic ilio-femoral venous obstructive lesions: a single-center study of safety, efficacy and quality-of-life improvement

BACKGROUND

Post-thrombotic syndrome (PTS) is a frequent complication of deep vein thrombosis (DVT) despite adequate treatment. Venous angioplasty and stent placement has been progressively used to restore and maintain venous patency in PTS patients. This study reports our single-center experience with the use of endovascular treatment for chronic post-thrombotic symptomatic ilio-femoral venous obstructive lesions.

METHODS

A prospective mono-centric observational cohort study of PTS patients with chronic symptomatic ilio-femoral venous obstructive lesions referred for endovascular treatment was conducted from March 2012 to April 2016. Procedure consisted in recanalization, pre-dilation and self-expandable stenting of stenotic or occluded iliac and/or femoral veins. Severity of PTS, quality-of-life and treatment outcomes were assessed using Villalta scale and Chronic Venous Insufficiency Questionnaire (CIVIQ-20) at baseline and 3 months after the procedure. Imaging follow-up was based on duplex ultrasound (US) and computed tomography (CT).

RESULTS

Twenty-one patients (11 females, 10 males; median age, 41 years; range, 32-60) were included. Recanalization and stenting was successfully accomplished in all prime procedures, 4 patients benefitted from an additional procedure. Immediate technical success rate was 96% considering 25 procedures, performed without any complications. Median follow-up was 18 months (range, 6-30 months) with a 90.5% stent patency rate. Villalta score significantly decreased from baseline compared with 3 months after the procedure [14 (range, 11-22) and 5 (range, 1-10), respectively, P<0.0001], showing a significant decrease in the severity of PTS. CIVIQ-20 score significantly decreased from baseline compared with 3 months after stenting [48.5 (range, 39-73) and 26.5 (range, 21-45), respectively, P<0.0001] thus showing a significant improvement of quality-of-life. Post-procedural CIVIQ-20 score was significantly associated with Villalta score (95% CI, 1.53-2.95; P<0.0001).

CONCLUSIONS

Our results confirm the high clinical success rate and safety of endovascular PTS treatment and highlight the significant impact of stenting on the quality of life of patients with chronic symptomatic ilio-femoral venous obstructive lesions.

MMP3 -1171 5A/6A Promoter Genotype Influences Serum MMP3 Levels and Is Associated with Deep Venous Thrombosis

BACKGROUND

The aim of this study was to investigate the roles of MMP3 (matrix metalloproteinase-3) gene polymorphism and protein expression in deep venous thrombosis (DVT) among Chinese Han population.

METHODS

A total of 280 subjects were included in this study and categorized as case group (144 DVT patients) and control group (136 healthy individuals). Polymerase chain reaction-restriction fragment length polymorphism was used to detect MMP3 promoter -1171 5A>6A genotype and allele frequencies. MMP3 serum levels were measured by enzyme-linked immunosorbent assay. SPSS version 18.0 statistical software was used for data analysis.

RESULTS

There was significant difference in genotype frequencies of MMP3 gene -1171 5A>6A between the case group and the control group (all P < 0.05). Furthermore, the 6A allele on MMP3 -1171 5A>6A may be associated with increased risk of DVT (odds ratio 1.961, 95% confidence interval 1.309-2.939, P < 0.01). The MMP3 serum level in DVT patients was markedly higher than the control group (case group: 28.45 ± 10.97 vs.

CONTROL GROUP

18.18 ± 9.03, P < 0.05). Serum MMP3 level in DVT patients carrying 5A/6A and 6A/6A genotypes was higher than the control group (P < 0.05). The bilateral calf circumference difference was significantly higher in DVT patients than the control group among all the genotypes at MMP3 gene -1171 5A>6A (all P < 0.05).

CONCLUSION

MMP3 gene -1171 5A>6A polymorphism and upregulated protein expression may be associated with DVT risk in Chinese Han population.

The role of Kuwait in the development of early thrombus removal in patients with acute iliofemoral vein thrombosis: in memory of Dr. Nael Al-Naqeeb

Many physicians in Kuwait have contributed to the development of the management of acute iliofemoral deep venous thrombosis utilizing open surgical thrombectomy for early thrombus removal. This concept is now accepted around the world, with new endovascular procedures replacing open surgery. Its development is described and the latest guidelines for early thrombus removal are presented.

Catheter-directed thrombolysis for iliofemoral deep vein thrombosis

BACKGROUND

Recent international guidance recommends the use of catheter-directed thrombolysis (CDT) in selected patients with symptomatic iliofemoral deep vein thrombosis (DVT). The aim of this study was to estimate the potential increase in workload as a result of this recommendation.

METHODS

Using the radiology database, a review was performed of all DVTs diagnosed between August 2010 and February 2012 at a large tertiary referral hospital. The National Institute for Health and Clinical Excellence and American College of Chest Physicians guidance was applied retrospectively to this cohort, using case-note review by two independent clinicians to determine which patients would have been suitable for CDT.

RESULTS

Some 563 patients had DVT confirmed radiologically over the 18-month interval. Fifty-three of the 128 patients with iliofemoral DVT would have been eligible for intervention with CDT, equivalent to 4·4 patients per 100 000 per year. Only eight (15 per cent) of the 53 were actually referred to vascular services for treatment. All eight patients had successful CDT, which involved a stay in critical care for monitoring (median 2 (range 1-3) sessions).

CONCLUSION

Vascular units should be prepared for a major increase in the requirement for CDT for iliofemoral DVT. This increase will affect inpatient beds, the interventional radiology suite, critical care and interhospital referrals.

The results of aspiration thrombecomy in the endovascular treatment for iliofemoral deep vein thrombosis

Purpose

The aim of this study is to evaluate the results of aspiration thrombectomy (AT) in the endovascular treatment for iliofemoral deep vein thrombosis (DVT) through the comparison of catheter directed thrombolysis (CDT) alone group and CDT with AT group.

Methods

From November 2001 to April 2011, 100 patients received endovascular treatment with CDT alone or CDT with AT for iliofemoral DVT at Yeungnam University Medical Center. We compared procedure, clinical outcomes and complications between the two groups.

Results

The mean age of patients was 60.48 ± 14.57 years. The patients consisted of 41 men and 59 women. CDT alone and CDT with AT were performed in 29 and 71 patients, respectively. The mean procedural time of the CDT-alone group was longer than the CDT with AT group (P < 0.001) and dose of urokinase used during the procedure significantly decreased in the CDT with AT group (P < 0.001). There were no statistically significant differences in clinical outcomes between the two groups. Cases of pulmonary embolism was not noted in each group in our series, but entrapped thrombus during procedure was noted in 6 of 37 in the CDT with AT group and 0 of 9 in the CDT-alone group among 46 patients with prophylactic inferior vena cava (IVC) filter insertion.

Conclusion

In conclusion, CDT with AT is safe and effective for the treatment of an acute iliofemoral DVT. In AT treatment, prophylactic IVC filter insertion should be considered for the prevention of pulmonary embolism by floating thrombi.

Pharmacomechanical thrombolysis in the management of paget-schroetter syndrome

Paget-Schroetter syndrome (PSS) is a rare form of thoracic outlet syndrome caused by axillosubclavian vein thrombosis which typically presents in healthy young adults. Prompt therapy, traditionally by means of catheter-directed thrombolysis (CDT) prior to definitive surgery, can prevent the subsequent onset of postthrombotic syndrome (PTS) and considerable disability. As CDT is associated with major haemorrhage and high overall treatment cost, pharmacomechanical thrombectomy (PMT) seems to be an attractive alternative which combines pharmacological thrombolysis with mechanical clot disruption. The Trellis-8 peripheral infusion catheter is an example of such a treatment which provides topical thrombolysis in an isolated zone. We describe the use of the Trellis-8 PMT system in the successful management of three patients with PSS.

Endovascular treatment for post-thrombotic syndrome. Two case studies and a literature review

The recent application of endovascular treatment techniques to venous pathologies has meant that new therapeutic solutions can be offered to patients suffering from post-thrombotic syndrome. This often-underestimated condition frequently complicates cases of deep vein thrombosis, whether treated or not, leading to a chronic and disabling set of clinical symptoms (oedema, claudication, pain, venous ulcers, etc.) due to the combination of the pathophysiological phenomena of obstructions and reflux. These clinical signs see only minimal improvement when managed with the classic medical treatment, venotonic agents, and venous compression. We report the cases of two patients suffering with chronic post-thrombotic venous obstruction of the lower limbs in whom endovascular treatment brought clear and long-lasting clinical improvement.

[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.