Local and systemic thrombolytic therapy for acute venous thromboembolism

Predictors of long-term outcomes after catheter-directed thrombolysis combined with stent implantation in acute deep vein thrombosis secondary to iliac vein compression

The purpose of this study is to analyze predictive factors for long-term clinical outcomes after catheter-directed thrombolysis (CDT) combined with stent implantation for acute deep vein thrombosis (DVT) secondary to iliac vein compression (IVC). A retrospective analysis was performed to review clinical data and follow-up information on 52 patients who underwent CDT combined with stent implantation for acute DVT secondary to IVC from June 2015 to March 2020. Clinical outcomes including stent patency and incidence of postthrombotic syndrome (PTS) were investigated using Kaplan-Meier analysis. All included patients were categorized into 2 groups according to the presence of PTS. Potential risk factors, including age, gender, degree of iliac vein stenosis, time from onset to treatment, dosage of thrombolytic agent, stent extending below the inguinal ligament, and duration of anticoagulation for PTS were evaluated using multivariate logistic regression analysis. Over a median follow-up of 24 months, 4 individuals underwent reintervention due to in-stent stenosis or stent compression. Primary stent patency was 98.1% at 1 month, 94.2% at 6 months, 90.4% at 12 months, and 88.5% at 24 months. Freedom from PTS was 98.1% at 6 months, 84.6% at 12 months, and 75% at 24 months. No treatment-related mortality or morbidity was observed. Based on the development of PTS, 13 patients with PTS were classified into group A and 39 patients without PTS were regarded as group B. Upon multivariate logistic regression analysis, key prognostic factors for PTS were degree of iliac vein stenosis and time from onset to treatment. CDT combined with stent implantation is safe and effective for acute DVT secondary to IVC in the long-term perspective. Severe iliac vein stenosis and longer period from onset to treatment may be associated with a higher risk of PTS.

Update on Thrombolytic Therapy in Acute Pulmonary Thromboembolism

Thrombolytic treatment accelerates the dissolution of thrombus in acute pulmonary thromboembolism (PTE) and is potentially a lifesaving treatment. High-risk PTE is the clearest indication for this therapy, and its use in intermediate-risk cases is still controversial. A PTE response team may enable a rapid and effective determination of risk and treatment in these controversial clinical cases. Approved thrombolytic agents for the PTE treatment are streptokinase, urokinase, and alteplase. Currently, the most widely used agent is alteplase. It has a short infusion time (2 h) and a rapid effect. Newer, unapproved agents for the PTE treatment are tenecteplase and reteplase. The active resolution of thrombus via thrombolytic agents improves rapidly pulmonary perfusion, hemodynamic defect, gas exchange, and right ventricular dysfunction. However, it is important to determine appropriate candidates carefully, to prevent hemorrhage, which is the most important side effect of these drugs. Catheter-directed thrombolysis seems to be an alternative in patients not eligible for systemic thrombolytic therapy.

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.

A prospective randomized trial of catheter-directed thrombolysis with additional balloon dilatation for iliofemoral deep venous thrombosis: a single-center experience

PURPOSE

Catheter-directed thrombolysis (CDT) is effective for acute iliofemoral deep venous thrombosis (DVT), but CDT remains partially effective for subacute DVT. The aim of this study was to conduct a prospective randomized controlled single-centre clinical trial to compare CDT alone with CDT with additional balloon dilatation for the treatment of iliofemoral DVT.

METHODS

The trial was performed between February 2007 and January 2011. Iliofemoral DVT patients lacking effective therapy before enrollment were randomly assigned either to CDT (control group) or to CDT with additional balloon dilatation (intervention group). Insufficiency Epidemiological and Economic Study-Quality of Life (VEINES-QOL), Severity of Venous Lower Limb Symptoms (VEINES-Sym), 36-Item Short-Form Health Survey (SF-36), and Villalta scores were obtained at scheduled follow-up.

RESULTS

Seven hundred twenty-two patients were screened, and 386 eligible patients were randomized. No significant difference for mean total Villalta score was observed between the intervention group (4.20 ± 3.05) and the control group (4.89 ± 3.45). However, post hoc analysis of the scores in subacute patients showed significant differences between the intervention group and the control group from 1 month (6.79 ± 4.23, 8.28 ± 5.03, P = 0.02) to 24 months (4.21 ± 3.08, 5.67 ± 3.71, P = 0.006). A significant difference was also observed in subacute patients at the end of follow-up for VEINES-QOL/Sym (52.87 ± 6.52, 50.31 ± 6.07, P = 0.009; 51.87 ± 6.37, 49.72 ± 5.96, P = 0.02) and SF-36 PCS/MCS (45.02 ± 12.07, 41.13 ± 11.68, P = 0.03; 53.26 ± 11.43, 49.50 ± 11.06, P = 0.03).

CONCLUSION

Subacute iliofemoral DVT patients lacking effective therapy during acute phase, might receive more benefits from CDT with additional balloon dilatation. However, CDT alone is highly effective for acute patients.

80-kV pulmonary CT angiography with 40 mL of iodinated contrast material in lean patients: comparison of vascular enhancement with iodixanol (320 mg I/mL)and iomeprol (400 mg I/mL)

OBJECTIVE

The purpose of this article is to compare the vascular enhancement obtained with a low-kilovoltage pulmonary CT angiography (CTA) protocol in lean patients, using 40 mL of a moderate-concentration isoosmolar (iodixanol, 320 mg I/mL) and a high-concentration low-osmolar (iomeprol, 400 mg I/mL) iodinated contrast medium injected at the same iodine delivery rate.

SUBJECTS AND METHODS

Forty-two lean patients (31 men and 11 women; body mass index, ≤ 23 kg/m(2)) with suspected pulmonary embolism and non-small cell lung carcinoma underwent pulmonary CTA with a 64-MDCT scanner using a tube voltage of 80 kV. Twenty-three patients (54.8%) received 40 mL of iodixanol (320 mg I/mL) injected at a rate of 5 mL/s, and the remaining 19 patients (45.2%) were administered an equal volume of iomeprol (400 mg I/mL) at a flow rate of 4 mL/s. Intraarterial density was measured in the common pulmonary artery trunk, the main right and left pulmonary arteries, lobar arteries, and at the segmental level, for a total of 15 regions of interest per patient. Intravascular enhancement homogeneity from central to subsegmental level was also assessed visually using a semiquantitative score (1 = poor, 2 = good, and 3 = excellent).

RESULTS

The overall vascular density of pulmonary arteries down to the segmental level was significantly higher with iodixanol (320 mg I/mL) than with iomeprol (400 mg I/mL) (p = 0.036). Enhancement homogeneity was good with both contrast agents, with no statistically significant difference between them (p = 0.8966).

CONCLUSION

In 80-kV pulmonary CTA of lean patients, higher intravascular enhancement can be achieved with 40 mL of iodixanol (320 mg I/mL) than with the same volume of iomeprol (400 mg I/mL), with good vessel conspicuity down to the subsegmental level.

[The patient with pulmonary embolism or vascular emergency requiring intensive care]

Acute pulmonary embolism requires ICU management only for patients with hemodynamic instability who need artificial ventilation, or for hemodynamically stable patients with significant right ventricular dysfunction. For both patient groups, echocardiography is the most relevant diagnostic method. The main therapeutic consideration is on systemic thrombolysis. It is indicated in almost all patients with hemodynamic instability but only in selected cases of right ventricular dysfunction. All other patients receive standard anticoagulation only. A second vascular emergency scenario is type 2 heparin-induced thrombocytopeniae (HIT II) which may cause venous as well as arterial complications. Alternative anticoagulation has to be established from the first moment of clinical suspicion. It has to be continued in a therapeutic dosage if HIT II is confirmed, and has to be stopped if the diagnosis is refuted. The latter case is by far more frequent. Regarding arterial occlusions (acute limb ischemia, acral gangrene, iatrogenic vascular trauma) hints are given for the management in the setting of intensive care.

[Treatment of postoperative thrombosis]

For the treatment of deep vein thrombosis (DVT), rapid diagnosis and prompt therapy are crucial to minimize the risk of fatal pulmonary embolism and long-term complications, including the postthrombotic syndrome and recurrent thromboembolism. The treatment of acute DVT remains controversial. In this review, treatment options in relation to exposing and predisposing risk factors are discussed. Evidence-based data and recommendations from official guidelines are presented.

[A 49-year-old woman with deep vein thrombosis, pulmonary embolism, and left-sided paralysis]

We report the case of a 49-year-old female patient who was admitted stationary because of a left-sided paralysis which had appeared some hours before. An embolic occlusion of the right A. cerebri media turned out to be the cause. A paradoxical embolism could be assumed because of an existing deep vein thrombosis and an increased right-ventricular pressure within a hemodynamically relevant fulminant pulmonary embolism as well as the additional existence of a patent foramen ovale (PFO). Systemic lysis as treatment of the pulmonary embolism was contraindicated because slight bleeding had occurred in the area of the right basal ganglia after treatment of the embolic occlusion of the right A. cerebri media by a local lysis. Subsequently and in the acuteness, a catheter interventional PFO-closure via a double-umbrella device was placed and the pulmonary embolism was effectively treated by a local lysis through the insertion of a pigtail-catheter into the right pulmonary artery.

The treatment of deep vein thrombosis in the pelvis and leg

INTRODUCTION

Deep vein thrombosis is associated with a risk of pulmonary embolism and post thrombotic syndrome (PTS).

METHODS

Selective literature review with special reference to the American College of Chest Physicians' current guidelines and the German S2 interdisciplinary guideline.

RESULTS AND DISCUSSION

The most important therapeutic measure is prompt and adequate anticoagulation with heparin or fondaparinux. Thrombolysis or thrombectomy is only indicated in highly selected severe cases. The risk of PTS can be reduced by immediate ongoing treatment with compression stockings. Prevention of relapse is achieved using vitamin K antagonists with a target INR of 2.0 to 3.0. The duration of anticoagulation should be tailored to the localisation and etiology of the thrombosis, from at least three months to indefinite treatment. The ongoing risk of bleeding secondary to anticoagulation should be reevaluated at regular intervals as a cost-benefit analysis. New anticoagulants for acute and long term treatment will soon be available for clinical use.

Electrocardiography and Wells scoring in predicting the anatomic severity of pulmonary embolism

Pulmonary embolism (PE) is a major health problem associated with a significant morbidity and mortality. Immediate recognition of submassive and massive cases is extremely important in order to commencement of early and appropriate therapy that could be life saving. The aim of this study was to assess the ability of two scoring systems, electrocardiography (ECG) and simplified Wells (sWells) clinical scorings in predicting anatomic severity of PE. Hence, ECG and sWells scorings were combined in order to test the hypothesis if this new scoring does enhance the prediction of severity. Fifty six patients with proven PE with high (50 patients) and moderate (six patients)-probability of ventilation/perfusion (V/Q) scan were retrospectively studied. Baseline ECGs were analysed by two independent observers in order to constitute ECG scorings. Baseline sWells scores were also calculated. Anatomic severity of PE was calculated by scintigraphically and categorized into mild (<50% perfusion defect) (group 1), and severe (50% perfusion defect) (group 2) diseases. The mean of ECG scores, sWells scores and the combined scores were 5.23+/-3.42 and 5.85+/-3.82; 6.60+/-1.88 and 7.03+/-2.40; and 10.73+/-3.60 and 11.60+/-4.32 in groups 1 and 2, respectively (p>0.05). An ECG score of 6.5 predicted severe disease (perfusion defect 50%) with a sensitivity of 41.7% and a specificity of 82%). sWells and combined scores did not provide better sensitivity or specificity values based on ROC curve analysis. Our results indicated that ECG scoring could be valuable test in predicting anatomic severity of PE, adding sWells scoring to ECG scoring did not provide any beneficial effect.

Evaluation and management of the acutely dyspneic patient: the role of biomarkers

The etiology of dyspnea can often be difficult to rapidly and accurately determine and can delay timely and appropriate therapies. The current literature reveals important diagnostic, prognostic, and therapeutic implications of several currently used biomarkers: sensitive d -dimer, myoglobin, creatine kinase-MB, cardiac troponins, and b-type natriuretic peptide. These biomarkers were found to have a high sensitivity and negative predictive value for rapidly ruling out potential serious etiologies of dyspnea, namely, pulmonary embolism (PE), acute myocardial infarction (AMI), and congestive heart failure (CHF). In the setting of a low to moderate pretest probability of PE, a negative sensitive d -dimer can rule out a PE with 97% accuracy. After 10 hours from the onset of symptoms, normal levels of myoglobin, creatine kinase-MB, and cardiac troponin I can rule out an AMI with greater than 96% accuracy. A b-type natriuretic peptide level less than 80 pg/mL can confidently rule out decompensated CHF with greater than 99% accuracy. However, no literature was found analyzing the use of these biomarkers in combination. A dyspnea biomarker panel could rapidly and accurately assist a clinician to rule out PE, AMI, and CHF. If a PE, AMI, or CHF is determined to be the cause of dyspnea, a biomarker panel could help risk stratify and help determine initial therapies. Subsequent clinical research is needed to corroborate this postulation.

Thrombolysis for Central Venous Occlusion Causing Bilateral Chylothorax in a Patient with Down Syndrome

A 20-year-old woman with Down syndrome (trisomy 21) and acute lymphoblastic leukemia presented with severe respiratory compromise secondary to bilateral chylothorax as a result of central venous thrombosis and extensive upper-limb deep venous thrombosis. The chylothorax was successfully managed by catheter-directed thrombolysis and angioplasty of the venous occlusions. The development of venous thrombosis was likely to have been multifactorial. It is recognized that there is an increased incidence of congenital lymphatic anomalies in Down syndrome, which may have been a contributing factor in the development of chylothorax in this patient. This report illustrates the angiographic findings, demonstrates the successful vascular recanalization, and discusses the etiology and management of central venous thrombosis and chylothorax. The case is also presented to contribute to the expanding evidence in support of catheter-directed venous thrombolysis in selected clinical circumstances.

Venous Thrombolysis: Current Perspectives

Venous thromboembolism is a common problem in hospital and community patients and is associated with longer hospital stays, significant morbidity, and mortality. It is the third most common cardiovascular disease after ischemic coronary artery disease and stroke. A quarter of patients with acute myocardial infarction and more than half of patients with acute ischemic stroke may develop venous thromboembolism. The traditional treatment of venous thrombosis has been with anticoagulation, initially with heparin, followed by warfarin long term. The concept of thrombolysis for venous thrombosis is relatively new, but its exact role remains unsettled and largely unexplored. Reports of catheter fragmentation with systemic thrombolysis as well as catheter-directed thrombolysis are promising, and groups of patients who would benefit from thrombolytic therapy as the primary treatment are now being identified.

Catheter Interventiohal Therapy in an Elderly Patient With Deep Vein Thrombosis and a Brain Tumor

A 92-year-old woman with a brain tumor developed swelling of the left lower extremity. Venography showed considerable thrombi from the left common iliac vein to the femoral vein. Following implantation of a temporary inferior vena cava filter, catheter aspiration therapy and catheter-directed thrombolysis were performed. Venography after 3 days showed disappearance of the thrombi and an improvement in vein flow. A permanent inferior vena cava filter was implanted. Local intensive thrombectomy and thrombolysis by catheter together with a temporary inferior vena cava filter were effective treatments in this elderly patient with deep vein thrombosis.