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Nguyen D, Berman SS, Balderman JA, Sabat JE, Mendoza B, Leon LR, Pacanowski JP, Kraemer C. Initial experience with the ambulatory management of acute iliofemoral deep vein thrombosis with May-Thurner syndrome with percutaneous mechanical thrombectomy, angioplasty and stenting. J Vasc Surg Venous Lymphat Disord 2024:101875. [PMID: 38513797 DOI: 10.1016/j.jvsv.2024.101875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/07/2024] [Accepted: 03/12/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVE Patients undergoing intervention for acute iliofemoral deep vein thrombosis (IFDVT) with May-Thurner syndrome (MTS) typically require inpatient (IP) hospitalization for initial treatment with anticoagulation and management with pharmacomechanical thrombectomy. Direct oral anticoagulants and percutaneous mechanical thrombectomy (PMT) devices offer the opportunity for outpatient (OP) management. We describe our approach with these patients. METHODS Patients receiving intervention for acute IFDVT from January 2020 through October 2022 were retrospectively reviewed. Patients undergoing unilateral thrombectomy, venous angioplasty, and stenting for IFDVT with MTS comprised the study population and were divided into two groups: (1) patients admitted to the hospital and treated as IPs and (2) patients who underwent therapy as OPs. The two groups were compared regarding demographics, risk factors, procedural success, complications, and follow-up. RESULTS A total of 92 patients were treated for IFDVT with thrombectomy, angioplasty, and stenting of whom 58 comprised the IP group and 34 the OP group. All 92 patients underwent PMT using the Inari ClotTriever (Inari Medical), intravascular ultrasound, angioplasty, and stenting with 100% technical success. Three patients in the IP group required adjuvant thrombolysis. There was no difference in primary patency of the treated IFDVT segment at 12 months between the two groups (IP, 73.5%; OP, 86.7%; P = .21, log-rank test). CONCLUSIONS Patients with acute IFDVT and MTS deemed appropriate for thrombectomy and iliac revascularization can be managed with initiation of ambulatory direct oral anticoagulant therapy and subsequent return for ambulatory PMT, angioplasty, and stenting. This approach avoids the expense of IP care and allows for effective use of resources at a time when staffing and supply chain shortages have led to inefficiencies in the provision of IP care for nonemergent conditions.
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Affiliation(s)
- Daniel Nguyen
- Pima Heart and Vascular, Tucson, AZ; The University of Arizona School of Medicine, Tucson, AZ
| | - Scott S Berman
- Pima Heart and Vascular, Tucson, AZ; Section of Vascular Surgery, The University of Arizona, Tucson, AZ.
| | | | - Joseph E Sabat
- Pima Heart and Vascular, Tucson, AZ; Section of Vascular Surgery, The University of Arizona, Tucson, AZ
| | | | - Luis R Leon
- Pima Heart and Vascular, Tucson, AZ; Section of Vascular Surgery, The University of Arizona, Tucson, AZ
| | - John P Pacanowski
- Pima Heart and Vascular, Tucson, AZ; Section of Vascular Surgery, The University of Arizona, Tucson, AZ
| | - Cody Kraemer
- Pima Heart and Vascular, Tucson, AZ; Section of Vascular Surgery, The University of Arizona, Tucson, AZ
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Anatomical consideration of deep calf veins: application to catheter-directed thrombolysis. Surg Radiol Anat 2021; 43:2071-2076. [PMID: 34432130 PMCID: PMC8385696 DOI: 10.1007/s00276-021-02821-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/16/2021] [Indexed: 11/05/2022]
Abstract
Purpose An antegrade approach is frequently used in catheter-directed thrombolysis to remove deep-vein thrombosis. However, the antegrade approach is difficult when accessing veins with small diameters; therefore, understanding the variation of deep calf vein is important. Methods This study measured the diameters and surface areas of the proximal and distal posterior tibial vein, peroneal vein, and anterior tibial vein to determine which are preferable for venous access. This study dissected 132 legs from Korean and Thai cadavers. The proximal and distal posterior tibial vein, peroneal vein, and anterior tibial vein were scanned and measured. Results The mean diameter and surface area were largest for the proximal tibial vein, at 6.34 mm and 0.312 cm2, respectively, followed by the anterior tibial vein (5.22 mm and 0.213 cm2), distal posterior tibial vein (3.29 mm and 0.091 cm2), and peroneal vein (3.43 mm and 0.081 cm2). The proximal posterior tibial vein and anterior tibial vein have large diameters and surface areas, which make them ideal for applying an antegrade approach in catheter-directed thrombolysis. Conclusions The distal posterior tibial vein and peroneal vein are not recommended due to their smaller surface areas and also the anatomical variations therein.
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Notten P, ten Cate H, ten Cate‐Hoek AJ. Postinterventional antithrombotic management after venous stenting of the iliofemoral tract in acute and chronic thrombosis: A systematic review. J Thromb Haemost 2021; 19:753-796. [PMID: 33249698 PMCID: PMC7986750 DOI: 10.1111/jth.15197] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 11/23/2020] [Indexed: 12/27/2022]
Abstract
Venous stenting has become a common treatment option for central deep venous outflow obstructions and postthrombotic syndrome. Following successful recanalization and stenting, stent patency is endangered by in-stent thrombosis and recurrent venous thromboembolism. Antithrombotic therapy might reduce patency loss. This systematic review summarizes the literature on antithrombotic therapy following (post)thrombotic venous stenting. A systematic PubMed, MEDLINE, EMBASE, and Cochrane search was performed for studies addressing antithrombotic therapy prescribed following venous stenting of the iliofemoral tract indicated by acute or chronic thrombotic pathology. A total of 277 articles was identified of which 64 (56 original studies) were selected. Overall, a mean primary patency rate of 82.3% was seen 1 year after the intervention, which decreased to 73.3% after 2 years. In the majority (43 of 56 studies, 77%), treatment was based on use of vitamin K antagonists, either with (18%) or without (59%) use of antiplatelet drugs. Only two studies (4%) directly assessed the effect of antithrombotic therapy on treatment outcomes. The impact of postinterventional antithrombotic therapy on stent patency remains unknown because of limited and insufficient data available in current literature. Further clinical research should more clearly address the role of antithrombotic therapy for preservation of long-term patency following venous stenting.
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Affiliation(s)
- Pascale Notten
- Department of Vascular SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- School for Cardiovascular DiseasesCARIM, Cardiovascular Research Institute MaastrichtMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Hugo ten Cate
- School for Cardiovascular DiseasesCARIM, Cardiovascular Research Institute MaastrichtMaastricht University Medical CentreMaastrichtThe Netherlands
- Laboratory of Clinical Thrombosis and HemostasisMaastricht UniversityMaastrichtThe Netherlands
- Thrombosis Expertise CentreHeart Vascular CentreMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Arina J. ten Cate‐Hoek
- School for Cardiovascular DiseasesCARIM, Cardiovascular Research Institute MaastrichtMaastricht University Medical CentreMaastrichtThe Netherlands
- Laboratory of Clinical Thrombosis and HemostasisMaastricht UniversityMaastrichtThe Netherlands
- Thrombosis Expertise CentreHeart Vascular CentreMaastricht University Medical CentreMaastrichtThe Netherlands
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Yi KH, Kim HJ. Is variation in posterior tibial veins a risk factor for deep-vein thrombosis? Clin Anat 2020; 34:829-834. [PMID: 32996214 DOI: 10.1002/ca.23691] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/05/2020] [Accepted: 09/26/2020] [Indexed: 11/10/2022]
Abstract
INTRODUCTION This study proposes variations in the posterior tibial vein as one of the risk factors for deep-vein thrombosis. Understanding the anatomical classification of the posterior tibial vein would guide the antegrade approach of catheter-directed thrombolysis. MATERIALS AND METHODS One hundred thirty-four legs from Korean and Thai cadavers were dissected. The posterior tibial veins were classified into four types according to the number of proximal and distal veins. RESULTS The most common type was type Ia (64/134), followed by type IIa (28/134), type Ib (24/134), and type IIb (16/134). CONCLUSIONS The anterior tibial and fibular veins had exactly two paired veins; however, the posterior tibial vein had many variations. We assume that patients with type IIb and IIa have a higher risk of thrombosis and hidden symptoms due to collateral formation. Additionally, the classification of the posterior tibial vein and dividing into proximal and distal posterior tibial vein would help practitioners predict the course and guide the application of catheter-directed thrombolysis.
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Affiliation(s)
- Kyu-Ho Yi
- Inje County Public Health Center, Inje, Republic of Korea.,Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 PLUS Project, Yonsei University College of Dentistry, Seoul, Republic of Korea
| | - Hee-Jin Kim
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 PLUS Project, Yonsei University College of Dentistry, Seoul, Republic of Korea.,Department of Materials Science & Engineering, College of Engineering, Yonsei University, Seoul, Republic of Korea
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Shaydakov ME, Diaz JA, Comerota AJ, Lurie F. Targeted gene expression analysis of human deep veins. J Vasc Surg Venous Lymphat Disord 2020; 9:770-780.e7. [PMID: 32860957 DOI: 10.1016/j.jvsv.2020.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/15/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Endothelial-derived molecules involved in thrombosis and hemostasis have been investigated mainly in arteries and in experimental animals. The actual presence and integral function of these molecules in the human deep venous system have received less attention. Our aim was to evaluate the expression of certain prothrombotic and antithrombotic genes in the normal human deep veins of the lower extremities. METHODS Macroscopically intact and competent valve-containing segments of human deep veins were prospectively collected from patients who had undergone above-knee amputation. Vein samples were separated into four zones: zone 1, postvalve (downstream, proximal) vein wall; zone 2, the valve cusp; zone 3, prevalve (upstream, distal) vein wall; and zone 4, vein wall within the valve cusp (cusp removed). Real-time quantitative polymerase chain reaction for principal genes involved in coagulation, fibrinolysis, and inflammation was performed to quantify messenger RNA. Selected protein gene products were measured by the western blot assay. One additional valve-containing segment underwent mass spectrometry analysis to investigate global differences in the proteome between the study zones. RESULTS Seventeen valve-containing vein segments were analyzed. Significant upregulation of antithrombotic (protein C receptor [PROCR], thrombomodulin [THBD], tissue factor pathway inhibitor [TFPI]), prothrombotic (con Willebrand factor [VWF]), and proinflammatory (selectin P [SELP], intercellular adhesion molecule 1 [ICAM1]) genes was found in the valve cusp compared with the vein wall (P < .05). PROCR and THBD demonstrated the highest level of upregulation in the valve cusp. PROCR, serpin peptidase inhibitor, clade E, member 1 (SERPINE1), and SELP were upregulated in the valve cusp at the protein level (P < .05). Messenger RNA composition in the vein wall within the valve cusp was similar to the prevalve and postvalve vein wall for all genes, except for two times overexpressed ICAM1 (P < .05). Substantial differences within the proteome between the study zones were observed with mass spectrometry. CONCLUSIONS The biological properties of the valve cusp, vein wall within the valve cusp, and vein wall beyond the valve cusp are different. The endothelium of the valve cusps of a normal competent deep venous valve may be naturally less thrombogenic compared with the vein wall. The endothelium of the valve cusp may have a higher potential to interact with white blood cells compared with the vein wall. Mass spectrometry demonstrates substantial differences in the proteome between the vein wall and the valve cusps that were not anticipated before. (J Vasc Surg Venous Lymphat Disord 2021;9:770-80.) CLINICAL RELEVANCE: Deep vein thrombosis (DVT) is a major cause of mortality, morbidity, and impaired quality of life. Multiple risk factors have been identified, although their relative weight and pathophysiologic interactions remain obscure. Many patients with multiple risk factors for DVT never develop this condition. Conversely, in numerous cases DVT cannot be attributed to any known clinical risk factor. The molecular mechanisms that initiate DVT are unclear. An improved understanding of the normal biology of human deep veins will serve as an important foundation for new hypotheses of the pathogenesis of DVT. The latter may suggest new projects on novel therapeutic strategies.
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Affiliation(s)
- Maxim E Shaydakov
- Conrad Jobst Research Vascular Laboratories, University of Michigan Medical School, Ann Arbor, Mich; Jobst Vascular Institute, ProMedica Toledo Hospital, Toledo, Ohio; Department of Surgery, Central Michigan University College of Medicine, Saginaw, Mich.
| | - Jose A Diaz
- Conrad Jobst Research Vascular Laboratories, University of Michigan Medical School, Ann Arbor, Mich; Division of Surgical Research, Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tenn
| | - Anthony J Comerota
- Jobst Vascular Institute, ProMedica Toledo Hospital, Toledo, Ohio; Inova Heart and Vascular Institute, Inova Alexandria Hospital, Alexandria, Va
| | - Fedor Lurie
- Jobst Vascular Institute, ProMedica Toledo Hospital, Toledo, Ohio
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Weinberg I, Vedantham S, Salter A, Hadley G, Al-Hammadi N, Kearon C, Julian JA, Razavi MK, Gornik HL, Goldhaber SZ, Comerota AJ, Kindzelski AL, Schainfeld RM, Angle JF, Misra S, Schor JA, Hurst D, Jaff MR. Relationships between the use of pharmacomechanical catheter-directed thrombolysis, sonographic findings, and clinical outcomes in patients with acute proximal DVT: Results from the ATTRACT Multicenter Randomized Trial. Vasc Med 2019; 24:442-451. [PMID: 31354089 PMCID: PMC6943930 DOI: 10.1177/1358863x19862043] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Few studies have documented relationships between endovascular therapy, duplex ultrasonography (DUS), post-thrombotic syndrome (PTS), and quality of life (QOL). The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial randomized 692 patients with acute proximal deep vein thrombosis (DVT) to receive anticoagulation or anticoagulation plus pharmacomechanical catheter-directed thrombolysis (PCDT). Compression DUS was obtained at baseline, 1 month and 12 months. Reflux DUS was obtained at 12 months in a subset of 126 patients. Clinical outcomes were collected over 24 months. At 1 month, patients who received PCDT had less residual thrombus compared to Control patients, evidenced by non-compressible common femoral vein (CFV) (21% vs 35%, p < 0.0001), femoral vein (51% vs 70%, p < 0.0001), and popliteal vein (61% vs 74%, p < 0.0001). At 12 months, in the ultrasound substudy, valvular reflux prevalence was similar between groups (85% vs 91%, p = 0.35). CFV non-compressibility at 1 month was associated with higher rates of any PTS (61% vs 46%, p < 0.001), a higher incidence of moderate-or-severe PTS (30% vs 19%, p = 0.003), and worse QOL (difference 8.2 VEINES-QOL (VEnous INsufficiency Epidemiological and Economic Study on Quality of Life) points; p = 0.004) at 24 months. Valvular reflux at 12 months was associated with moderate-or-severe PTS at 24 months (30% vs 0%, p = 0.01). In summary, PCDT results in less residual thrombus but does not reduce venous valvular reflux. CFV non-compressibility at 1 month is associated with more PTS, more severe PTS, and worse QOL at 24 months. Valvular reflux may predispose to moderate-or-severe PTS. ClinicalTrials.gov Identifier NCT00790335.
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Affiliation(s)
- Ido Weinberg
- Vascular Medicine Section, Cardiology Division, Massachusetts General Hospital, Boston, MA, USA
- Vascular Ultrasound Core-Laboratory (VasCore), Boston, MA, USA
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Amber Salter
- Division of Biostatistics, Washington University in St. Louis, St. Louis, MO, USA
| | - Gail Hadley
- Vascular Ultrasound Core-Laboratory (VasCore), Boston, MA, USA
| | - Noor Al-Hammadi
- Division of Biostatistics, Washington University in St. Louis, St. Louis, MO, USA
| | - Clive Kearon
- McMaster University, Department of Oncology, Hamilton, Ontario, Canada
| | - Jim A. Julian
- McMaster University, Department of Oncology, Hamilton, Ontario, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, Ontario, Canada
| | | | - Heather L. Gornik
- Vascular Center, University Hospitals Harrington Heart & Vascular Institute, Cleveland, OH
| | - Samuel Z. Goldhaber
- Brigham and Women’s Hospital, Division of Cardiovascular Medicine, and Harvard Medical School, Boston, MA, USA
| | - Anthony J. Comerota
- Inova Heart and Vascular Institute, Inova Alexandria Hospital, Alexandria, VA, USA
| | - Andrei L. Kindzelski
- Division of Blood Diseases & Resources, National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Robert M. Schainfeld
- Vascular Medicine Section, Cardiology Division, Massachusetts General Hospital, Boston, MA, USA
| | - John F. Angle
- Department of Radiology, University of Virginia, Charlottesville, VA, USA
| | - Sanjay Misra
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Darren Hurst
- Department of Radiology, St. Elizabeth Healthcare, Edgewood, KY, USA
| | - Michael R. Jaff
- Newton-Wellesley Hospital, Newton, and Harvard Medical School, Boston, MA
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Sebastian T, Engelberger RP, Spirk D, Hakki LO, Baumann FA, Spescha RS, Kucher N. Cessation of anticoagulation therapy following endovascular thrombus removal and stent placement for acute iliofemoral deep vein thrombosis. VASA 2019; 48:331-339. [DOI: 10.1024/0301-1526/a000774] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Summary. Background: The optimal duration of anticoagulation therapy (AT) following catheter-based therapy of acute iliofemoral deep vein thrombosis (IFDVT) with stent placement is unknown. Theoretically, resolving the underlying obstructive iliac vein lesion by a stent may eliminate the main trigger for recurrence, the post-thrombotic syndrome (PTS), and the need for extended-duration AT. Patients and methods: From 113 patients with acute IFDVT who underwent endovascular thrombus removal and stent placement, we compared patency rates and clinical outcomes between 58 patients on limited-duration AT (3–12 month) and 55 patients on extended-duration AT (> 12 months). Results: Mean follow-up duration was 26 ± 18 (range 3–77) months; it was 24 ± 18 (range 3–69) months after cessation of AT in the limited-duration AT group. In comparison to patients with extended-duration AT, patients with limited-duration AT were younger (38 versus 54 years; p < 0.001), more often female (74 % versus 49 %; p = 0.01), and had less often prior venous thromboembolism (VTE) (9 % versus 35 %; p = 0.001). May-Thurner syndrome was more frequent in the limited-duration AT group (66 % versus 38 %; p = 0.004). Overall, primary and secondary patency rates at 24 months were 80 % (95 % CI, 70–87 %) and 95 % (95 % CI, 88–98 %), respectively, with no difference between the groups. Overall, 17 (15 %) patients developed recurrent VTE, of which 14 (82 %) events were thrombotic stent occlusions, and 13 (76 %) events occurred during AT. In the limited-duration AT group, 98 % patients were free from the PTS at two years with a VTE recurrence rate of 3.5 per 100 patient years after cessation of AT. Conclusions: In selected patients with acute IFDVT and patent venous stent, particularly in younger and otherwise healthy patients with May-Thurner syndrome, it appears to be safe to discontinue AT 3–12 months after endovascular treatment. Clinical Trial Registration: The study is registered on the National Institutes of Health website (ClinicalTrials.gov; identifier NCT02433054).
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Affiliation(s)
- Tim Sebastian
- Clinic for Angiology, University Hospital Zurich, Switzerland
| | - Rolf P. Engelberger
- Division of Angiology, Cantonal Hospital Fribourg, Fribourg, Switzerland
- Medical Faculty, University of Bern, Switzerland
| | - David Spirk
- Institute of Pharmacology, University of Bern, Switzerland
| | | | | | | | - Nils Kucher
- Clinic for Angiology, University Hospital Zurich, Switzerland
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8
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Sebastian T, Hakki LO, Spirk D, Baumann FA, Périard D, Banyai M, Spescha RS, Kucher N, Engelberger RP. Rivaroxaban or vitamin-K antagonists following early endovascular thrombus removal and stent placement for acute iliofemoral deep vein thrombosis. Thromb Res 2018; 172:86-93. [PMID: 30391776 DOI: 10.1016/j.thromres.2018.10.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/16/2018] [Accepted: 10/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal anticoagulant following catheter-based therapy of acute iliofemoral deep vein thrombosis (IFDVT) is unknown. METHODS From the Swiss Venous Stent registry, an ongoing prospective cohort study, we performed a subgroup analysis of patients with acute IFDVT who underwent catheter-based early thrombus removal followed by nitinol stent placement. Duplex ultrasound and Villalta scores were used to determine patency rates and incidence of the post-thrombotic syndrome (PTS) in patients treated with either rivaroxaban (n = 73) or a vitamin K-antagonist (VKA; n = 38) for a minimum duration of 3 months. RESULTS Mean follow-up duration was 24 ± 19 months (range 3 to 77 months). Anticoagulation therapy was time-limited (3 to 12 months) in 56% of patients (47% in the rivaroxaban group and 58% in the VKA group, p = 0.26), with shorter mean duration of anticoagulation in the rivaroxaban group (180 ± 98 days versus 284 ± 199 days, p = 0.01). Overall, primary and secondary patency rates at 24 months were 82% (95%CI, 71-89%) and 95% (95%CI, 87-98%), respectively, with no difference between the rivaroxaban (87% [95%CI, 76-94%] and 95% [95%CI, 85-98%]) and the VKA group (72% [95%CI, 52-86%] and 94% [95%CI, 78-99%]; p > 0.10 for both). Overall, 86 (86%) patients were free from PTS at latest follow-up, with no difference between the rivaroxaban and the VKA groups (57 [85%] versus 29 [88%]; p = 0.76). Two major bleeding complications (1 in each group) occurred in the peri-interventional period, without any major bleeding thereafter. CONCLUSIONS In patients with acute IFDVT treated with catheter-based early thrombus removal and venous stent placement, the effectiveness and safety of rivaroxaban and VKA appear to be similar. CLINICAL TRIAL REGISTRATION The study is registered on the National Institutes of Health website (ClinicalTrials.gov; identifier NCT02433054).
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Affiliation(s)
- Tim Sebastian
- Clinic for Angiology, University Hospital Zurich, Switzerland
| | | | - David Spirk
- Institute of Pharmacology, University of Bern, Switzerland
| | | | - Daniel Périard
- Division of Angiology, Cantonal Hospital Fribourg, Fribourg, Switzerland
| | - Martin Banyai
- Clinic for Angiology, University Hospital Zurich, Switzerland
| | | | - Nils Kucher
- Clinic for Angiology, University Hospital Zurich, Switzerland.
| | - Rolf P Engelberger
- Medical Faculty, University of Bern, Switzerland; Division of Angiology, Cantonal Hospital Fribourg, Fribourg, Switzerland
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Wang H, Qi X, Luo H, Zhang Q, Chen Y, Sun J. Catheter-directed thrombolysis through anterior tibial vein for treating acute extensive deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2018; 6:681-688. [PMID: 30126796 DOI: 10.1016/j.jvsv.2018.04.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/12/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the feasibility, efficacy, and safety of catheter-directed thrombolysis (CDT) through an anterior tibial vein approach for acute extensive lower extremity deep venous thrombosis (DVT). METHODS There were 125 consecutive patients with acute extensive lower extremity DVT who received CDT through an anterior tibial vein approach between October 2014 and June 2017. The patients with iliac vein compression syndrome were treated with balloon dilation and stent implantation after CDT. The thrombus score differences, limb circumference differences, venous patency, and complications were retrospectively analyzed. RESULTS The anterior tibial vein approach was successfully achieved in 118 patients (94.40% [118/125]). The mean thrombolysis time was 5.28 ± 1.10 days, and the average dose of urokinase was 3,903,400 ± 766,900 IU. Metal stents were placed in 50 patients (42.37% [50/118]). There were 109 patients (92.37% [109/118]) who had successful lysis (grade II and grade III lysis); 31 patients (91.18% [31/34]) achieved grade III lysis (no residual thrombus) within 3 days of symptom onset. In contrast, only 33.96% (18/53) of those treated within 4 to 7 days and 9.68% (3/31) of those treated after 7 days achieved grade III lysis. Compared with findings before CDT, the limb circumference above and below the knee was significantly reduced (7.22 ± 2.54 cm vs 1.58 ± 0.75 cm and 5.14 ± 1.41 cm vs 1.19 ± 0.49 cm, respectively). The incidence of bleeding was 10.17% (12/118). Six patients had puncture site bleeding, and three patients suffered major bleeding. One puncture site infection and two catheter-directed infections were observed during treatment. Two patients had accidental anterior tibial artery injury and recovered without complications, and no nerve injury occurred. During a follow-up of 19.39 ± 7.47 months (6-32 months), femoral venous insufficiency and popliteal venous insufficiency were present in 21.65% (21/97) and 30.93% (30/97) of the patients. The overall patency and post-thrombotic syndrome rates were 83.51% (81/97) and 21.65% (21/97). CONCLUSIONS CDT through an anterior tibial vein approach is a feasible, effective, and safe method for acute extensive lower extremity DVT patients. In addition, the anterior tibial vein approach can be an alternative to the traditional CDT approach.
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Affiliation(s)
- Haiyang Wang
- Department of Vascular Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Xiaotong Qi
- Department of Vascular Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Hailong Luo
- Department of Vascular Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Qian Zhang
- Department of Vascular Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yikuan Chen
- Department of Vascular Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jianming Sun
- Department of Vascular Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China.
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10
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Li W, Chuanlin Z, Shaoyu M, Yeh CH, Liqun C, Zeju Z. Catheter-directed thrombolysis for patients with acute lower extremity deep vein thrombosis: a meta-analysis. Rev Lat Am Enfermagem 2018; 26:e2990. [PMID: 29947719 PMCID: PMC6047892 DOI: 10.1590/1518-8345.2309.2990] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/07/2017] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Wang Li
- MSc, RN, School of Nursing, Chongqing Medical University, Chongqing, Chongqing, China
| | - Zhang Chuanlin
- MSc, RN, The First Affiliated Hospital, Chongqing Medical University, Chongqing, Chongqing, China
| | - Mu Shaoyu
- Professor, School of Nursing, Chongqing Medical University, Chongqing, Chongqing, China
| | - Chao Hsing Yeh
- PhD, Professor, School of Nursing, Johns Hopkins University, Baltimore, MD, United States of America
| | - Chen Liqun
- MSc, RN, School of Nursing, Chongqing Medical University, Chongqing, Chongqing, China
| | - Zhang Zeju
- MSc, RN, School of Nursing, Chongqing Medical and Pharmaceutical College, Chongqing, Chongqing, China
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Taha MA, Busuttil A, Bootun R, Davies AH. A systematic review on the use of deep venous stenting for acute venous thrombosis of the lower limb. Phlebology 2018; 34:115-127. [PMID: 29788818 DOI: 10.1177/0268355518772760] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim is to evaluate venous stent patency, the development of post-thrombotic syndrome, recurrence, quality of life and the optimal post-procedural anticoagulation regimen in the treatment of iliofemoral deep venous thrombosis. METHOD AND RESULTS EMBASE and Medline databases were interrogated to identify studies in which acute deep venous thrombosis patients were stented. Twenty-seven studies and 542 patients were identified. Primary, assisted primary and secondary patency rates 12 months after stent placement ranged from 74 to 95, 90 to 95 and 84 to 100%, respectively. The observed post-thrombotic syndrome rate was 14.6%. The incidence of stent re-thrombosis was 8%. In 26% of studies, patients received additional antiplatelet therapy. Quality of life questionnaires employed in 11% of studies, demonstrating an improvement in the chronic venous insufficiency questionnaire (22.67 ± 3.01 versus 39.34 ± 6.66). CONCLUSION Venous stenting appears to be an effective adjunct to early thrombus removal; however, further studies are needed to identify optimal anticoagulant regimen and effect on quality of life.
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Affiliation(s)
- Mohamed Ah Taha
- 1 Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, London, UK.,2 Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Assiut, Egypt
| | - Andrew Busuttil
- 1 Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, London, UK
| | - Roshan Bootun
- 1 Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, London, UK
| | - Alun H Davies
- 1 Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, London, UK
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12
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Elbasty A, Metcalf J. Safety and Efficacy of Catheter Direct Thrombolysis in Management of Acute Iliofemoral Deep Vein Thrombosis: A Systematic Review. Vasc Specialist Int 2017; 33:121-134. [PMID: 29354622 PMCID: PMC5754069 DOI: 10.5758/vsi.2017.33.4.121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 09/20/2017] [Accepted: 09/27/2017] [Indexed: 11/20/2022] Open
Abstract
Purpose Catheter direct thrombolysis (CDT) has been shown to be an effective treatment for deep venous thrombosis. The objective of the review is to improve safety and efficacy of the CDT by using ward based protocol, better able to predict complications and treatment outcome through monitoring of haemostatic parameters and clinical observation during thrombolysis procedure. Materials and Methods MEDLINE, EMBASE, CENTRAL and Web of Science were searched for all articles on deep venous thrombosis, thrombolysis and correlations of clinical events (bleeding, successful thrombolysis) during thrombolysis with hemostatic parameters to March 2016. The risk of bias in included studies was assessed by Cochrane Collaboration’s tool and Cochrane Risk of Bias Assessment Tool: for Non-Randomized Studies of Interventions. Results Twenty-four studies were included in the review and we found that improving safety and efficacy of CDT by using ward based protocol depending on eight factors; strict patient selection criteria, types of fibrinolytic drugs, mode of fibrinolytic drug injection, biochemical markers monitoring (fibrinogen, D-dimer, activated partial thromboplastin time, plasminogen activator inhibitor-1), timing of intervention, usage of intermittent pneumatic calf, ward monitoring and thrombolysis imaging assessment (intravascular ultrasound). These factors may help to improve safety and efficacy by reducing total thrombolytic drug dosage and at the same time ensure successful lysis. There is a marked lack of randomized controlled trials discussing the safety and efficacy of catheter direct thrombolysis. Conclusion CDT can be performed safely and efficiently in clinical ward, providing that careful nursing, biochemical monitoring, proper selection and mode of infusion of fibrinolytic drugs, usage of Intermittent pneumatic calf and adequate thrombolysis imaging assessment are ensured.
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Affiliation(s)
- Ahmed Elbasty
- Department of Vascular Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - James Metcalf
- Department of Vascular Surgery, Royal Bournemouth General Hospital, Bournemouth, UK
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13
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Wang L, Zhang C, Mu S, Yeh CH, Chen L, Zhang Z, Wang X. Safety of catheter-directed thrombolysis for the treatment of acute lower extremity deep vein thrombosis: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e7922. [PMID: 28858115 PMCID: PMC5585509 DOI: 10.1097/md.0000000000007922] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Despite established guidelines, catheter-directed thrombolysis (CDT) for the management of acute lower extremity deep vein thrombosis (DVT) should not be overstated because the risks of CDT are uncertain. We performed a meta-analysis to comprehensively and quantitatively evaluate the safety of CDT for patients with acute lower extremity DVT. METHODS Relevant databases, including PubMed, Embase, Cochrane, Ovid MEDLINE, and Scopus, were searched up to January 2017. The inclusion criteria were applied to select patients with acute lower extremity DVT treated by CDT or compared CDT with anticoagulation. In case series studies, the pooled estimates of safety outcomes for complications, pulmonary embolism (PE), and mortality were calculated across studies. In studies comparing CDT with anticoagulation, summary odds ratios (ORs) were calculated. RESULTS Of the 1696 citations identified, 24 studies (6 comparing CDT with anticoagulation and 18 case series) including 9157 patients met the eligibility criteria. In the case series studies, the pooled risks of major, minor, and total complications were 0.03 (95% confidence interval [CI]: 0.02-0.04), 0.07 (95% CI: 0.05-0.08), and 0.09 (95% CI: 0.08-0.11), respectively; other pooled risk results were 0.00 for PE (95% CI: 0.00-0.01) and 0.07 for mortality (95% CI: 0.03-0.11). Our meta-analysis of 6 studies comparing the risk of complications and PE related to CDT with those related to anticoagulation showed that CDT was associated with an increased risk of complications (OR = 4.36; 95% CI: 2.94-6.47) and PE (OR = 1.57; 95% CI: 1.37-1.79). CONCLUSION Acute lower extremity DVT patients receiving CDT are associated with a low risk of complications. However, compared with anticoagulation, CDT is associated with a higher risk of complications and PE. Rare mortality related to thrombolytic therapy was reported. More evidence should be accumulated to prove the safety of CDT.
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Affiliation(s)
- Li Wang
- School of Nursing, Chongqing Medical University
| | - Chuanlin Zhang
- Intensive Care Unit, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Shaoyu Mu
- School of Nursing, Chongqing Medical University
| | | | - Liqun Chen
- School of Nursing, Chongqing Medical University
| | - Zeju Zhang
- School of Nursing, Chongqing Medical and Pharmaceutical College, Chongqing, PR China
| | - Xueqin Wang
- Intensive Care Unit, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
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Wang W, Wu Y, Fang T, Xu D. Thrombectomy Combined with Indwelling-catheter Thrombolysis is more Effective than Pure Thrombectomy for the Treatment of Lower Extremity Deep Venous Thrombosis. Open Med (Wars) 2017; 12:177-183. [PMID: 28730176 PMCID: PMC5471913 DOI: 10.1515/med-2017-0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/24/2017] [Indexed: 11/15/2022] Open
Abstract
This study was a retrospective analysis of the efficacy of thrombectomy plus local catheter-directed thrombolysis (CDT) for the treatment of lower extremity deep venous thrombosis (LDVT). The experimental group underwent thrombectomy plus LCDT, whereas the control group underwent thrombectomy plus systemic thrombolysis via the dorsalis pedis vein. Venography and vascular color Doppler ultrasound were performed 7 days after surgery and at follow-up. The differences in the thigh and calf circumferences of normal and affected limbs were compared between groups. The venous patency score and venous patency rate were used for outcome evaluation. Compared with the control group, the experimental group showed a lower venous patency score and higher venous patency rate after treatment (P<0.05). Thirty patients were followed for 3 to 6 months, and according to the last evaluation, the differences in thigh and calf circumference between the normal and affected limbs remained lower in the experimental group than in the control group (P<0.05). Moreover, the venous patency score was lower, and the venous patency rate was higher in the experimental group than in the control group (P<0.05).
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Affiliation(s)
- Wenli Wang
- Vascular surgery, Yantaishan Hospital, Yantai264001, China
| | - Yanfang Wu
- Vascular surgery, Yantaishan Hospital, Yantai264001, China
| | - Tao Fang
- Vascular surgery, Yantaishan Hospital, Yantai264001, China
| | - Dunyuan Xu
- No. 91 Jiefang Road, Zhifu District, Yantai264001, China
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15
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Morrow KL, Kim AH, Plato SA, Shevitz AJ, Goldstone J, Baele H, Kashyap VS. Increased risk of renal dysfunction with percutaneous mechanical thrombectomy compared with catheter-directed thrombolysis. J Vasc Surg 2017; 65:1460-1466. [DOI: 10.1016/j.jvs.2016.09.047] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 09/30/2016] [Indexed: 11/27/2022]
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16
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Editor's Choice – Factors Associated with Long-Term Outcome in 191 Patients with Ilio-Femoral DVT Treated With Catheter-Directed Thrombolysis. Eur J Vasc Endovasc Surg 2017; 53:419-424. [DOI: 10.1016/j.ejvs.2016.12.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 12/12/2016] [Indexed: 11/20/2022]
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17
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Abstract
Catheter-directed thrombolysis for deep venous thrombosis is considered the basic treatment modality for intrathrombus removal. This method is preferably used in patients with iliofemoral deep venous thrombosis due to poor spontaneous recanalization in this segment, especially on the left side. The method was published almost 25 years ago and has gained ground in the treatment because of poor results from systemic thrombolysis and because of the possibility of stenting any underlying iliac obstruction during the procedure. However, the publications of catheter-directed thrombolysis reveal a great heterogeneity concerning catheter-directed thrombolysis technique and the lack of high quality evidence about monitoring as a tool to minimize the risk of bleeding and pulmonary embolism. Strict inclusion and exclusion criteria, correct composition and infusion of thrombolysis agent, imaging thrombus clearance during catheter-directed thrombolysis, ensuring flow enhancement during the bedridden situation, careful evaluation of indication for stenting based on imaging, and sufficient conversion to anticoagulation treatment following catheter-directed thrombolysis are essential. The aim of this paper is to discuss different treatment aspects of catheter-directed thrombolysis for iliofemoral thrombosis and to suggest a monitoring model for future treatment.
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Affiliation(s)
- Niels Bækgaard
- Vascular Clinic, Gentofte Hospital and Rigshospitalet, Copenhagen, Denmark
| | - Lotte Klitfod
- Vascular Clinic, Gentofte Hospital and Rigshospitalet, Copenhagen, Denmark
| | - Maja Jørgensen
- Center of Thrombosis and Hemostasis, Dept. of Clinical Chemistry, Næstved Hospital, Næstved, Denmark
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18
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Karageorgiou J, Fowler K, Vedantham S, Saad N. Endovascular intervention for deep venous thrombosis in patients with inferior vena cava filters. Vasc Med 2016; 21:459-466. [PMID: 27178760 DOI: 10.1177/1358863x16649678] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with inferior vena cava (IVC) filter-associated deep venous thrombosis (DVT) are a challenging subset of patients for endovascular intervention. Given the lack of available data pertaining to this clinical scenario, the purpose of this study was to evaluate the authors' experience with the use of endovascular treatment for DVT in patients with IVC filters. Primary aims included assessing the technical and clinical success, complications, and clinical patency in these patients. This was a retrospective single-center review of adult patients with IVC filters undergoing endovascular treatment of DVT between 1/2005 and 4/2014. Patient electronic medical records were reviewed for demographic data, anticoagulation status, symptoms, symptomatic extremities, extent of thrombosis, therapies received, technical and clinical success, and complications. Query yielded 82 patients (mean 53 years, range 18-96; 66% male), all of whom were included in our analysis. The majority of patients presented with lower extremity pain and swelling, with extensive clot burden despite the use of anticoagulant medication. Treatment elements utilized included pharmacologic lysis in 92%, mechanical thrombectomy in 77%, angioplasty in 63% and stent placement in 50% of patients. Interventions were technically successful in restoring flow in 87% of patients, and clinically successful in improving presenting symptoms in 79% of patients. By SIR criteria, 24% of patients experienced complications (categorized as 10% minor and 14% major). There were two deaths from intracranial hemorrhage. The probability of thrombosis-free survival at 1, 3, 6, 9 and 12 months was 0.85 (CI 0.74-0.93), 0.81 (CI 0.69-0.89), 0.74 (CI 0.62-0.83), 0.70 (CI 0.57-0.8) and 0.70 (CI 0.57-0.8), respectively. Endovascular interventions are usually effective in relieving symptoms in patients with DVT and pre-existing IVC filters. However, these outcomes are achieved with significant complication rates that may exceed those observed when endovascular therapy is provided for other DVT populations.
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Affiliation(s)
- John Karageorgiou
- Department of Radiology, Mallinckrodt Institute of Radiology, St Louis, MO, USA
| | - Kathryn Fowler
- Department of Radiology, Mallinckrodt Institute of Radiology, St Louis, MO, USA
| | - Suresh Vedantham
- Department of Radiology, Mallinckrodt Institute of Radiology, St Louis, MO, USA
| | - Nael Saad
- Department of Radiology, Mallinckrodt Institute of Radiology, St Louis, MO, USA
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Zaghlool DS, Franz RW, Jenkins J. EkoSonic Thrombolysis as a Therapeutic Adjunct in Venous Occlusive Disease. Int J Angiol 2016; 25:203-209. [PMID: 27867284 DOI: 10.1055/s-0036-1580698] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
The use of ultrasound waves in conjunction with local thrombolysis may accelerate clot resolution and serve as an important therapeutic adjunct in the treatment of venous occlusive disease. Our goal was to provide a larger sample population over a 5-year period to evaluate our experience with the EkoSonic endovascular system (EKOS, EKOS Corporation, Bothell, WA). We suspected that ultrasound-accelerated thrombolysis (UAT) using EKOS would provide excellent thrombolysis and midterm patency rates with minimal thrombolytic complications. A retrospective study was conducted to provide a case series with UAT using EKOS. Data were collected over a 5-year period. Primary end points included degree of thrombolysis. Secondarily, we analyzed thrombolytic usage, complication rates, and midterm patency, over a 1-year period. A total of 48 limbs were treated with UAT. Forty cases were diagnosed as acute, whereas the remaining 8 were chronic. Complete thrombolysis was successful in 38/48 (79%) of patients, and partial thrombolysis was accomplished in 10/48 (21%) of patients. Overall mean infusion time was 22.4 hours ±3.6. There were a total of three complications (6%), all of which were minor bleeding. One-year patency was shown to be 87% with no signs of valvular reflux. UAT using EKOS demonstrated effective rates of thrombolysis with very few complications. In addition, our 1-year patency rates were comparable to published data using conventional catheter-directed thrombolysis. UAT provides lytic therapy by utilizing the benefits of ultrasonic waves to help augment the fibrinolytic process. Our institution currently favors the use of EKOS as the treatment of choice in patients that are appropriate thrombolytic candidates.
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Affiliation(s)
- D S Zaghlool
- Division of Vascular Surgery, Grant Medical Center, Columbus, Ohio
| | - R W Franz
- Division of Vascular Surgery, Grant Medical Center, Columbus, Ohio
| | - J Jenkins
- Division of Vascular Surgery, Grant Medical Center, Columbus, Ohio
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Endovascular Thrombolysis in the Management of Iliofemoral Thrombosis in Children: A Multi-Institutional Experience. J Vasc Interv Radiol 2016; 27:524-30. [DOI: 10.1016/j.jvir.2015.12.753] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 12/19/2015] [Accepted: 12/22/2015] [Indexed: 02/01/2023] Open
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21
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Du XL, Kong LS, Meng QY, Qian A, Li WD, Chen H, Li XQ, Li CL. Safety and Efficacy of Low Dosage of Urokinase for Catheter-directed Thrombolysis of Deep Venous Thrombosis. Chin Med J (Engl) 2016; 128:1787-92. [PMID: 26112721 PMCID: PMC4733708 DOI: 10.4103/0366-6999.159355] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Catheter-directed thrombolysis (CDT) has been a mainstay in treating deep venous thrombosis (DVT). However, the optimal dosage of a thrombolytic agent is still controversial. The goal of this study was to evaluate the safety and efficacy of low dosage urokinase with CDT for DVT. Methods: A retrospective analysis was performed using data from a total of 427 patients with DVT treated with CDT in our single center between July 2009 and December 2012. Early efficacy of thrombolysis was assessed with a thrombus score based on daily venography. The therapeutic safety was evaluated by adverse events. A venography or duplex ultrasound was performed to assess the outcome at 6 months, 1 year and 2 years postoperatively. Results: The mean total dose of 3.34 (standard deviation [SD] 1.38) million units of urokinase was administered during a mean of 5.18 (SD 2.28) days. Prior to discharge, Grade III (complete lysis) was achieved in 154 (36%) patients; Grade II (50–99% lysis) in 222 (52%); and Grade I (50% lysis) in 51 (12%). The major complications included one intracranial hemorrhage, one hematochezia, five gross hematuria, and one pulmonary embolism. Moreover, no death occurred in the study. Conclusions: Treatment of low-dose catheter-directed thrombosis is an efficacious and safe therapeutic approach in patients with DVT offering good long-term outcomes and minimal complications.
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Affiliation(s)
| | | | | | | | | | | | - Xiao-Qiang Li
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu, China
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Saha P, Black S, Breen K, Patel A, Modarai B, Smith A. Contemporary management of acute and chronic deep venous thrombosis. Br Med Bull 2016; 117:107-20. [PMID: 26893407 DOI: 10.1093/bmb/ldw006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2016] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Prakash Saha
- Academic Department of Vascular Surgery, King's College London, St. Thomas' Hospital, London SE1 7EH, UK
| | - Stephen Black
- Academic Department of Vascular Surgery, King's College London, St. Thomas' Hospital, London SE1 7EH, UK
| | - Karen Breen
- Department of Thrombosis and Haemostasis, Guy's and St. Thomas' Hospitals, NHS Foundation Trust, London SE1 7EH, UK
| | - Ashish Patel
- Academic Department of Vascular Surgery, King's College London, St. Thomas' Hospital, London SE1 7EH, UK
| | - Bijan Modarai
- Academic Department of Vascular Surgery, King's College London, St. Thomas' Hospital, London SE1 7EH, UK
| | - Alberto Smith
- Academic Department of Vascular Surgery, King's College London, St. Thomas' Hospital, London SE1 7EH, UK
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24
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Liew A, Douketis J. Catheter-directed thrombolysis for extensive iliofemoral deep vein thrombosis: review of literature and ongoing trials. Expert Rev Cardiovasc Ther 2015; 14:189-200. [PMID: 26568115 DOI: 10.1586/14779072.2016.1121096] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In patients with extensive lower limb deep vein thrombosis (DVT) that, typically, extends into the iliofemoral veins, catheter-directed thrombolysis (CDT) can achieve faster and more complete thrombus lysis as compared with systemic thrombolysis, while providing an acceptable safety profile through administration of lower doses of thrombolytic agents. Through a reduction in thrombus burden, CDT has the potential to mitigate the risk for post-thrombotic syndrome by restoring venous patency and preserving venous valve function. The efficacy of CDT may be improved by adjunctive approaches that include percutaneous mechanical thrombectomy, angioplasty with or without stenting, and ultrasound-assisted CDT. CDT may also have a specific therapeutic role in the management of iliofemoral DVT involving patients who are pregnant or with May-Thurner syndrome. This article summarizes the literature in this area and discusses recently completed and ongoing randomized trials on the use of CDT in patients with extensive lower limb DVT.
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Affiliation(s)
- Aaron Liew
- a Institute of Cellular Medicine , Newcastle University , Newcastle Upon Tyne , UK
| | - James Douketis
- b Department of Medicine , McMaster University , Hamilton , Canada
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25
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Duan PF, Ni CF. Randomized study of different approaches for catheter-directed thrombolysis for lower-extremity acute deep venous thrombosis. J Formos Med Assoc 2015; 115:652-7. [PMID: 26228686 DOI: 10.1016/j.jfma.2015.07.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 06/18/2015] [Accepted: 07/01/2015] [Indexed: 10/23/2022] Open
Abstract
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.
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Affiliation(s)
- Peng-Fei Duan
- Department of Interventional Radiology, The First Affiliated Hospital of Soo Chow University, Suzhou, China
| | - Cai-Fang Ni
- Department of Interventional Radiology, The First Affiliated Hospital of Soo Chow University, Suzhou, China.
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Park KM, Moon IS, Kim JI, Yun SS, Hong KC, Jeon YS, Cho SG, Kim JY. Mechanical Thrombectomy with Trerotola Compared with Catheter-directed Thrombolysis for Treatment of Acute Iliofemoral Deep Vein Thrombosis. Ann Vasc Surg 2014; 28:1853-61. [DOI: 10.1016/j.avsg.2014.06.056] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 06/06/2014] [Accepted: 06/10/2014] [Indexed: 10/25/2022]
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Venous stenting after deep venous thrombosis and antithrombotic therapy: A systematic review. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.rvm.2014.03.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Vedantham S, Sista AK, Klein SJ, Nayak L, Razavi MK, Kalva SP, Saad WE, Dariushnia SR, Caplin DM, Chao CP, Ganguli S, Walker TG, Nikolic B. Quality Improvement Guidelines for the Treatment of Lower-Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal. J Vasc Interv Radiol 2014; 25:1317-25. [DOI: 10.1016/j.jvir.2014.04.019] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 04/22/2014] [Accepted: 04/22/2014] [Indexed: 02/07/2023] Open
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Basic data related to thrombolytic therapy for acute venous thrombosis. Ann Vasc Surg 2014; 28:1039-44. [PMID: 24440195 DOI: 10.1016/j.avsg.2013.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 12/30/2013] [Indexed: 11/20/2022]
Abstract
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.
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Compartment syndrome following thrombolysis: clinical features and associated conditions. J Thromb Thrombolysis 2013; 38:201-7. [DOI: 10.1007/s11239-013-1025-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jin Y, Zhou D, Chen L, Huang X, Xu G, Huang J, Shen L. Placement of vena cava filter via percutaneous puncture of the great saphenous vein. Exp Ther Med 2013; 6:321-324. [PMID: 24137182 PMCID: PMC3786820 DOI: 10.3892/etm.2013.1157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 03/05/2013] [Indexed: 11/14/2022] Open
Abstract
The aim of this study was to investigate the feasibility and safety of vena cava filter (VCF) placement via percutaneous puncture of the great saphenous vein (GSV) in the prevention of pulmonary embolisms. Using ultrasound positioning, VCF placement via percutaneous puncture of the GSV was performed on 12 patients with deep vein thrombosis (DVT) in the lower extremities. Transcatheter thrombolysis was conducted simultaneously. The postoperative filter position, puncture wound recovery and fluency of the GSV were observed. All filters were successfully released, with accurate positioning. No hematoma was observed at the puncture point during the perioperative period. In certain patients, local petechiae appeared around the puncture point during the thrombolysis period, which did not require special treatment. Re-examination using ultrasound revealed unobstructed blood flow in the GSV. VCF placement via percutaneous puncture of the GSV is a new filter placement method. The feasibility and safety of this method for the prevention of pulmonary embolisms has been demonstrated in a small number of sample cases.
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Affiliation(s)
- Yiqi Jin
- Department of Vascular Surgery, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu 215002, P.R. China
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Nicolaides A, Fareed J, Kakkar AK, Comerota AJ, Goldhaber SZ, Hull R, Myers K, Samama M, Fletcher J, Kalodiki E, Bergqvist D, Bonnar J, Caprini JA, Carter C, Conard J, Eklof B, Elalamy I, Gerotziafas G, Geroulakos G, Giannoukas A, Greer I, Griffin M, Kakkos S, Lassen MR, Lowe GDO, Markel A, Prandoni P, Raskob G, Spyropoulos AC, Turpie AG, Walenga JM, Warwick D. Thrombolytic Therapy. Clin Appl Thromb Hemost 2013; 19:198-204. [DOI: 10.1177/1076029612474840o] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Hashimoto S, Shiraishi J, Kimura M, Ito D, Matsui A, Yokoi H, Arihara M, Irie H, Hyogo M, Shima T, Kohno Y. Zilver stent implantation through 4.5 French guiding sheath in iliac vein compression syndrome complicated with acute deep vein thrombosis. J Cardiol Cases 2013; 7:e53-e56. [DOI: 10.1016/j.jccase.2012.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 09/21/2012] [Accepted: 11/01/2012] [Indexed: 11/26/2022] Open
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Haig Y, Enden T, Slagsvold CE, Sandvik L, Sandset PM, Kløw NE. Determinants of Early and Long-term Efficacy of Catheter-directed Thrombolysis in Proximal Deep Vein Thrombosis. J Vasc Interv Radiol 2013. [DOI: 10.1016/j.jvir.2012.09.023] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Vogel D, Walsh ME, Chen JT, Comerota AJ. Comparison of vein valve function following pharmacomechanical thrombolysis versus simple catheter-directed thrombolysis for iliofemoral deep vein thrombosis. J Vasc Surg 2012; 56:1351-4. [DOI: 10.1016/j.jvs.2012.02.053] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 02/14/2012] [Accepted: 02/26/2012] [Indexed: 11/25/2022]
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Acute deep vein thrombosis and endovascular techniques: It is time for a new aggiornamento! Diagn Interv Imaging 2012; 93:725-33. [DOI: 10.1016/j.diii.2012.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Pernès JM. [The role of thrombolysis in the clinical management of deep vein thrombosis]. JOURNAL DES MALADIES VASCULAIRES 2011; 36 Suppl 1:S20-S27. [PMID: 22177765 DOI: 10.1016/s0398-0499(11)70004-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
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.
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Affiliation(s)
- J-M Pernès
- Pôle Cardiovasculaire Interventionnel, Hôpital Privé d'Antony, 25 rue de la providence, 92160 Antony, France.
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Comerota AJ. Thrombolysis for deep venous thrombosis. J Vasc Surg 2011; 55:607-11. [PMID: 21802241 DOI: 10.1016/j.jvs.2011.06.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 05/22/2011] [Accepted: 06/02/2011] [Indexed: 11/15/2022]
Abstract
The key questions addressed in this summary are whether clot removal should be part of the preferred therapy for patients with acute deep venous thrombosis (DVT), and whether there is evidence that a strategy of thrombus removal offers better outcomes for patients than anticoagulation alone. Evidence is defined as an outward sign or something that furnishes proof. Evidence in medicine is not limited to direct, blinded comparisons of one form of treatment compared with another but rather the body of knowledge that provides insight to clinicians to offer patient care. Evidence-based medicine follows from information available to form the foundation for the use of a treatment for a specific disease. Reports of strategies of thrombus removal for acute DVT, especially in patients with iliofemoral DVT, consistently demonstrate improved outcomes relative to postthrombotic morbidity. This summary reviews the evidence supporting this strategy as the preferred initial management of patients with extensive proximal DVT.
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Catheter-Directed Thrombolysis for Acute Iliofemoral Deep Venous Thrombosis. Ann Vasc Surg 2011; 25:707-15. [PMID: 21306867 DOI: 10.1016/j.avsg.2010.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 12/17/2010] [Indexed: 11/23/2022]
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Low-dose, once-daily, intraclot injections of alteplase for treatment of acute deep venous thrombosis. J Vasc Interv Radiol 2011; 22:1107-16. [PMID: 21664144 DOI: 10.1016/j.jvir.2011.03.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 03/25/2011] [Accepted: 03/31/2011] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To evaluate the safety and efficacy of once-daily intraclot injections of low doses (≤ 10 mg) of tissue plasminogen activator (tPA) for thrombolysis of venous thrombosis. MATERIALS AND METHODS In prospective studies, 33 patients with subclavian, jugular, and central venous thrombosis (SJ-CVT) (all but two cases associated with central catheters) were treated once a day with ≤ 4 mg/day of tPA, and 30 patients with acute deep vein thrombosis of the lower extremity (DVT-LE) < 14 days old were treated once a day with ≤ 10 mg/leg/day of tPA by intraclot "lacing" of thrombus without continuous infusions of tPA. RESULTS Patency was restored in 26 (79%) of 33 patients with SJ-CVT using an average total dose of 7.1 mg of tPA/per patient and average of 2.1 treatments or days of therapy. Five patients received thrombolytic therapy for SJ-CVT as outpatients. Initial patency was restored in 29 (97%) of 30 patients with acute DVT-LE using an average total dose of 20 mg of tPA per patient over an average of 2.7 treatments/or days per patient. Follow-up imaging examinations at 6 months showed continued patency in 27 (96%)/of 28 patients. There were no major bleeding complications, and no patient required a blood transfusion. CONCLUSIONS Intraclot injection of low doses of alteplase is effective for acute venous thrombosis, and pharmacokinetic data suggest potentially greater safety.
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Broholm R, Jørgensen M, Just S, Jensen LP, Bækgaard N. Acute Iliofemoral Venous Thrombosis in Patients with Atresia of the Inferior Vena Cava Can Be Treated Successfully with Catheter-directed Thrombolysis. J Vasc Interv Radiol 2011; 22:801-5. [DOI: 10.1016/j.jvir.2011.01.449] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Revised: 01/11/2011] [Accepted: 01/26/2011] [Indexed: 11/29/2022] Open
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Manninen H, Juutilainen A, Kaukanen E, Lehto S. Catheter-directed thrombolysis of proximal lower extremity deep vein thrombosis: a prospective trial with venographic and clinical follow-up. Eur J Radiol 2011; 81:1197-202. [PMID: 21498014 DOI: 10.1016/j.ejrad.2011.03.068] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 03/17/2011] [Accepted: 03/23/2011] [Indexed: 11/19/2022]
Abstract
PURPOSE To prospectively evaluate the primary and long-term venographic and clinical results of catheter-directed thrombolysis in the treatment of proximal deep vein thrombosis (DVT) of lower extremity. MATERIALS AND METHODS Fifty-six patients with mean age of 48 (range 15-81) years with acute DVT (symptom duration of less than 2 weeks), extending to high femoral (16 patients) or iliac vein (40 patients) were treated with selective catheter-directed thrombolysis. The mean total dose of 3.8 (range 1.0-8.1) million units of urokinase was administered during a mean of 39 (range 6-72) hours. Endovascular stenting was performed in 9 of the iliac DVT patients. RESULTS Complete procedural venographic success was achieved in 79% of patients. Major complications were noted in 7% of patients and the total rate of complications was 13%. Mean venographic follow-up was 3.5 years (range 3 months to 9.6 years); well preserved femoral vein valves and fully recanalized deep crural veins were observed in 83% and 57% of patients. Normal clinical findings in the affected limb were noted during the latest follow-up visit in 67% of patients. Clinical post-thrombotic syndrome occurred in 9% of patients. CONCLUSION Catheter-directed thrombolysis achieves good primary success with acceptable complication rate and effectively reduces prevalence of post-thrombotic syndrome.
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Affiliation(s)
- Hannu Manninen
- Department of Clinical Radiology, Kuopio University Hospital, Digital Imaging Centre, Kuopio, Finland.
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Davenport DL, Xenos ES. Early Outcomes and Risk Factors in Venous Thrombectomy: An Analysis of the American College of Surgeons NSQIP Dataset. Vasc Endovascular Surg 2011; 45:325-8. [DOI: 10.1177/1538574411401759] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: Thrombus removal has been shown to improve venous physiology in acute iliofemoral deep-venous thrombosis. Our study focuses on the contemporary application of venous thrombectomy based on data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Methods: Data submitted by over 200 hospitals to the ACS NSQIP participant use file was accessed for the years 2005-2008. The ACS NSQIP protocol provides clinically rigorous preoperative risk and 30-day outcomes for a prospective and systematic sample of vascular surgery patients. Patients were identified who had undergone venous thrombectomy through leg access (Primary procedure CPT 34421 or 34451). Demographic and clinical variables along with 30-day morbidity (1 or more of 21 defined complications) and mortality were evaluated. Secondary/concomitant procedures CPT codes were collected. Univariate analysis between groups was performed using χ 2 or T-tests with P ≤ .05 considered significant. Results: A total of 91 patients were identified who underwent primary venous thrombectomy. The mean age was 62.5 ± 15.8 y and 45 of 91 (49.5%) were female. Thirty-day mortality was 8.8% (8/91). Composite morbidity was 25.3% (23/91). Intraoperative transfusion was required in 18.7% of the patients, lower extremity fasciotomy was performed in 8.8% of the patients and an inferior vena cava (IVC) filter was placed in 2.2% of the patients. An arteriovenous anastomosis was created in only 1 patient; venous angioplasty was performed in 3.3% of the patients. Conclusions: Venous thrombectomy is associated with significant postoperative morbidity and mortality. This is at least partially due to the associated comorbidities of this patient population, approximately 1/5 in our study were ASA class 4. Most frequent causes of morbidity are pulmonary and wound infection complications. Only 2 patients had an IVC filter placed during the operation. Adjunctive procedures to assist vein patency such as arteriovenous fistula creation or venous angioplasty were infrequently performed.
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Affiliation(s)
| | - Eleftherios S. Xenos
- Department of Surgery, University of Kentucky, Lexington, KY, USA, VA Medical Center, Lexington, KY, USA,
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Kurtoglu M, Koksoy C, Hasan E, Akcalı Y, Karabay O, Filizcan U. Long-term efficacy and safety of once-daily enoxaparin plus warfarin for the outpatient ambulatory treatment of lower-limb deep vein thrombosis in the TROMBOTEK trial. J Vasc Surg 2010; 52:1262-70. [DOI: 10.1016/j.jvs.2010.06.070] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Revised: 06/02/2010] [Accepted: 06/03/2010] [Indexed: 11/27/2022]
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Wysokinska EM, Sobande F, Wysokinski WE, Bjarnason H, McBane Ii RD. Iliac vein thrombosis: feasibility assessment of randomized controlled trials of endovascular pharmacomechanical thrombolysis. J Thromb Haemost 2010; 8:1943-9. [PMID: 20586916 DOI: 10.1111/j.1538-7836.2010.03968.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Optimal treatment for iliac vein thrombosis has not been established by randomized clinical trials largely owing to difficulty in patient recruitment. To assess the feasibility of a prospective randomized trial of thrombolysis and stenting, we determined the incidence of iliac vein thrombosis and randomization eligibility based on criteria for two ongoing trials. METHODS All patients with incident leg deep vein thrombosis during the calendar year 2005 seen at the Mayo Clinic were identified to determine the frequency of iliac vein involvement and the number undergoing endovascular therapies. Each patient was assessed for eligibility for potential randomization into a theoretic trial of thrombolytic therapy. RESULTS Ninety-five (of 394) patients had iliac vein involvement. Of these, only nine patients would have been suitable for randomization. Of the remaining 86 patients, prolonged symptom duration (n = 28), active cancer (n = 24) and advanced age (n = 19) were the most common exclusion criteria. Of 31 patients who had intervention, 75% had at least one contraindication for randomization. CONCLUSIONS Despite a philosophy of aggressive treatment for iliac vein thrombosis at this institution, the number of cases that could potentially be randomized into a clinical trial is relatively small. Trial design may require either multicenter cooperation or exclusion criteria revision for adequate recruitment.
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Affiliation(s)
- E M Wysokinska
- Division of Haematology, Mayo Foundation, Rochester, MN, USA
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Long-term Results after Transfemoral Venous Thrombectomy for Iliofemoral Deep Venous Thrombosis. Eur J Vasc Endovasc Surg 2010; 40:134-8. [DOI: 10.1016/j.ejvs.2010.02.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 02/16/2010] [Indexed: 11/18/2022]
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O'Connell JB, Chandra A, Russell MM, Davis G, Sanchez I, Lawrence PF, DeRubertis BG. Thrombolysis for Acute Lower Extremity Deep Venous Thrombosis in a Tertiary Care Setting. Ann Vasc Surg 2010; 24:511-7. [DOI: 10.1016/j.avsg.2010.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 09/26/2009] [Accepted: 02/03/2010] [Indexed: 11/24/2022]
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