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Ozcinar E, Dikmen N, Kayan A, Kandemir M, Saricaoglu MC. Pharmacomechanical Thrombectomy and Catheter-Directed Thrombolysis, with or without Iliac Vein Stenting, in the Treatment of Acute Iliofemoral Deep Vein Thrombosis. J Cardiovasc Dev Dis 2024; 11:214. [PMID: 39057634 PMCID: PMC11276789 DOI: 10.3390/jcdd11070214] [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: 05/22/2024] [Revised: 07/05/2024] [Accepted: 07/07/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND This study aims to evaluate and compare the outcomes and clinical efficacy of pharmacomechanical thrombectomy (PMCT) plus catheter-directed thrombolysis (CDT) and PMCT combined with CDT and venous stenting in managing acute iliofemoral deep vein thrombosis (DVT), while also assessing the long-term safety and efficacy of these interventions. METHODS A retrospective case-control study spanning 3 years involved 112 patients presenting with acute symptomatic iliofemoral deep vein thrombosis (DVT), each with a symptom duration of less than 14 days. Patients were consecutively categorized into two groups based on individual clinical indications: PMCT + CDT vs. PMCT + CDT + venous stent. Statistical analyses were conducted to compare clinical features and outcomes between the two groups. Additionally, patients were followed up for 24 months post-treatment, during which quality of life (QoL) and severity of post-thrombotic syndrome (PTS) were analyzed. RESULTS In this retrospective study, we analyzed a total of 112 consecutive patients, with 63 patients undergoing PMCT + CDT and 49 patients undergoing PMCT + CDT + venous stent. Between the two groups, regarding primary outcomes at 6 months, there was no difference in the observed cumulative patency rates, standing at 82.5% for PMCT + CDT and 81.6% for PMCT + CDT + stent. Survival analyses for primary, primary-assisted, and secondary patency yielded comparable results for PMCT + CDT, with p-values of 0.74, 0.58, and 0.72, respectively. The two-year patency rate was high in both groups (85.7% for PMCT + CDT vs. 83.7% for PMCT + CDT + stent). Additionally, during the follow-up period, there were no statistically significant differences observed in the incidence of PTS or the average Villalta score between the two groups. At 24 months post-intervention, the incidence of post-thrombotic syndrome (PTS) was 11.1% in the PMCT + CDT group and 22% in the PMCT + CDT + stent group (p = 0.381). Both treatment arms of the study groups experienced bleeding complications during the thrombolysis therapy; in the PMCT + CDT group, there were three cases of gastrointestinal bleeding, compared to two cases in the PMCT + CDT + stent group (p = 0.900). Additionally, there was one intracranial hemorrhage in the PMCT + CDT group and two in the PMCT + CDT + stent group. CONCLUSIONS Pharmacomechanical thrombectomy (PMCT) combined with catheter-directed thrombolysis (CDT) therapy has shown significant efficacy in alleviating leg symptoms and reducing the occurrence of post-thrombotic syndrome (PTS), including the incidence of moderate-to-severe PTS. On the other hand, the utilization of PMCT + CDT + stent therapy, tailored to individual patients' clinical and venous conditions, may enhance long-term venous patency and lead to superior outcomes, including improved quality of life parameters.
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Affiliation(s)
- Evren Ozcinar
- Department of Cardiovascular Surgery, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara 06230, Turkey; (E.O.); (M.K.); (M.C.S.)
| | - Nur Dikmen
- Department of Cardiovascular Surgery, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara 06230, Turkey; (E.O.); (M.K.); (M.C.S.)
| | - Ahmet Kayan
- Department of Cardiovascular Surgery, Kirikkale High Specialization Hospital, Kirikkale 71300, Turkey;
| | - Melisa Kandemir
- Department of Cardiovascular Surgery, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara 06230, Turkey; (E.O.); (M.K.); (M.C.S.)
| | - Mehmet Cahit Saricaoglu
- Department of Cardiovascular Surgery, Heart Center, Cebeci Hospitals, Ankara University School of Medicine, Ankara 06230, Turkey; (E.O.); (M.K.); (M.C.S.)
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Zhang Y, Wei H, Liu Y, Wang Q, He C. Clinical characteristics of lower extremity deep vein thrombosis in young vs. middle-aged adults: a single-center retrospective study. Front Cardiovasc Med 2024; 11:1381391. [PMID: 38737715 PMCID: PMC11082356 DOI: 10.3389/fcvm.2024.1381391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 04/04/2024] [Indexed: 05/14/2024] Open
Abstract
Background The incidence of deep vein thrombosis (DVT) in the lower extremities is increasing in the younger population. However, there are fewer reported comparisons in the literature for lower extremity DVT. Methods Patients aged <40 years admitted with lower-extremity DVT between January 2018 and December 2023 were retrospectively analyzed and followed up for 1 year. Results A total of 61 patients were included in the study and divided into two groups: 33 patients over 30 years of age (middle-aged group) and 28 patients under 30 years of age (young group). A significant gender difference was observed, with a higher proportion of males in the young group compared to the middle-aged group (P < 0.001). Five patients in the young group were treated with anticoagulation alone, whereas all patients in the middle-aged group underwent endovascular therapy. A higher prevalence of inferior vena cava thrombosis in the young group compared to the middle-aged group (60.71% vs. 33.3%, P = 0.032). The proportion of iliac vein stenosis was significantly higher in the middle-aged groups than in the young group (P = 0.002). There was no statistically significant difference in venous function scores (Villalta and rVCSS) between the two groups during both the preoperative period and the postoperative follow-up (P > 0.05). The incidence of lower-extremity DVT post-thrombotic syndrome and thrombus recurrence was higher in the young group than in the middle-aged group at 1 year postoperatively (PTS: 78.57% vs. 33.3%, P < 0.001, and thrombus recurrence: 28.57% vs. 9.09%, P < 0.05). Univariate and multivariate analyses revealed that inferior vena cava thrombosis was an independent risk factor for severe DVT post-thrombotic syndrome and recurrent DVT (P < 0.05), whereas gender was an independent risk factor for recurrent DVT (P < 0.05). Conclusions This study suggests differences in the clinical characteristics and prognosis of lower-extremity DVT.
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Affiliation(s)
| | | | | | - Qiqi Wang
- Department of Vascular Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Chunshui He
- Department of Vascular Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
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Li W, Zaid Al-Kaylani A, Zeebregts CJ, El Moumni M, de Vries JPPM, van der Doef HPJ, Bokkers RPH. Effectiveness and safety of catheter-directed thrombolysis in conjunction with percutaneous mechanical thrombectomy for acute iliofemoral deep vein thrombosis: A meta-analysis. J Vasc Surg Venous Lymphat Disord 2023; 11:843-853.e2. [PMID: 36893883 DOI: 10.1016/j.jvsv.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/13/2022] [Accepted: 01/23/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Patients with severe acute low iliofemoral deep vein thrombosis (DVT), such as phlegmasia cerulea dolens, benefit from catheter-directed thrombolysis (CDT). This meta-analysis investigated the effectiveness and safety of adjuvant percutaneous mechanical thrombectomy (PMT) during CDT compared with CDT alone in the treatment of acute iliofemoral DVT. METHODS A meta-analysis was performed in accordance with the PRISMA guidelines. Medline, Embase, the Cochrane Library, China National Knowledge Internet, and Wanfang data were searched for studies on the management of acute iliofemoral DVT by means of CDT or CDT with adjuvant PMT. Randomized, controlled trials and nonrandomized studies were included. The primary outcomes were venous patency rate, major bleeding complications, and post-thrombotic syndrome occurrence within 2 years of the procedure. The secondary outcomes were thrombolytic time and volume, as well as the rates of thigh detumescence and iliac vein stenting. RESULTS The meta-analysis included 20 eligible studies with a total of 1686 patients. The rates of venous patency (mean difference, 10.11; 95% confidence interval [CI], 5.59-14.62) and thigh detumescence (mean difference, 3.64; 95% CI, 1.10-6.18) of the adjuvant PMT group were higher than those of the CDT alone group. Compared with CDT alone, the adjuvant PMT group experienced fewer incidences of major bleeding complications (odds ratio, 0.45; 95% CI, 0.26-0.77) and occurrences of post-thrombotic syndrome within 2 years of the procedure (odds ratio, 0.55; 95% CI, 0.33-0.92). Furthermore, the duration of thrombolytic therapy was shorter, and the total dose of administered thrombolytics was lower with adjuvant PMT. CONCLUSIONS Adjuvant PMT during CDT is associated with improved clinical outcomes and a lower incidence of major bleeding complications. The studies investigated were, however, single-center cohort studies, and future randomized controlled trials are needed to substantiate these findings.
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Affiliation(s)
- Weihao Li
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Abdallah Zaid Al-Kaylani
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Mostafa El Moumni
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jean-Paul P M de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Hubert P J van der Doef
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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Intravascular ultrasound evaluation during iliofemoral venous stenting is associated with improved midterm patency outcomes. J Vasc Surg Venous Lymphat Disord 2022; 10:1294-1303. [PMID: 35872140 DOI: 10.1016/j.jvsv.2022.05.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 05/12/2022] [Accepted: 05/25/2022] [Indexed: 12/24/2022]
Abstract
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.
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Budak AB, Gunertem OE, Ozisik K, Gunaydin S. Pharmacomechanical catheter-directed thrombolysis for acute iliofemoral deep vein thrombosis in a large study population. J Vasc Surg Venous Lymphat Disord 2021; 10:818-825. [PMID: 34890845 DOI: 10.1016/j.jvsv.2021.11.005] [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: 09/18/2020] [Accepted: 11/18/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND We have analyzed our single-center immediate and follow-up results in the management of acute iliofemoral deep vein thrombosis (IFDVT) using pharmacomechanical catheter-directed thrombolysis (PMCDT) to determine the safety, accuracy, and effects on quality of life and whether this treatment strategy prevents post-thrombotic syndrome (PTS). METHODS The cases of 230 patients who had undergone PMCDT to treat IFDVT from January 2017 to December 2018 were retrospectively reviewed. The preoperative, operative, and postoperative variables, Marder scores, outcomes, and follow-up assessments with the Villalta score and venous clinical severity score were investigated. RESULTS Anatomic success was achieved for 95.2% of the 230 patients. The mean Marder score had decreased from 12.65 ± 2.1 to 2.4 ± 1.3 postoperatively (P < .01). Early recurrent thrombosis had developed in 13 patients (5.65%). The primary patency at the 1-, 6-, and 12-month follow-up visits was 94.0%, 87.2%, and 81.7%, respectively. From 1 to 6 months, the Villalta score had decreased from 8.32 ± 4.14 to 3.43 ± 0.61 and the venous clinical severity score had decreased from 4.0 ± 1.8 to 1.82 ± 0.36 (P < .05). No statistically significant difference was found in the PTS severity scores at 12 months of follow-up compared with at 6 months. The mean change in the venous disease-specific quality of life from baseline to 12 months was 29.41 ± 1.99 (P = .029). The total recurrence rate was 19.63% at 1 year. CONCLUSIONS For a select group of patients with acute IFDVT, the use of PMCDT and postoperative anticoagulation therapy offered significant reductions in clot burden, leg pain, and swelling, achieving a significant reduction in PTS severity scores at 6 months.
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Affiliation(s)
- Ali Baran Budak
- Department of Cardiovascular Surgery, Alanya Practice and Research Center, Başkent University Faculty of Medicine, Antalya, Turkey.
| | - Orhan Eren Gunertem
- Department of Cardiovascular Surgery, Medicalpark Ankara Hospital, Ankara, Turkey
| | - Kanat Ozisik
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
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Salem KM, Saadeddin Z, Go C, Malak OA, Eslami MH, Hager E, Al-Khoury G, Chaer RA, Avgerinos ED. Risk factors for acute kidney injury after pharmacomechanical thrombolysis for acute deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2020; 9:868-873. [PMID: 33186753 DOI: 10.1016/j.jvsv.2020.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pharmacomechanical thrombolysis (PMT) is an established treatment for selected patients with acute deep vein thrombosis (DVT). Despite significant clinical success, hemolysis can lead to acute kidney injury (AKI) with unknown longer term implications. Our aim was to characterize the rate of AKI after PMT and identify those patients at the greatest risk. METHODS A retrospective medical record review of patients with acute DVT who had undergone PMT in our institution from 2007 to 2018 was performed. The baseline demographics, comorbidities, preoperative clinical characteristics, procedural details, postoperative hospital course, and follow-up data were reviewed. The primary outcome was postoperative AKI (≥1.5 times preoperative creatinine), and longer term renal impairment. Logistic regression modeling was used to identify associated factors. RESULTS A total of 137 patients (mean age, 47 ± 16.6 years; 49.6% male) who had undergone PMT for treatment of acute DVT were identified (85.4% AngioJet system; Boston Scientific Corp, Marlborough, Mass). Of the 137 patients, 30 (21.9%) had developed AKI in the periprocedural period, 1 of whom had required hemodialysis in the perioperative period. The patients who had developed AKI had had significantly greater rates of preoperative coronary artery disease (23.1% vs 4.7%; P = .002), diabetes mellitus (19.2% vs 6.6%; P = .045), dyslipidemia (42.3% vs 17.9%; P = .008), and hypertension (53.6% vs 29.3%; P = .018). No significant difference was found in preoperative creatinine (0.99 vs 0.92 mg/dL; P = .65) or glomerular filtration rate (GFR; 96.9 vs 91.8 mL/min; P = .52) between the two groups. Multivariate analysis demonstrated bilateral DVT (odds ratio [OR], 4.35; 95% confidence interval [CI], 1.47-12.86; P = .008), single-session PMT (OR, 3.05; 95% CI, 1.02-9.11; P = .046), and female sex (OR, 2.85; 95% CI, 1.01-8.04; P = .048) were significant predictors of AKI. Of the 30 patients, 10 had had normal renal function at discharge and 15 and 25 patients had had normal renal function at the first and subsequent clinical follow-up visits, respectively. The remaining five patients (3.6%) had progressed to moderate (GFR, <60 mL/min) or severe (GFR, <30 mL/min) renal insufficiency, with one requiring long-term hemodialysis. CONCLUSIONS The use of PMT for treatment of acute DVT conferred a risk of AKI that will progress to chronic renal failure in a small fraction of affected patients. Patients with bilateral extensive DVTs have a greater risk of AKI; thus, longer priming with a thrombolytic drip before PMT should be preferred for this population.
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Affiliation(s)
- Karim M Salem
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pa.
| | - Zein Saadeddin
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pa
| | - Catherine Go
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pa
| | - Othman A Malak
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pa
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pa
| | - Eric Hager
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pa
| | - Georges Al-Khoury
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pa
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pa
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pa
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Go C, Chaer RA, Avgerinos ED. Catheter Interventions for Acute Deep Venous Thrombosis: Who, When and How. VASCULAR AND ENDOVASCULAR REVIEW 2020. [DOI: 10.15420/ver.2019.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Deep venous thrombosis (DVT) is common and can be a source of morbidity by way of pulmonary embolism and post-thrombotic syndrome. Recent trials have demonstrated both early and late symptomatic benefit in venous thrombolysis and early recanalisation of the iliocaval system of selected patients. Based on the emerging evidence, national societies have published guidelines that recommend early thrombus removal in iliofemoral DVT in patients with low bleeding risk and good life expectancy. In light of these recommendations, endovenous thrombolysis and/or thrombectomy have become more popular among vein specialists. As more venous technology becomes available, surgeons and interventionalists should take pause and ensure their patient selection and treatment algorithms parallel that of existing and emerging evidence. This article summarises current evidence, technology, and the approach used at a high-volume academic centre in treating iliofemoral DVT.
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Affiliation(s)
- Catherine Go
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, US
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, US
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, US
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Yin SW, Guo LW, Bian L, Xiang TM, Pan SQ. Evaluation of Percutaneous Mechanical Thrombectomy via the AngioJet System Combined with Catheter-Directed Thrombolysis for the Treatment of Symptomatic Lower Extremity Deep Venous Thrombosis. Ann Vasc Surg 2019; 65:66-71. [PMID: 31751599 DOI: 10.1016/j.avsg.2019.11.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 10/22/2019] [Accepted: 11/09/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Current methods of treating lower extremity deep venous thrombosis (LEDVT), such as catheter-directed thrombolysis (CDT) alone, or percutaneous mechanical thrombectomy (PMT) alone, are accompanied by unacceptably high risks of complications. This preliminary retrospective study evaluated the efficacy of CDT combined with PMT (via the AngioJet system), relative to CDT alone, in treating LEDVT. METHODS Forty-two patients (43 limbs) with symptomatic deep venous thrombosis received either CDT alone (n = 12) or PMT combined with CDT (PMT + CDT) from May 2012 to December 2016. The groups were compared for clinical outcomes and demographics, LEDVT risk factors, and dosages of urokinase. Thrombus removal, by venographic evidence, was classified as grades I (<50%), II (50 to 99%), or III (>99%). RESULTS In the CDT (PMT + CDT) cohorts, grades I, II, and III thrombus removal was achieved by 8% (3%), 17% (10%), and 75% (87%) of patients, respectively. The urokinase dosage and hospitalization required by the CDT group (5.29 ± 0.45 million IU, 20.4 ± 4.6 days) were significantly greater than those required by the PMT + CDT group (4.08 ± 1.15 million IU, 16.0 ± 6.0 days; P = 0.001, 0.039). The clinical outcomes of the 2 groups were similar. CONCLUSION Combined PMT and CDT was effective and safe for LEDVT clinical therapy, and hospital stay, urokinase dosage, and complications were less compared with patients who received CDT only.
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Affiliation(s)
- Shi-Wu Yin
- Department of Intervention and Vascular Surgery, The Second People's Hospital of Hefei, Anhui Hefei, China.
| | - Li-Wen Guo
- Department of Intervention Therapy, Zhejiang Cancer Hospital, Zhejiang Hangzhou, China
| | - Lu Bian
- Department of Intervention and Vascular Surgery, The Second People's Hospital of Hefei, Anhui Hefei, China
| | - Ting-Miao Xiang
- Department of Intervention and Vascular Surgery, The Second People's Hospital of Hefei, Anhui Hefei, China
| | - Sheng-Quan Pan
- Department of Intervention and Vascular Surgery, The Second People's Hospital of Hefei, Anhui Hefei, China
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Go C, Saadeddin Z, Pandya Y, Chaer RA, Eslami MH, Hager ES, Singh MJ, Avgerinos ED. Single- versus multiple-stage catheter-directed thrombolysis for acute iliofemoral deep venous thrombosis does not have an impact on iliac vein stent length or patency rates. J Vasc Surg Venous Lymphat Disord 2019; 7:781-788. [PMID: 31495769 PMCID: PMC7917433 DOI: 10.1016/j.jvsv.2019.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 05/18/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Incomplete venous thrombolysis and residual nonstented iliac vein disease are known predictors of recurrent deep venous thrombosis (DVT). Controversy exists as to whether the number of thrombolysis sessions affects total stent treatment length or stent patency. The goal of this study was to evaluate the outcomes of patients who underwent single vs multiple catheter-directed lysis sessions with regard to stent extent and patency. METHODS Consecutive patients who underwent thrombolysis and stenting for acute iliofemoral DVT between 2007 and 2018 were identified and divided into two groups on the basis of the number of treatments performed (one vs multiple sessions). Operative notes and venograms were reviewed to determine the number of lytic sessions performed and stent information, including size, location, total number, and length treated. End points included total stent length, 30-day and long-term patency, and post-thrombotic syndrome (Villalta score ≥5). The χ2 comparisons, logistic regression, and survival analysis were used to determine outcomes. RESULTS There were 79 patients who underwent lysis and stenting (6 bilateral interventions; mean age, 45.9 ± 17 years; 48 female). Ten patients (12 limbs) underwent single-stage treatment with pharmacomechanical thrombolysis, and the remaining 69 (73 limbs) had two to four operating room sessions combining pharmacomechanical and catheter-directed thrombolysis. Patients who underwent a single-stage procedure were older and more likely to have a malignant disease. These patients received less tissue plasminogen activator compared with the multiple-stage group (17.2 ± 2.2 mg vs 27.6 ± 11.6 mg; P = .008). Average stent length was 8.8 ± 5.2 cm for the single-stage group vs 9.2 ± 4.6 cm for the multiple-stage group (P = .764). Patients who underwent a single-stage procedure had no difference in average length of stay from that of patients who underwent multiple sessions (8.5 days vs 5.9 days; P = .269). The overall 30-day rethrombosis rate was 7.3%. Two-year patency was 72.2% and 74.7% for the single and multiple stages, respectively (P = .909). The major predictors for loss of primary patency were previous DVT (hazard ratio [HR], 5.99; P = .020) and incomplete lysis (HR, 5.39; P = .014) but not number of procedures (HR, 0.957; P = .966). The overall post-thrombotic syndrome rate was 28.4% at 5 years and was also not associated with the number of treatment sessions. CONCLUSIONS Single- vs multiple-stage thrombolysis for DVT is not associated with a difference in extent of stent coverage. Patency rates remain high for iliac stenting irrespective of the number of lytic sessions, provided lysis is complete and the diseased segments are appropriately stented.
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Affiliation(s)
- Catherine Go
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Zein Saadeddin
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Yash Pandya
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Eric S Hager
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michael J Singh
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Bozok Ş, Tayfur K. Initial experience with a new pharmacomechanical thrombectomy device for deep venous thrombosis: Report of 91 cases. Phlebology 2019; 34:707-714. [PMID: 30939998 DOI: 10.1177/0268355519833235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Şahin Bozok
- Department of Cardiovascular Surgery, Faculty of Medicine, Usak University, Usak, Turkey
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Outcomes and predictors of failure of iliac vein stenting after catheter-directed thrombolysis for acute iliofemoral thrombosis. J Vasc Surg Venous Lymphat Disord 2019; 7:153-161. [PMID: 30660580 DOI: 10.1016/j.jvsv.2018.08.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/11/2018] [Indexed: 12/24/2022]
Abstract
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.
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Wang W, Sun R, Chen Y, Liu C. Meta-analysis and systematic review of percutaneous mechanical thrombectomy for lower extremity deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2018; 6:788-800. [DOI: 10.1016/j.jvsv.2018.08.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 08/05/2018] [Indexed: 01/01/2023]
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Liu X, Cao P, Li Y, Zhao J, Li L, Li H, Zhang Y. Safety and efficacy of pharmacomechanical thrombolysis for acute and subacute deep vein thrombosis patients with relative contraindications. Medicine (Baltimore) 2018; 97:e13013. [PMID: 30412139 PMCID: PMC6221726 DOI: 10.1097/md.0000000000013013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
To evaluate the safety and efficacy of pharmacomechanical thrombolysis (PMT) performed for patients with relative contraindications.From June 2014 to December 2016, 112 patients with acute or subacute proximal deep vein thrombosis (DVT) were enrolled in this study. 60 patients (including 27 acute DVT patients and 33 subacute DVT patients) were treated with catheter-directed thrombolysis (CDT), and 52 patients with relative contraindications (including 25 acute DVT patients and 27 subacute DVT patients) with PMT. Assessment of venous recanalization was conducted using venography the time Inferior vena cava filter is removed, and complications were used to compare safety and efficacy between the groups.The outcomes of acute DVT patients no matter which kind of therapy performed, CDT or PMT, were significant better than subacute DVT patients (PCDT = .04 and PPMT = .01). However, there was no significant difference between CDT acute group and PMT acute group or between CDT subacute group and PMT subacute group (Pacute = .80 and Psubacute = .84). For complications of all patients, there was no mortality and major bleeding occurred.PMT could be a safe and effective management for DVT patients with relative contraindications, and the acute DVT may achieve better outcomes when they receive CDT or PMT.
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Pathogenesis of Thromboembolism and Endovascular Management. THROMBOSIS 2017; 2017:3039713. [PMID: 28154761 PMCID: PMC5244017 DOI: 10.1155/2017/3039713] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 11/13/2016] [Accepted: 11/27/2016] [Indexed: 02/03/2023]
Abstract
Venous thromboembolism (VTE), a disease that includes deep venous thrombosis (DVT) and pulmonary embolism (PE), is associated with high mortality, morbidity, and costs. It can result in long-term complications that include postthrombotic syndrome (PTS) adding to its morbidity. VTE affects 1/1000 patients, costs $13.5 billion annually to treat, and claims 100,000 lives annually in the US. The current standard of care for VTE is anticoagulation, though thrombolysis may be performed in patients with PE and threatened limb. This review discusses pathogenesis and medical treatment of VTE and then focuses on endovascular treatment modalities. Mechanical- and catheter-directed thrombolysis (CDT) is discussed, as well as patient selection criteria, and complications. The first prospective study (CaVenT) comparing CDT with anticoagulation alone in acute DVT, despite study shortcomings, corroborates the existing literature indicating improved outcomes with CDT. The potential of the ongoing prospective, multicenter, randomized ATTRACT trial is also highlighted.
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Avgerinos ED, El-Shazly O, Jeyabalan G, Al-Khoury G, Hager E, Singh MJ, Makaroun MS, Chaer RA. Impact of inferior vena cava thrombus extension on thrombolysis for acute iliofemoral thrombosis. J Vasc Surg Venous Lymphat Disord 2016; 4:385-91. [PMID: 27638990 DOI: 10.1016/j.jvsv.2016.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 05/21/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Inferior vena cava (IVC) thrombosis may occur in patients with iliofemoral deep venous thrombosis (DVT), and its impact on thrombolysis outcomes is poorly defined. This study compared outcomes of patients undergoing thrombolysis for acute iliofemoral DVT with and without IVC involvement. METHODS Patients who underwent thrombolysis for iliofemoral DVT between May 2007 and March 2014 were identified from a prospectively maintained database and divided into two groups: those with IVC involvement and those without. End points were technical and clinical success (≥50% lysis or freedom from 30-day DVT recurrence), long-term DVT recurrence, and post-thrombotic syndrome (PTS; Villalta score ≥5). Multivariate regression models were used to determine predictors of anatomic and clinical failures. RESULTS There were 102 patients (127 limbs) treated with various combinations of catheter-directed or pharmacomechanical thrombolysis. In 46 patients, thrombus extended into the IVC (54.3% extended up to the renal veins; 87% had ≥50% luminal reduction; 50% occurred in association with an indwelling thrombosed IVC filter). The caval group had fewer women and more previous DVTs but otherwise was similar to the noncaval group. Pharmacomechanical thrombolysis was used more frequently in the caval thrombus group (97.8% vs 82.1%; P = .011), and iliac vein stenting was used more often in the noncaval group (41.3% vs 62.5%; P = .033). Clinical success was similar between the two groups (88.7% for caval vs 89.3% for noncaval; P = .921). All failures in the caval group occurred in patients with an indwelling thrombosed IVC filter. Primary patency at 2 years for the caval and noncaval groups was 76.7% and 78.0%, respectively (P = .787). Valve reflux and PTS at 2 years were higher in the noncaval group (50.8% and 34.3% vs 23.3% and 11.5% in the caval group; P = .013 and P = .035). On multivariate analysis, incomplete lysis was predictive of recurrence (hazard ratio [HR], 22.7; P < .001) and PTS (HR, 5.59; P = .010), whereas caval involvement (HR, 0.22; P = .005) was protective from PTS. CONCLUSIONS IVC thrombosis does not have an impact on the technical success of thrombolysis in patients with iliofemoral DVT; the presence of a thrombosed IVC filter, though, may make failure more likely. Caval thrombosis may not affect primary patency but is associated with a lower incidence of PTS after successful lysis.
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Affiliation(s)
- Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Omar El-Shazly
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Geetha Jeyabalan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - George Al-Khoury
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Eric Hager
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michael J Singh
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Mousa AY, Broce M. Catheter-directed thrombolysis versus full anticoagulation alone in treating proximal iliofemoral deep venous thrombosis. Vascular 2016; 25:111-112. [PMID: 27311976 DOI: 10.1177/1708538116655957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Albeir Y Mousa
- 1 Department of Surgery, Robert C. Byrd Health Sciences Center/West Virginia University, Charleston Area Medical Center Vascular Center of Excellence, Charleston, WV, USA
| | - Mike Broce
- 2 Center for Health Services and Outcomes Research, Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
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Avgerinos ED, Hager ES, Naddaf A, Dillavou E, Singh M, Chaer RA. Outcomes and predictors of failure of thrombolysis for iliofemoral deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2015; 3:35-41. [DOI: 10.1016/j.jvsv.2014.07.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 07/15/2014] [Indexed: 01/30/2023]
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