Combined regional thrombolysis and surgical thrombectomy for treatment of iliofemoral vein thrombosis

A systematic review on the use of deep venous stenting for acute venous thrombosis of the lower limb

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.

Advances in Operative Thrombectomy for Lower Extremity Venous Thrombosis

Lower extremity deep venous thrombosis is a leading cause of morbidity and mortality. The mainstay of therapy is medical. However, anticoagulation does not remove the thrombus and restore venous patency. In select patients, early thrombus removal and anticoagulation can restore venous patency, preserve venous valve function, and may reduce the incidence of postthrombotic syndrome. Catheter-directed therapies are minimally invasive with low complication rates. However, in patients with a contraindication to thrombolytic agents who can receive anticoagulation, open thrombectomy should be considered if indications for thrombus removal are met and patients are good operative risks.

Acute Venous Iliofemoral Thrombosis: Early Surgical Thrombectomy Is Effective and Durable

BACKGROUND

The first-line recommendation for the treatment of acute iliofemoral deep vein thrombosis (IFDVT) is catheter-directed thrombolysis or pharmacomechanical thrombolysis. Recent analysis of surgical thrombectomy has shown comparable results. However, this procedure is not commonly given as much importance as interventional techniques. We analyzed the patient outcome of surgical thrombectomy using modern endovascular techniques in both the short and long term.

METHODS

All consecutive patients who underwent surgical thrombectomy at our institution between April 2008 and April 2017 were included. Only patients with iliofemoral thrombosis, and only those with the first onset of symptoms <10 days, were analyzed. All patients received preoperative duplex ultrasound and contrast-enhanced computed tomography scans for thrombus extension and detection of pulmonary embolism. All operations were performed by vascular surgeons with open and endovascular skills in a C-arm-equipped operating room. During follow-up (FU), all patients received clinical examination for symptoms of postthrombotic syndrome (PTS), as well as duplex ultrasound.

RESULTS

Within a 9-year period, 21 patients underwent surgical thrombectomy for IFDVT (17 females/4 males). Primary technical success was 100%; 10 (47.6%) patients received additional primary stenting. 30-day mortality was 0%, 3 patients (14.3%) needed reoperation for early rethrombosis, while secondary 30-day patency was 100%. During FU (median, 6 years; range, 1-104 months), 1 patient received additional stenting for stenosis of the common iliac vein. Nineteen patients (90.5%) presented patent iliofemoral veins without signs of rethrombosis. Two patients (9.5%) died during FU of cancer without signs for recurrent IFDVT. All patients with patent veins were free of symptoms for PTS.

CONCLUSIONS

Surgical thrombectomy for acute IFDVT is a successful, safe, and durable procedure and provides alternative treatment options for acute IFDVT in selected cases.

Original approach for thrombolytic therapy in patients with Ilio-femoral deep vein thrombosis : 2 years follow-up

Objective

The aim of the study was to discuss the results of catheter-directed thrombolysis and complementary procedures to treat acute iliofemoral deep vein thrombosis (DVT) evaluating the safety and effectivness of an easy access such as the Great Saphenous Vein.

Methods and materials

A total of 22 consecutive patients with iliofemoral thrombosis and two patients with femoro-popliteal thrombosis on recent onset diagnosed with Ultrasound Doppler and contrast venography underwent intrathrombus drip infusion of urokinase while intravenous heparin was continued using saphenical access. Residual venous stenosis were treated in six patients by percutaneous balloon Angioplasty and stenting. All patients underwent routine venous duplex imaging at 30 days, 3 months, 6 months and every 6 months thereafter.

Results

Complete patency of thrombosed veins was restored in 22 patients (91 %) with prompt symptomatic relief. There were no major complications in the immediate outcomes. At follow-up, two patients reported a persistant slim iliac vein stenosis, two patients had post-thrombotic syndrome, and two patients showed Deep Vein Reflux.

Conclusion

Local thrombolysis using saphenical access was a safe and effective approach for the treatment of acute iliofemoral deep vein thrombosis. It seems to be a valid, easy and safe alternative, reducing the risks of haematoma and venous lesions, which can be observed when using femoral, popliteal, and trans-jugular access.

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.

Interventionelle Therapie einer deszendierenden Beckenvenenthrombose bei einer jungen Frau

Wir schildern den Fall einer 15-jährigen Patientin mit deszendierender Beckenvenenthrombose des linken Beines bei einer ilio-cavalen Gefäßanomalie, bei der nach zunächst frustraner Thrombektomie in einem zweiten Schritt, dann in einem spezialisierten Zentrum, eine kombinierte Behandlung im Sinne einer Spätthrombektomie mit lokoregionärer Thrombolyse, AV-Fistelanlage und Stentim-plantation durchgeführt wurde. Im Langzeitverlauf ist die Patientin beschwerdefrei ohne klinische oder meßtechnische Zeichen eines postthrombotischen Syndroms.

Die Möglichkeit einer interventionellen Therapie proximaler Thrombosen sollte insbesondere bei jüngeren Patienten häufiger als heute üblich in Erwägung gezogen werden. Dabei sollte immer an die Möglichkeit von Gefäßanomalien und anatomischen Varian-ten gedacht und eine entsprechend subtile Diagnostik präinterventionell vorgenommen werden. Nach den derzeitigen Empfehlungen kommt in etwa zwei Drittel der Fälle solcher Thrombosen eine restitutive Therapie in Betracht.

pharmacomechanical Thrombectomy for Early Thrombus Removal

Objectives:

To review the current literature on the outcomes of pharmacomechanical thrombectomy (PMT) for early thrombus removal in patients with venous thromboembolism (VTE).

Methods:

We searched the MEDLINE database and performed a manual search of the references of selected articles to select reports reporting the outcomes of PMT alone and PMT compared to catheter-direct thrombolysis (CDT). Outcomes of interest included clot lysis rate, incidence of pulmonary embolism, major bleeding, recurrent deep vein thrombosis, number of venograms needed and amount of lytic utilized.

Results

We found nine articles that reported outcomes of PMT. Three devices were utilized for PMT, the Angiojet, Trellis and Helix. Different thrombolytics were used to facilitate thrombus removal including urokinase, reteplase, tecneteplase, and tissue plasminogen activator (t-PA). Complete and partial thrombus removal were achieved in up to 84% and 64% and 81% and 59% of the limbs treated with PMT and CDT alone, respectively. Data on PE and bleeding risk after PMT compared to CDT are scarce. The duration of the thrombolysis process, amount of lytics and number of venograms were substantially reduced in the patients who had PMT compared to those who underwent CDT alone. Two articles evaluated the obstacles that limit the indication of PMT in patients with VTE.

Conclusion:

VTE is a prevalent burden in Western societies. The rationale of early thrombus is to reduce valvular damage and improve venous patency in order to reduce the risk of PTS. PMT is a feasible, safe and faster alternative to expedite the thrombolysis process in patients with VTE.

Pharmacomechanical Thrombolysis for Phlegmasia Cerulea Dolens

Phlegmasia cerulea dolens (PCD) is limb-threatening. Traditional treatments are very morbid. We examine the efficacy of percutaneous treatment of PCD. Between May 2005 and September 2008, we treated 21 limbs in 20 patients with lower extremity PCD who were candidates for thrombolysis. Diagnosis was by clinical examination and duplex ultrasound. Catheter access to the deep venous system was obtained through a popliteal vein. Therapy used pulse spray thrombolysis with tissue plasminogen activator (tPA). Infusion catheters and adjunctive percutaneous techniques were used as indicated. Postoperatively, patients were treated with systemic anticoagulation, compression hose, and interval follow-up. Limbs were graded according to the CEAP classification. Twenty patients (13 male) were treated with a mean age of 55.8 years. Nine patients had hypercoagulable states, four May Thurner syndrome, three a history of cancer, one postcolon resection, one acute myocardial infarction, and one postfemoral vein puncture. All patients had resolution of PCD without the need for open surgery. The initial tPA dose was 19.5 mg with pulse spray thrombolysis. Infusion catheters were required in 18 patients and used for 16.1 hours (range, 8 to 36 hours) until complete thrombolysis. Venous angioplasty was necessary in 14 patients with nine of these requiring venous stents. One patient required above-knee amputation despite successful treatment of her PCD. Mean follow-up was 10.7 months (range, 1 to 39 months). All patients demonstrated no or minimal residual thrombus and intact valvular function and a mean clinical CEAP score of 2.4. Percutaneous treatment of PCD produced excellent results with minimal morbidity.

Prospective determination of candidates for thrombolysis in patients with acute proximal deep vein thrombosis

PURPOSE

To prospectively determine the distribution, extent, and age of venous thrombosis in patients presenting with acute signs and symptoms of venous thromboembolism and identify candidates for thrombolysis.

MATERIALS AND METHODS

Five hundred seventy-six consecutive patients (281 male, 295 female; mean age 58) referred for lower extremity deep vein thrombosis (DVT) assessment between November 2007 and April 2008 were included in the study. Documented cases of DVT were categorized by age (acute, chronic, and acute on chronic), anatomic location, and extent. Patients with iliofemoral and femoropopliteal DVT were evaluated for thrombolysis using standard criteria.

RESULTS

DVT was found in 19% of patients (112/576). Of these, 31 patients (27.7%, 31/112) had isolated calf DVT, 61 patients (54.5%, 61/112) had proximal vein thrombosis extending into the femoropopliteal venous segments, and 20 patients (17.9%, 20/112) presented with iliofemoral DVT. Using standard criteria, 12 patients were selected as potential candidates for pharmacomechanical thrombolysis (PhMT). This equated to an incidence of 2% (12/576) in the population studied, 11% of patients (12/112) with DVT, 26.1% of patients (12/46) presenting with acute proximal DVT, and 20% of patients (4/20) with iliofemoral DVT.

CONCLUSION

The incidence of potential candidates for thrombolysis is low. These data should be considered when recruiting centers to participate in ongoing clinical trials assessing the efficacy of these techniques.

May-Thurner syndrome: case report and review of the literature involving modern endovascular therapy

May-Thurner syndrome is a rare clinical entity involving venous obstruction of the left lower extremity. Obstruction occurs secondary to compression of the left common iliac vein between the right common iliac artery and the underlying vertebral body. Current management largely involves endovascular therapy. A review was conducted of six studies containing at least five patients with May-Thurner syndrome treated by endovascular therapy. We compiled data on 113 patients, analyzing patient demographics, treatment details, and outcome. An 18-year-old female presented 1 week after the onset of left lower extremity pain and swelling. Duplex ultrasonography revealed extensive left-sided deep venous thrombosis (DVT). Thrombolysis followed by iliac vein stent placement restored patency to the venous system, with subsequent resolution of symptoms. Review of 113 patients revealed that the majority were females (72%) presenting with DVT (77%), most of which was acute in onset (73%). Therapy consisted of catheter-directed thrombolysis and subsequent stent placement in the majority of patients, resulting in a mean technical success of 95% and a mean 1-year patency of 96%. Endovascular therapy is the current mainstay of treatment for May-Thurner syndrome. Review of the current literature supports treatment via catheter-directed thrombolysis followed by stent placement with good early results.

Midterm Follow-up After Pharmacomechanical Thrombolysis for Lower Extremity Deep Venous Thrombosis

Objective: To provide follow-up in patients treated with pharmacomechanical thrombolysis (PhMT) for lower extremity deep venous thrombosis (DVT). Methods: Retrospective analysis of prospectively collected data. Patients underwent clinical evaluation, duplex ultrasound, venous clinical severity scoring, venous segmental disease scoring, and venous disability scoring. Results: Fourteen patients were available for evaluation. Median age was 40 years (19—58). Median follow-up was 24 months (13—69 months). Thirteen of 14 patients (93%) had a venous disability score < 1 and 13 of 14 patients (93%) had a venous clinical severity scoring < 5. In all but 1 patient the venous segmental disease scoring score was < 5. All iliac segments were patent, all but 3 patients had partial infrainguinal obstruction and 5 of 14 (36%) had reflux. Conclusions: Our data demonstrate that the good early clinical results after PhMT can be sustained on longer follow-up and may prevent the development of advanced postthrombotic syndrome.

Late results of surgical venous thrombectomy with iliocaval stenting

PURPOSE

Iliac vein occlusive disease leads to 73% of rethrombosis that occurs after venous thrombectomy when left untreated. The goal of this study is to present our long-term results of stenting of iliocaval occlusive lesions persisting after surgical venous thrombectomy.

METHODS

From November 1995 to April 2007, 29 patients (19 women), with a median age of 38 years, had surgical venous thrombectomy with creation of an arteriovenous fistula and angioplasty and stenting. All were admitted for acute (<10 days) deep venous thrombosis (DVT) involving the iliocaval segment, of which eight had concomitant acute pulmonary embolism. Six patients had a history of DVT (2 with previous venous thrombectomy), two were pregnant, and three had postpartum DVT. No patients had short- or mid-term life-threatening factors. The underlying lesion was left iliocaval compression (May-Thurner syndrome) in 22 patients, chronic left common iliac vein occlusion in 3, residual clot in 3, and compression of the left external iliac vein by the left internal iliac artery in 1.

RESULTS

Neither perioperative death nor pulmonary embolism occurred. Four early complications occurred after stenting (13.8%). Median hospital length of stay was 8 days (range, 5-22 days). Median follow-up was 63 months (range, 2-137 months). Three late complications occurred (10.3 %): one rethrombosis due to stent crushing during pregnancy and two restenosis, which were treated by iterative stenting. At the end of the follow-up, the median venous clinical severity score was 3 (range 1-12) and the venous disability score was 1 (range 0-2). Primary, assisted primary and secondary patency rates were, respectively, 79%, 86%, and 86% at 12, 60, and 120 months. Patients with patent iliocaval segments had significantly fewer infrainguinal obstructive lesions (4% vs 50%) and a higher rate of valvular competence (76% vs 0%) than those who experienced rethrombosis. Venous scores were also worse in patients with rethrombosis.

CONCLUSION

Stenting is a safe, efficient, and durable technique to treat occlusive iliocaval disease after venous thrombectomy. Its use can prevent most of the rethrombosis that occurs after venous thrombectomy without major adverse effects.

Treatment of symptomatic lower extremity acute deep venous thrombosis: role of mechanical thrombectomy

Systemic anticoagulation with heparin or its unfractionated derivatives followed by warfarin therapy has been the mainstay of treatment in patients with lower extremity deep venous thrombosis (DVT). Although heparin is an effective treatment modality in preventing thrombus propagation, it provides minimal therapeutic effect in dissolving preexisting venous thrombus. The clinical consequence of DVT, owing in part to loss of venous endothelial and valvular function, is postphlebitic syndrome or chronic venous insufficiency. Current advances in endovascular therapy have resulted in various endovascular thrombectomy systems that can effectively remove a large venous thrombus burden, which may represent a potential advantage of preserving venous valvular function and thereby reduce the likelihood of postphlebitic syndrome. In this article, we review a variety of surgical and interventional methods in venous thrombus removal. Current treatment modalities using mechanical thrombectomy devices and pharmacomechancial thrombectomy strategy are also discussed.

Stenting of Common Iliac Vein Obstructions Combined with Regional Thrombolysis and Thrombectomy in Acute Deep Vein Thrombosis

OBJECTIVES

To evaluate the efficacy of stent placement after infrainguinal loco-regional thrombolysis and iliac thrombectomy (surgical TT) of acute deep vein thrombosis (DVT) in patients with May-Thurner-Syndrome.

MATERIAL AND METHODS

We retrospectively analysed a group of 11 patients (9 women) (mean age 34 years, range 16-64 years) with surgical TT and additional intra-operative stenting due to compression of the common iliac vein. Patients underwent venography to demonstrate outflow patency after surgical TT, and to identify any obstruction at the level of the left-sided common iliac vein ("Beckenvenen-Sporn"). Obstruction at the level of arterial crossing was treated using Wallstents placed via an introducer sheath from the inguinal access site. Stents were fully deployed using balloons adjusted to the size of vein. Patients were treated with oral anticoagulants for 6 months, and followed using duplex ultrasonography.

RESULTS

Technical success defined as complete vein patency and normal valve function was documented in all 11 patients. One patient needed early stent extension due to residual stenosis. At 6 months follow-up one patient (9%) had an asymptomatic occlusion of the stented common iliac vein. In all 11/11 (100%) patients the femoral segment was found to be patent, and in 1/11 (9%) there was mild reflux with few clinical symptoms of post-thrombotic syndrome. The calculated cumulative primary patency rate for venous iliac stents was 82%, and assisted patency rate was 91%, which remained unchanged over a mean follow-up of 22 months.

CONCLUSION

Combining surgical TT and stenting of common iliac vein obstructions in DVT is safe, effective, and results in a acceptable venous patency.

Pharmacomechanical Thrombectomy of Acute Deep Vein Thrombosis with the Trellis-8 Isolated Thrombolysis Catheter

PURPOSE

To evaluate the performance of the Trellis-8 isolated thrombolysis catheter during single-session pharmacomechanical thrombectomy (PMT) combined with low-dose thrombolysis with tissue plasminogen activator (TPA) in the treatment of patients with acute deep vein thrombosis (DVT) and multiple comorbidities.

MATERIALS AND METHODS

Retrospective analysis was performed of 19 consecutive patients with acute above-knee DVT treated by PMT with the Trellis device followed by venous angioplasty and stent placement. Isolated thrombolysis with low-dose TPA was used with all patients. Concurrent therapies included retrievable inferior vena cava filter insertion (n = 4). The primary endpoint was restoration of rapid inline venous flow; the secondary endpoint was thrombus clearance.

RESULTS

Restoration of rapid inline venous flow was achieved in all cases; thrombus removal was less than 50% in one case (4%), 50%-95% in 18 cases (82%), and at least 95% in three cases (14%). The median administered dose of TPA was 13.4 mg per patient. The mean treatment time was 91 minutes per limb (range, 61-129 min), with a mean of 21 minutes per thrombosed segment (range, 8-31 min). There were no major complications. Primary patency rate of the treated venous segments at 2 days was 86% (n = 19) and the primary assisted patency rate was 100% at 30 days. Two patients died of advanced malignancy at 17 and 24 days.

CONCLUSIONS

The Trellis system was an effective method for the treatment of acute DVT. Based on the present data, the Trellis system could prove to be a safe and feasible single-session PMT method for the treatment of acute DVT in a broader patient population and warrants further investigation in a large-scale study.

Treatment of Acute Iliofemoral Deep Venous Thrombosis: A Strategy of Thrombus Removal

Patients with acute iliofemoral deep vein thrombosis (DVT) suffer the most severe postthrombotic sequelae. The majority of physicians treat all patients with acute DVT with anticoagulation alone, despite evidence that postthrombotic chronic venous insufficiency, leg ulceration, and venous claudication are common in patients treated only with anticoagulation. The body of evidence to date in patients with iliofemoral DVT suggests that a strategy of thrombus removal offers these patients the best long-term outcome. Unfortunately, currently published guidelines use outdated experiences to recommend against the use of techniques designed to remove thrombus, ignoring recent clinical studies showing significant benefit in patients who have thrombus eliminated. Contemporary venous thrombectomy, intrathrombus catheter-directed thrombolysis, and pharmacomechanical thrombolysis are all options that can be offered to successfully remove venous thrombus with increasing safety. The authors review evidence supporting the rationale for thrombus removal and discuss the most effective approaches for treating patients with acute iliofemoral DVT.