Pharmacomechanical thrombectomy for iliofemoral deep vein thrombosis: An alternative in patients with contraindications to thrombolysis

In Vivo Porcine Model of Acute Iliocaval Deep Vein Thrombosis

CLINICAL IMPACT

The study establishes a rapid, technically straightforward, and reproducible porcine large animal model for acute iliocaval deep vein thrombosis (DVT). The procedure can be performed with basic endovascular skillsets. With its procedural efficiency and consistency, the platform is promising for comparative in vivo testing of venous thrombectomy devices in a living host, and for future verification and validation studies to determine efficacy of novel thrombectomy devices relative to predicates.

Risk factors and outcomes regarding the acute kidney injury after AngioJet thrombectomy for acute lower-extremity deep vein thrombosis

OBJECTIVE

To investigate the risk factors and outcomes regarding acute kidney injury (AKI) after AngioJet thrombectomy for acute lower-extremity deep vein thrombosis (DVT).

METHODS

Patients were divided into AKI and non-AKI groups according to whether AKI occurred postoperatively. The demographic data, pre-operative and post-operative laboratory data and surgical differences were compared between the two groups. Logistic regression and Wilcoxon signed-rank test were used to identify the AKI risk factors and outcomes, respectively.

RESULTS

Among the 341 patients who met the inclusion criteria, 45 developed AKI (AKI group) and 296 had normal renal function (non-AKI group) post-surgery. There were significant differences between the two groups in the course (t = 10.885, P = 0.000); preoperative history of a major surgery within 3 months (3M-MS) (odds ratio [OR] = 5.492, P = 0.001); duration of aspiration thrombectomy (Z = -8.803, P = 0.000); volumes of aspiration (Z = -8.215, P = 0.000); contrast volume (Z = -3.204, P = 0.001) and pulmonary thrombectomy (OR = 18.200, P = 0.002); and preoperative complications of hypertension (OR = 4.637, P = 0.002), diabetes (OR = 18.088, P = 0.000), or pulmonary embolism (OR = 0.085, P = 0.011). Wilcoxon signed-rank test showed that the renal function of every patient in the AKI group returned to normal 3 months after the surgery.

CONCLUSIONS

The course, preoperative complications of diabetes or hypertension, 3M-MS, contrast volume, duration and volume of aspiration thrombectomy, and pulmonary thrombectomy are risk factors for post-AngioJet-thrombectomy AKI, which is temporary.

Venous Intervention

Any overview of the treatment of venous disease should begin with a brief examination of its history. From the first rudimentary attempt at venous thrombectomy in the early 1920s to the evolution of percutaneous and mechanical thrombectomy and endovascular stents in the 21st century. It is the aim of this review to provide a comprehensive summary of the state of the art of venous disease treatment at the turn of the new century.

Intravascular ultrasound evaluation during iliofemoral venous stenting is associated with improved midterm patency outcomes

OBJECTIVE

Intravascular ultrasound (IVUS) examination is increasingly used in the treatment of iliofemoral venous disease and provides more sensitive and specific detection of stenotic lesions when compared with traditional multiplanar venography alone. Correlations with deep venous stent patency, however, have not yet been investigated. The objective of the study was to evaluate the impact of the use of IVUS examination in addition to multiplanar venography on iliofemoral venous patency.

METHODS

Consecutive patients who underwent stenting for symptomatic thrombotic or nonthrombotic iliofemoral venous lesions (NIVLs) between 2014 and 2020 at a single institution were identified and divided into two groups based on whether IVUS examination was used before stent deployment in addition to multiplanar venography compared with venography alone. A retrospective review of demographic, operative, and follow-up data was performed. Thirty-day and 2-year stent patency were measured as primary end points. χ² analysis, logistic regression models, and Kaplan-Meier survival analysis were used to determine outcomes. Technical details and outcomes were additionally examined among patients treated for acute deep venous thrombosis, post-thrombotic syndrome, or NIVLs separately on subgroup analysis.

RESULTS

We identified 150 patients (173 limbs, 23 bilateral) who underwent iliofemoral stenting during the study period at our institution (mean age: 48.8 ± 16.8 years, 61% female). Adjunctive IVUS utilization before stent deployment was reported in 69 of 173 (39.9%) treated limbs. IVUS examination was more likely to be used in patients who underwent stenting for NIVLs compared with thrombotic disease (41.0% vs 11.2%, P < .01). There was no difference in the number of stents deployed between IVUS and non-IVUS cohorts. However, IVUS examination was associated with the increased total length of the stent deployed (126 ± 56 vs 112 ± 48 mm, P = .04) and a higher rate of infrainguinal stent extension (17.4% vs 6.7%, P = .03). In addition, mean stent diameter was significantly higher when IVUS examination was performed before stent placement (16.3 ± 3.7 vs 15.2 ± 1.9 mm, P < .01). Both 30-day (98.5% vs 89.4%, P = .02) and 2-year (90.3% vs 78.7%, P = .03) primary patency were significantly higher in the IVUS cohort. Adjunctive IVUS use was found to significantly protect against stent reintervention at 2 years on adjusted Cox regression analysis (hazard ratio: 0.22, 95% confidence interval: 0.07-0.71, P = .01).

CONCLUSIONS

Adjunctive IVUS utilization is associated with differences in stent diameter and length selections as well as landing segments in the treatment of thrombotic and nonthrombotic iliofemoral venous disease. IVUS examination before stent deployment significantly protects against 30-day and 2-year stent reintervention when compared with the use of multiplanar venography alone. These data provide stronger evidence for routine IVUS use in addition to venography before iliofemoral venous stenting.

Diagnosis and treatment of iliac vein stenosis

Stenosis of the iliac veins is common in patients with chronic venous insufficiency. The article describes the methods for the diagnosis and treatment of iliac vein stenosis. The causes of iliac vein stenosis include extravasal compression or the consequences of ileofemoral thrombosis. Stenosis of the iliac veins exists in 1/4 of the entire adult population, but clinical manifestations do not occur in all patients. Stenosis of the iliac veins should be considered in case of an unknown edema, more often in the left lower extremity, since venous duplex ultrasound of lower extremities is not sensitive and specific enough when examining the veins above the inguinal ligament. The most accurate diagnostic method is intravascular ultrasound (IVUS) but the appeared computed tomography angiography (CTA) and magnetic resonance angiography (MRA) with high-quality images have become a good replacement for IVUS. The main method of treatment of iliac vein stenosis, besides stenting, isindispensable drug therapy consisting of antithrombotic and phlebotonic drugs.

Delayed Yet Successful Mechanical Thrombectomy for Phlegmasia Cerulea Dolens in a Limb with Severe Arterial Disease and May-Thurner Syndrome

Phlegmasia cerulea dolens (PCD) is a rare but life-threatening complication of acute deep venous thrombosis that lacks consensus regarding the approach to management. We present a case of PCD developing shortly after a spinal surgery and manifesting as acute swelling and discoloration in a leg with existing severe atherosclerotic arterial disease. The patient's critical limb ischemia was completely and rapidly reversed by percutaneous mechanical thrombectomy using the ClotTriever device despite a delay in treatment. An underlying iliac vein compression “May-Thurner” syndrome was discovered using intravascular ultrasound and treated with angioplasty. This case identifies mechanical thrombectomy using the ClotTriever system as a possible effective and safe treatment for PCD.

Severe Acute Respiratory Syndrome Coronavirus 2 Infection and Thrombosis: Phlegmasia Cerulea Dolens Presenting with Venous Gangrene in a Child

A 12-year-old girl with severe acute respiratory syndrome coronavirus 2 infection presented as phlegmasia cerulea dolens with venous gangrene. Emergent mechanical thrombectomy was complicated by a massive pulmonary embolism and cardiac arrest, for which extracorporeal cardiopulmonary resuscitation and therapeutic hypothermia were used. Staged ultrasound-assisted catheter-directed thrombolysis was used for treatment of bilateral pulmonary emboli and the extensive lower extremity deep vein thrombosis while the patient received extracorporeal membrane oxygenation support. We highlight the need for heightened suspicion for occult severe acute respiratory syndrome coronavirus 2 infection among children presenting with unusual thrombotic complications.

The efficacy of rotational pharmaco-mechanical thrombectomy in patients with acute iliofemoral deep vein thrombosis: Is the standard treatment of deep vein thrombosis changing?

OBJECTIVE

In this study, we aimed to evaluate the efficiency of rotational thrombectomy device in pharmaco-mechanical thrombolysis for symptomatic acute ilio-femoral deep vein thrombosis.

MATERIALS AND METHODS

Between August 2013 and May 2018,82 patients with acute deep vein thrombosis comprising the iliofemoral segment whom underwent Pharmaco-mechanical thrombolysis were evaluated retrospectively. The Cleaner thrombectomy device was used. The resolution of thrombi was examined and graded. Development of post-thrombotic syndrome was assessed with Villalta scores.

RESULTS

75 patients (91.4%) had complete thrombus resolution. Between 50-99% resolution was noted in 6 patients (7.4%) and in one (1.2%) case less than %50 thrombus resolution was obtained. Seventy-five patients (91%) of the cohort could be treated in a single session; 7 patients (8.6%) required reintervention(s). Although improved post-thrombotic syndrome rates were lower at the short term, Villalta scores gradually increased during follow up.

CONCLUSIONS

In conclusion, Pharmaco-mechanical thrombolysis with Cleaner thrombectomy device is a safe and beneficial method for the treatment of acute iliofemoral deep vein thrombosis. Long term follow up data of large volume multicenter studies are warranted.

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

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

Percutaneous Thrombectomy with the JETi8 Peripheral Thrombectomy System for the Treatment of Deep Vein Thrombosis

PURPOSE

This study evaluated the safety and efficacy of the JETi8 peripheral thrombectomy system in treating acute deep vein thrombosis (DVT).

MATERIALS AND METHODS

A retrospective study was conducted in 18 consecutive patients (mean age, 41 years old [range, 15-74 years old]; 5 men and 13 women). There were 21 instances of DVTs (9 iliofemoral, 10 axillosubclavian, and 2 portal), which were treated using the JETi8 thrombectomy device between November 2016 and July 2018. Thrombus was laced with recombinant tissue plasminogen activator (r-TPA) (9.3 mg, on average; range, 2-12 mg) in 17 procedures (81%) prior to thrombectomy. Technical success was defined as restoration of antegrade flow using the JETi8 with or without additional treatment of an underlying obstructive lesion. Procedural success was defined as technical success with or without the addition of overnight catheter-directed thrombolysis (CDT) RESULTS: Mean procedure time was 83 minutes (range, 30-160 minutes), and mean thrombus reduction with the JETi8 alone was 92% (range, 60%-100%). Stent placement was required in 6 procedures (29%). Technical success using the JETi8 system alone was 76% (16 of 21 procedures), whereas 5 procedures (24%) required subsequent overnight CDT in the intensive care unit. Procedural success rate was 100% (20 of 20 procedures). Mean aspirated volume was 531 mL (range, 250-1,230 mL). The only adverse event was a subsegmental pulmonary embolism. Seven patients (33%) were discharged the same day. Recurrent thrombosis was observed in 5 patients (24%), of whom 3 were successfully treated with the JETi8 system.

CONCLUSIONS

The JETi8 system may be a safe and effective option for thrombectomy of acute DVT.

Iliac vein compression: epidemiology, diagnosis and treatment

Iliac vein compression (LIVC) is a prevalent finding in the general population, but a smaller number of patients are symptomatic. ILVC should be considered in symptomatic patients with unexplained unilateral lower leg swelling. Patients typically complain of one or more of the following symptoms: lower leg pain, heaviness, venous claudication, swelling, hyperpigmentation and ulceration. ILVC can be thrombotic, combined with acute or chronic DVT, or non-thrombotic. ILVC is best diagnosed with intravascular ultrasound (IVUS), but computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have emerged as valid screening tests. Venography underestimates the severity of ILVC but may provide insights into the anatomy and the presence of collaterals. Based on current available evidence, endovascular therapy with stenting remains the main treatment strategy for ILVC. Dedicated nitinol venous stents are currently under review by the Food and Drug Administration for potential approval in the United States. These stents have been released outside the US. There is no consensus to the optimal anticoagulation regimen post-ILVC stenting. Oral anticoagulants, however, remain a preferred therapy in patients with history of thrombotic ILVC.

Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use:

https://youtu.be/InSwn2AebNY

Initial experience with a new pharmacomechanical thrombectomy device for deep venous thrombosis: Report of 91 cases

Background

To evaluate the efficacy and safety of pharmacomechanical thrombectomy using a new rotational thrombectomy device with additional thrombus-removal methods for deep venous thrombosis.

Methods

A total of 91 patients admitted to our tertiary center with symptomatic iliac, ilio-femoral, femoro-popliteal deep venous thrombosis and who underwent hybrid pharmacomechanical thrombectomy constituted the study group. Postinterventional color Doppler ultrasonography was repeated at 1st, 6th, and 12th months. Villalta scoring system was used to evaluate the patients for the development of post-thrombotic syndrome after deep venous thrombosis. The patient-reported severity of pain in the index leg was measured on a Likert scale.

Results

Of the 91 patients whose charts were reviewed, the location of thrombus was iliofemoral in 60 (65.9%) and femoropopliteal in 31 (34.1%) patients, respectively. Duration of symptoms was 5.62 ± 3.43 (range, 2–15) days. Technical success was observed in 82 patients (90.1%) at 3 months, in 77 patients (84.6%) at 6 months, and in 74 patients (81.3%) at 12 months. Villalta score was over 10 points in 15 of 17 patients whose Doppler US revealed venous occlusions, at 12 months, and in 8 patients with recurrent deep venous thrombosis. Post-thrombotic syndrome was detected in 18 patients in our study. Twelve (13.2%) of these 18 patients had mild, 5 (5.5%) moderate, and 1 (1.1%) severe PTS. In predicting predisposing factors in 18 patients with PTS, 13 patients (72.2%) had a Villalta score ≥10, 10 patients (55.6%) had experienced a delayed endovascular procedure (≥10 days), and 8 patients (44.4%) had recurrent deep venous thrombosis.

Conclusion

The endovenous pharmacomechanical thrombectomy with the Mantis thrombectomy device in the treatment of acute and subacute iliofemoral deep venous thrombosis is a promising approach in terms of efficacy and safety in the early period regarding reasonable and long-term prevention of post-thrombotic syndrome, development of pulmonary thromboembolism, and adequate venous system patency.

Outcomes and predictors of failure of iliac vein stenting after catheter-directed thrombolysis for acute iliofemoral thrombosis

OBJECTIVE

Iliac vein stenting is recommended to treat venous outflow obstruction after catheter-directed thrombolysis for acute iliofemoral deep venous thrombosis (DVT). Data on the outcome of proximal and distal stent extension are limited. Proximal stent extension to the vena cava may obstruct the contralateral iliac vein, whereas distal extension below the inguinal ligament contradicts common practice for arterial stents. The aim of this retrospective study was to assess outcomes and predictors of failure of iliac vein stents and contralateral iliac vein thrombosis, taking into consideration stent positioning.

METHODS

Consecutive patients who underwent thrombolysis and stenting for DVT between May 2007 and September 2017 were identified from a prospectively maintained database. The intraoperative venograms were reviewed for proximal stent placement (covering >50% contralateral iliac vein orifice) and distal placement across the inguinal ligament. End points were ipsilateral DVT recurrence, post-thrombotic syndrome (PTS; Villalta score ≥5), and contralateral DVT. Patients with chronic contralateral DVT or contralateral iliac vein stenting at baseline were excluded from the contralateral DVT outcome evaluation. Survival analysis and Cox regression models were used to determine outcomes.

RESULTS

Of 142 patients lysed, 73 patients (12 bilateral DVTs; mean age, 45.8 ± 17.2 years; 46 female patients) were treated with various combinations of thrombolytic techniques and at least one self-expanding iliac stent (77 stented limbs). Thirty-day recurrence developed in nine (12.3%) patients. The 3-year primary patency and secondary patency rates were 75.2% and 82.2%, respectively. The single predictor for loss of primary patency was incomplete thrombolysis (≤50%; hazard ratio [HR], 7.41; P = .002). Overall, 3 of 12 (25%) stents extending below the inguinal ligament occluded at 1 month, 2 months, and 9 months, respectively. The overall rate of PTS (Villalta score ≥5) in the stented cohort was 14.4% at 5 years. This was predicted by incomplete lysis (<50%; HR, 7.09; P = .040), stent extension below the inguinal ligament (HR, 6.68; P = .026), and male sex (HR, 6.02; P = .041). Of the 17 stents that extended into the contralateral common iliac vein and 58 stents that did not, there were 1 (5.9%) and 5 (8.6%) contralateral DVTs (P = .588) at an average follow-up of 27.4 ± 33.7 and 22.2 ± 22.3 months (P = .552), respectively.

CONCLUSIONS

Iliac stenting after thrombolysis for acute DVT guarantees high patency and low PTS rates, provided adequate thrombus resolution has been achieved before stent placement. Stent placement below the inguinal ligament does not affect the patency but may be associated with a higher PTS rate. Stenting proximal to the iliocaval confluence, although a precipitating factor, may not independently increase the likelihood of contralateral DVT.

Aspiration thrombectomy for acute iliofemoral or central deep venous thrombosis

OBJECTIVE

The use of catheter-directed thrombolysis (CDT) may provide clinical benefit in patients with acute deep venous thrombosis (DVT), but significant doubt remains about its indications and risks. We assessed technical success in resolution of acute iliofemoral or central DVT after single-session treatment with a novel mechanical aspiration thrombectomy device as an alternative to initiation of CDT.

METHODS

This was a single-center retrospective review of patients with acute iliofemoral or central DVT treated with the Indigo continuous aspiration mechanical thrombectomy 8 system (Penumbra, Inc, Alameda, Calif) from 2016 to 2017. The primary outcome was technical success, defined as resolution of >70% of thrombus without need for postaspiration CDT, as an initial or adjunctive treatment. Secondary end points included DVT recurrence and treatment complications.

RESULTS

There were 10 patients (50% male) with a median age of 44 years (range, 19-68 years). Indication for treatment was DVT (n = 4), recurrent DVT (n = 1), stent thrombosis (n = 3), high-grade extrinsic narrowing of the inferior vena cava (IVC) due to immunoglobulin G4-related disease (n = 1), and IVC obstruction from liver tumor invasion (n = 1). Five patients had underlying May-Thurner syndrome. Five patients had iliofemoral involvement, two iliocaval, and one iliac vein alone. Two patients had central DVT, one of them involving the IVC and one involving the superior vena cava with brachiocephalic extension. Aspiration thrombectomy was technically successful in a total of six patients. Success was achieved in five of eight patients as the initial or main treatment modality and as an adjunctive treatment in one of two patients. Of the four patients in whom aspiration thrombectomy was not successful, three underwent successful further treatment with CDT. Recurrence after successful aspiration was seen in two patients. One patient developed pulmonary embolism that required no additional treatment. One patient experienced severe headaches treated with oral analgesics.

CONCLUSIONS

We observed a technical success of 60% for acute iliofemoral and central DVT with an aspiration thrombectomy system that allowed definitive treatment in one setting. As a novel therapy, this avoided the need for thrombolysis in the majority of selected cases with no bleeding complications and is a promising technique for acute DVT management.

Long-term results of additional thrombolytic therapy in patients with acute deep vein thrombosis treated with pharmacomechanical thromboaspiration: A comparative study

Background

This study aims to evaluate the clinical and ultrasonographic long-term results of additional thrombolytic therapy to pharmacomechanical thromboaspiration in patients with acute and subacute lower extremity deep vein thrombosis.

Methods

Medical data of a total of 68 patients ( 41 males, 27 females; mean age 38 years; range, 25 to 56 years) who were admitted to our department with the diagnosis of hyperacute or acute deep vein thrombosis between January 2013 and January 2015 were retrospectively analyzed. The patients were divided into two groups: thrombectomy without thrombolytic therapy (Group 1, n=33) and thrombectomy with thrombolytic therapy (Group 2, n=35). All patients were administered Clinical Symptom Scoring and Doppler ultrasonography at one, six, and 12 months.

Results

Clinical symptom scores were higher in Group 1 at one month (p<0.001), while there was no significant difference between the groups at six months (p=0.102). Group 1 had higher scores at 12 months (p=0.043). The complete patency rates for both groups were similar at one month (p=0.181); however, the rates were higher in Group 2 at six and 12 months (p=0.019 and p=0.002, respectively). There was no significant difference in the complete patency rates between the groups at one and six months (p=0.563 and p=0.064, respectively), while these rates were higher in Group 2 at 12 months (p=0.013). In patients with acute deep vein thrombosis, the complete patency rates were found to be higher in all control Doppler ultrasonography examinations.

Conclusion

In the treatment of both hyperacute and acute deep vein thrombosis, the addition of thrombolytic therapy to pharmacomechanical thromboaspiration improves the clinical symptoms and venous patency rates.

What is the definition of successful lysis: reporting standard?

Deep vein thrombosis, and the resultant development of post-thrombotic syndrome, is a significant health issue. Recent evidence demonstrates that the severity of post-thrombotic syndrome symptoms is directly related to the level of venous thrombosis and following treatment these subsequent symptoms are inversely related to the degree of thrombus removal. If we can improve, and preferably standardise the terminology associated with pre-treatment assessment of thrombus load and post-treatment success of thrombus removal techniques, we should then be able to choose more tailor-made techniques to greater benefit our patients. A number of scoring systems have been devised for the assessment of venous thrombus burden, with a majority impractical for everyday usage. In order to provide a more practical solution, the lower extremity thrombosis classification has been developed, using information on anatomical location for venous thrombus combined with a clinical indicator as to the likely sequelae. Anatomical success following venous thrombolysis can be defined by assessing restoration of anterograde flow in the treated vein or the percentage degree of thrombolysis, using venography. The second option is the method most frequently utilised, with the Venous Registry grading system applied. Data from recent trials have given us conflicting and confusing data mainly because we are not using standardised terminology. We urgently need to agree on a standard method of description of thrombus removal before stent placement which also incorporates the likely clinical impact of the area involved in the thrombosis.

The Angiovac Device: Understanding the Failures on the Road to Success

Objective

Current percutaneous thromboembolectomy techniques may obviate surgical intervention in high-risk patients with iliocaval thrombus or thrombus of the right side of the heart, but typically require thrombus fragmentation and thrombolysis with associated bleeding and thromboembolic complications. The AngioVac (Angiodynamics, Latham, NY USA) device uses a percutaneous venovenous bypass circuit to aspirate intact thrombus. A review of the literature was performed with regard to the AngioVac device to determine the factors correlating with successful thrombus extraction.

Methods

A literature search was performed with regard to use of the AngioVac device using the PubMed database. A meta-analysis was not performed given the small size and lack of statistical analysis of the individual reports included.

Results

Twenty-three reports describing 57 procedures in 56 patients were analyzed. Indications for thrombectomy included iliocaval thrombus in 53% (30), thrombus of the right side of the heart, in 49% (28), pulmonary embolus in 14% (8), and upper extremity venous/Glenn shunt thrombosis in 7% (4). The complete success rate, defined as removal of all thrombus, was 75% (43), with an 11% (6) partial success rate. In 14% (8) of cases, minimal or no thrombus was retrieved. When analyzed by indication, iliocaval thrombus and thrombus of the right side of the heart demonstrated 87% (26) and 82% (23) complete success rates, respectively. Pulmonary embolus demonstrated a significantly lower success rate at 12.5% [1; (P < .001)]. Complications occurred in 12% (7), including six hematomas and one retroperitoneal bleed.

Conclusions

The AngioVac device offers an excellent alternative to surgical thrombectomy for patients presenting with iliocaval or intracardiac thrombus, with success rates of more than 80%, although it seems that pulmonary emboli are less amenable. Appropriate patient selection can lead to improved outcomes. Larger numbers are needed to make more definite conclusions.

Safety and Efficacy of Low Dosage of Urokinase for Catheter-directed Thrombolysis of Deep Venous Thrombosis

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.

Iliofemoral deep vein thrombosis: Percutaneous endovascular treatment options

Venous thromboembolism is defined as an acute venous thrombotic event that targets two disease entities: deep vein thrombosis (DVT), pulmonary embolism, or both. The most common site of DVT origin is in the lower extremities, with 50% of patients exhibiting no symptoms. Although anticoagulation is the gold standard for DVT, early clot removal, especially of proximal iliofemoral DVT, is felt to reduce the incidence of postthrombotic syndrome (PTS) by preserving valve function. Up to one-half of all patients with an iliofemoral DVT treated only with anticoagulation subsequently develop long-term complications, including PTS. Beside anticoagulation, DVT treatment options may include pharmaceutical and/or mechanical therapies. Mechanical therapies consist of either endovascular percutaneous catheter-directed (PCD) interventions or open operative thrombectomy. There are several different PCD procedures available, consisting of catheter-directed thrombolysis, mechanical thrombectomy, combination pharmacomechanical devices, and postthrombus extraction (angioplasty and/or stenting). Endovascular therapies in the management of acute iliofemoral DVT are evolving with a variety of devices available to treat this disease entity. The purpose of this article is to provide an overview of the PCD therapies used when treating patients experiencing an acute iliofemoral DVT along with associated nursing considerations. Off-label device use is not included.

Economic Burden of Venous Thromboembolism in Patients Undergoing Major Abdominal Surgery

BACKGROUND

Venous thromboembolism (VTE) is a serious complication that arises after major abdominal surgery. VTE poses risks of negative outcomes and health care burden. The literature on the cost of VTE in Japanese surgical patients, however, is scarce.

OBJECTIVE

This study was conducted to investigate the economic consequences of VTE in Japanese patients with major abdominal surgery, using a hospital claims database.

METHODS

This is a retrospective, matched cohort study. Patients who had a VTE event up to 90 days after their first major abdominal surgery and initiated warfarin or heparin within 1 day of VTE diagnosis with continued treatment for more than 4 weeks were matched with controls for surgery type, hospital, and date of surgery ± 6 months in a 1:2 scheme. The primary outcome was 90-day costs associated with major abdominal surgery. The secondary outcomes were 6-month total costs, average length of initial inpatient stay, and cost of initial inpatient stay.

RESULTS

The 90-day cumulative incidence of VTE was 4.89%. The development of a VTE event in patients undergoing major abdominal surgery resulted in a 1.5-fold increase in the length of hospitalization and a 2.8-fold increase in total costs 90 days after the surgery. Total costs further increased to 3.4-fold at 6 months. Overall, costs incurred in patients with VTE are on average much higher than in patients without VTE throughout 6-month postsurgery.

CONCLUSIONS

The preventive care for VTE using more effective prophylactic treatment is recommended to reduce the economic burden associated with major abdominal surgery.

Management of upper extremity deep venous thrombosis in a hospice patient

BACKGROUND

In this case report, upper extremity deep venous thrombosis (UEDVT) is discussed with special attention to the diagnosis, treatment, and prevention in palliative care patients.

METHODS

A 43-year-old female with a history of metastatic breast cancer presented with a UEDVT. Standard anticoagulation was unsuccessful, so after a complete discussion about the treatment options, alternative therapy was used for clot lysis.

CONCLUSION

Aggressive treatment of UEDVT in a palliative care setting has the potential for improving the quality of life, yet because of the increased risk of complications and philosophy of palliative medicine, the treatment strategy for each patient should be carefully considered.

Percutaneous pharmacomechanical thrombectomy for acute iliofemoral deep vein thrombosis: A suitability study

Objectives

Percutaneous pharmacomechanical thrombectomy is an emerging therapy for acute deep vein thrombosis and may reduce long-term incidence of post-thrombotic syndrome. This study investigates the proportion of patients presenting with lower limb deep vein thrombosis who are potentially suitable for percutaneous pharmacomechanical thrombectomy.

Methods

A retrospective review of all duplex ultrasound scans for lower limb deep vein thrombosis over two-year period at a regional vascular unit was conducted. All acute occlusive iliofemoral deep vein thrombosis were screened for percutaneous pharmacomechanical thrombectomy suitability according to predefined criteria.

Results

There were 2513 duplex ultrasound scans for suspected lower limb deep vein thrombosis in the two-year period. There were 120 cases of acute occlusive iliofemoral deep vein thrombosis. After application of inclusion and exclusion criteria 48 out of 120 (40%) patients were identified as potential candidates for percutaneous pharmacomechanical thrombectomy.

Conclusions

This indicates that a large randomised trial of percutaneous pharmacomechanical thrombectomy is feasible given expected recruitment rates in a multicentre study.

Basic data related to thrombolytic therapy for acute venous thrombosis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Economic Impact of Venous Thromboembolism Following Major Orthopaedic Surgery in Japan

OBJECTIVES

Venous thromboembolism (VTE) is the most frequent complication following major orthopaedic surgery (MOS). Although studies in Western populations have demonstrated significantly higher costs for patients with VTE versus those without VTE after MOS, there is a paucity of such data in Japan. This study was conducted to understand the costs and VTE rates in Japanese patients.

METHODS

Data were extracted from a hospital claims database. MOS was defined as total hip replacement, total knee replacement, or hip fracture repair. Subjects who underwent more than one MOS during the same admission were excluded. Identified VTE cases were matched on a 1:2 matching scheme on the basis of surgery type, hospital, and date of surgery (±6 months). The primary outcome was the difference in 90-day costs. Secondary outcomes included differences in total 6-month costs postsurgery and average length and cost of initial hospital stay.

RESULTS

The 90-day cumulative VTE incidence was 0.774%, with 94% of the cases occurring within 30 days postsurgery. Total 90-day costs were significantly higher in patients with VTE (difference of 864,153 Japanese yen [US $10,538]). Average length of stay was longer for patients with VTE (66 days vs. 42 days). Costs incurred by patients with VTE were on average much higher than those incurred by patients without VTE throughout 5 months postsurgery.

CONCLUSIONS

The development of a VTE in patients undergoing MOS results in a 1.5-fold increase in the length of stay and a 1.7-fold increase in 90-day costs. Findings indicate that the avoidance of VTEs through more effective prophylaxis will help to reduce the economic burden associated with MOS.

Management of proximal deep vein thrombosis

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

Total preservation of patency and valve function after percutaneous pharmacomechanical thrombolysis using the Trellis®-8 system for an acute, extensive deep venous thrombosis

Pharmacomechanical thrombolysis is being used increasingly for the treatment of deep vein thrombosis (DVT) and aims to reduce the severity of post-thrombotic syndrome. We report the case of a 60-year-old woman with extensive lower limb DVT that was treated using pharmacomechanical thrombolysis leading to complete recovery of her deep venous system. The prompt use of pharmacomechanical thrombolysis for the acute management of extensive DVT should be considered when treating patients with extensive DVT in order to facilitate return of normal function.

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.