Mechanical Thrombectomy of Acute Iliofemoral Deep Vein Thrombosis with Use of an Arrow-Trerotola Percutaneous Thrombectomy Device

Endovascular Thrombectomy for Acute Iliofemoral Deep Venous Thrombosis Through a Jugular Approach with a Rotational Device

PURPOSE

To report the effectiveness of pharmacomechanical catheter-directed thrombolysis (PCDT) in the management of acute iliofemoral deep venous thrombosis (DVT) via the jugular vein using a slow rotation and large-tip device (SRD) in a large cohort of patients.

MATERIAL AND METHODS

From 2011 to 2021, 277 patients (mean age 45 years, 59.2% women) were treated in 6 centres with PCDT for ilio-fémoral DVT. PCDT was performed via the jugular vein and consisted of one session of fragmentation-fibrinolysis, aspiration and, if needed, angioplasty with stenting. The aim of PCDT was to achieve complete clearance of the venous thrombosis and to restore iliofemoral patency. Residual thrombotic load was assessed by angiography, venous patency by duplex ultrasound and clinical effectiveness by the rate of post-thrombotic syndrome (Villalta score > 4).

RESULTS

All patients were treated via the jugular vein using an SRD, and all but one were treated with fibrinolysis. Angioplasty with stenting was performed in 84.1% of patients. After the procedure, the residual thrombotic load at the ilio-fémoral region was < 10% in 96.1% of patients. The rate of major complications was 1.8% (n = 5), the rate of minor complications was 4% (n = 11), and one patient died from pulmonary embolism (0.4%) At a median follow-up of 24 months, primary and secondary iliofemoral patency was 89.6% and 95.8%, respectively. The rate of PTS was 13.8% at 12 months.

CONCLUSION

PCDT via the jugular vein using an SRD is an efficient treatment for acute iliofemoral DVT and results in high long-term venous patency and low PTS rates. Level of evidence Level 4, Case series.

Treatment of the acute severe pulmonary embolism using endovascular methods

Purpose

To present a single-centre experience with endovascular treatment of patients with severe symptoms secondary to acute pulmonary embolism (PE).

Material and methods

Twenty-five patients were treated due to contraindications or deficient effects of systemic thrombolytic therapy. The patients were treated with a combination of fragmentation and aspiration, only aspiration, or only fragmentation, and with catheter-directed thrombolytic therapy.

Results

The saturation was improved following treatment in all patients, except in one where the procedure could not be completed. There were no immediate or late procedure-related complications.

Conclusions

Endovascular treatment of severe PE is a safe and efficient option in patients with failing effect or contraindication to systemic thrombolysis.

Management of Cavoatrial Deep Venous Thrombosis: Incorporating New Strategies

Cavoatrial deep venous thrombosis (DVT) is diagnosed with increasing prevalence. It can be managed medically with anticoagulation or with directed interventions aimed to efficiently reduce the thrombus burden within the target venous segment. The type of management chosen depends greatly on the etiology and chronicity of the thrombosis, existing patient comorbidities, and the patient's tolerance to anticoagulants and thrombolytic agents. In addition to traditional percutaneous catheter-based pharmacomechanical thrombolysis, other catheter-based suction thrombectomy techniques have emerged in recent years. Each therapeutic modality requires operator expertise and a coordinated care paradigm to facilitate successful outcomes. Open surgical thrombectomy is alternatively reserved for specific patient conditions, including intolerance of anticoagulation, failed catheter-based interventions, or acute emergencies.

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.

Single-Session Endovascular Treatment of Symptomatic Lower Extremity Deep Vein Thrombosis: Is it Possible Even for Aged Thrombosis

BACKGROUND

Feasibility of single-session mechanical thrombetomy, without thrombolytics, for the treatment of the subacute deep vein thrombosis (DVT) of the lower extremity remains poorly described.

PURPOSE

To evaluate the feasibility and efficacy of single-session endovascular treatment of DVT of the lower extremity that is more than 10 days old.

MATERIALS AND METHODS

From January 2010 to December 2013, single-session endovascular treatment was performed in 21 limbs of 21 patients (8 men and 13 women) with DVT more than 10 days old at our hospital. The mean age of the thrombosis was 21.5 days (range 11-45 days). Two patients had malignancy-related obstructions. A 14F introducer sheath was inserted through the popliteal vein followed by aspiration thrombectomy with a large bore catheter. Balloon angioplasty and/or maceration of the thrombus were added when needed. Stent insertions were performed for patients with combined iliac vein stenosis. Technical success, clinical success, mean procedure time, and complications were evaluated.

RESULTS

The technical success rate was 90.5% (19 of 21 patients). Among the 19 successful cases, aspiration thrombectomy alone was performed in 16 (84.2%) patients, additional balloon angioplasty of the femoral vein was performed in 2 (10.5%) patients, and both balloon angioplasty of the femoral vein and rotational thrombectomy were performed in 1 (5.3%) patient. Iliac vein stenting was performed due to combined iliac vein narrowing in 13 (68.4%) of the 19 successful cases. The mean procedure time was 86 minutes (26-179 minutes). All of the patients with technical success (19 of 21 patients) showed marked improvement in symptoms at the time of discharge (clinical success). Unexplained gastrointestinal hemorrhage developed in 1 patient.

CONCLUSION

Single-session endovascular treatment is feasible and effective even for patients with aged deep vein thrombosis of the lower extremity more than 10 days old.

A phantom model study to identify the most effective manual aspiration thrombectomy for acute deep-vein thrombosis of the lower extremity

AIM

To identify the most effective manual aspiration thrombectomy (MAT) method for the initial endovascular management of acute deep-vein thrombosis (DVT) in the lower extremity using a phantom model.

MATERIALS AND METHODS

An acute DVT phantom model was created by infusing a bovine acute thrombus in a 20-mm diameter, 120-cm long plastic tube with banding of the distal portion. A total of 32 types of aspiration methods using combinations of two aspiration catheters (8 and 10 Fr), four syringes (10, 20, 40, and 50 ml), and four different aspiration methods (I, II, III, and IV) were performed. Each method was performed 10 times. The total weight of the aspirated thrombus was measured and compared among the 32 aspiration methods. The aspiration methods were classified based on the length of the dynamic catheter withdrawal (0 cm [method I], 15 cm [II], 30 cm [III], or >45 cm [IV]) while maintaining continuous negative pressure using a syringe. Analysis of variance and Student's t-test were used for statistical analysis.

RESULTS

There were no statistically significant differences in the total amount of aspirated thrombus among the various types of aspiration catheters and syringes; however, different aspiration methods showed significantly different results. Acute thrombus was most effectively aspirated by method IV irrespective of the catheter and syringe used. The longer the length of dynamic catheter withdrawal, the greater the amount of total thrombi that could be aspirated, irrespective of the type of aspiration catheter and syringe used (IV > III > II > I; p<0.05).

CONCLUSION

MAT can be performed most effectively using method IV. Effective MAT relies on the length of the dynamic catheter withdrawal while maintaining continuous negative pressure using a syringe in the initial endovascular management of acute DVT in the lower extremity.

Mechanical thrombolysis of thrombosed central venous port

PURPOSE

To evaluate the effectiveness of a mechanical thrombolysis for thrombosed central venous port (CVP).

METHODS

A total of 38 patients (22 women and 16 men, median age of 55 years) were referred to our interventional unit for thrombosed implanted CVPs. The period between CVP implantation and the initial suspicion of mechanical complication varied from 2 to 35 months (mean 11.5 months) and the interval since last use of the CVP averaged 47 days (range 28-324 days). Our mechanical thrombolysis technique was performed to fragment thrombus in the port chamber by whirling the floppy tip of 0.018-inch hair-wire. Only 19-gauge noncoring needle and 0.018-inch hire-wire were used without cut-down. After removing the hair-wire and placing a second needle, the fragmented thrombi was slowly aspirated with a negative pressure and the remnant thrombus was flushed out by pushing a saline fluid. The degree of fragmentation of thrombus was evaluated with posttreatment angiography; incomplete lysis was defined as more than 50 % of thrombus remaining, significant lysis was 10-50 % of initial thrombosis remaining, and near-complete lysis was less than 10 % thrombus remaining.

RESULTS

We observed near-complete lysis in 22 patients (58 %), significant lysis in 14 patients (37 %), and incomplete lysis in two patients (5 %). The technical success rate was 82 % (31 of 38 patients). There were no major or minor complications in the recovery room during a 30-min observation period or late complications at outpatient follow-up.

CONCLUSION

A mechanical thrombolysis technique can be used to dissolve thrombus effectively from thrombosed implanted CVP on an outpatient basis.

Removing vascular obstructions: a challenge, yet an opportunity for interventional microdevices

Cardiovascular diseases are the leading cause of death worldwide; they are mainly due to vascular obstructions which, in turn, are mainly caused by thrombi and atherosclerotic plaques. Although a variety of removal strategies has been developed for the considered obstructions, none of them is free from limitations and conclusive. The present paper analyzes the physical mechanisms underlying state-of-art removal strategies and classifies them into chemical, mechanical, laser and hybrid (namely chemo-mechanical and mechano-chemical) approaches, while also reviewing corresponding commercial/research tools/devices and procedures. Furthermore, challenges and opportunities for interventional micro/nanodevices are highlighted. In this spirit, the present review should support engineers, researchers active in the micro/nanotechnology field, as well as medical doctors in the development of innovative biomedical solutions for treating vascular obstructions. Data were collected by using the ISI Web of Knowledge portal, buyer's guides and FDA databases; devices not reported on scientific publications, as well as commercial devices no more for sale were discarded. Nearly 70% of the references were published since 2006, 55% since 2008; these percentages respectively raise to 85% and 65% as regards the section specifically reviewing state-of-art removal tools/devices and procedures.

[The role of thrombolysis in the clinical management of deep vein thrombosis]

Acute Deep Venous Thrombosis (DVT) therapies have been judged primarily on their ability to prevent symptomatic pulmonary embolism, early thrombus progression, and recurrent VTE. The cornerstones of current management of DVT, supported by the 2008 American College of Chest Physicians (ACCP) guidelines, are the routine use of anticoagulant therapy, graduated elastic compression stockings, and early ambulation. For selected appropriate patients with extensive acute proximal DVT, while the French recommendations (Afssaps 2009) still consider thrombolysis not indicated, ACCP guidelines now suggest in-situ thrombolysis in addition to anticoagulation to reduce the risk of subsequent postthrombotic syndrome (PTS) and recurrent DVT (Grade 2 B recommendation). Contemporary invasive endovascular treatments, called pharmacomechanical treatment, mitigate the drawbacks (major bleeding) historically associated with systemic thrombolytic approaches, by means of intra-thrombus delivery of drugs, followed by mechanical dispersion to accelerate lysis and then aspiration of remaining drug and clot debris. The proof of concept for the "open vein" hypothesis - that a strategy of early thrombus removal can reduce the incidence of PTS long term - comes incrementally and randomized trials (ATTRACT trial with a 2016 target completion date) are currently under way and might lead to a shift of the paradigms of the management of acute DVT focused on active thrombus removal.

Embolization during treatment of deep venous thrombosis: incidence, importance, and prevention

The standard of care for the treatment of acute deep venous thrombosis (DVT) is anticoagulation, which often prevents the formation of new thrombus and reduces the risk of pulmonary embolism (PE) but fails to eliminate the clot burden. Patients who have thrombus remaining in their deep venous system despite therapeutic anticoagulation are at high risk for developing symptoms of the postthrombotic syndrome, a debilitating condition that adversely affects their quality of life. Strategies of thrombus removal for acute DVT, such as operative thrombectomy, catheter-directed thrombolysis, and pharmacomechanical techniques, are designed to avoid postthrombotic morbidity by restoring patency to the deep veins, but there is concern that these techniques may result in fragmentation of clot and pulmonary embolization. Careful patient evaluation before treatment is essential for preventing complications and often reveals asymptomatic pulmonary emboli in as many as 50% of patients. Nonobstructive or free-floating thrombus in the vena cava is a risk factor for procedure-related embolization and is frequently an indication for the use of vena caval filtration. A review of the literature on acute DVT treated by anticoagulation alone or with strategies of thrombus removal reveals that pulmonary embolization is an infrequent occurrence. Treatment with anticoagulation alone, however, increases the risk of patients developing symptoms of the postthrombotic syndrome, whereas thrombus removal strategies reduce postthrombotic morbidity without increasing the risk of embolization.

Surgical venous thrombectomy for Japanese patients with acute deep vein thrombosis: a review of 5 years' experience

OBJECTIVE

Deep vein thrombosis (DVT) is a major risk factor for pulmonary thromboembolism (PTE). We carefully selected patients for surgical thrombectomy to treat acute-phase thrombosis and obtained favorable results.

METHODS

Over the past 5 years, we have performed surgical thrombectomy via a minimum femoral skin incision in 11 patients. Surgery was considered for patients with persistent phlegmasia cerulea dolens, despite thrombolytic therapy. All of our patients underwent surgery within 14 days of the onset of symptoms. During the operation, the patients were kept in the supine anti-Trendelenburg position to prevent PTE, and general anesthesia was maintained with positive-pressure mechanical ventilation. Blood flow to the inferior vena cava was occluded with a blocking catheter, and thrombectomy was performed with a thrombectomy catheter inserted parallel to the blocking catheter. A cell separator device was used effectively for autologous blood transfusion. To prevent reocclusion and promote collateral perfusion, we constructed an arteriovenous fistula for an iliac venous spur.

RESULTS

There were no major postoperative complications, such as PTE or peritoneal bleeding, and no cases of postthrombotic syndrome after an average 38.4 months of follow-up.

CONCLUSION

This surgical technique for venous thrombectomy is minimally invasive and safe for Japanese patients; surgical thrombectomy should be considered a treatment option for DVT in Japan.

Successful Treatment of Phlegmasia Cerulea Dolens with Combination Surgical and Catheter-Assisted Thrombectomy

Phlegmasia cerulea dolens is a rare condition caused by complete venous occlusion that leads to impaired arterial flow. Prompt diagnosis and treatment initiation are paramount in preventing progression to gangrene, the need for amputation, and possibly the death of the patient. Thrombolysis or surgical thrombectomy, for advanced disease and cases in which anticoagulation is contraindicated, represent the current standard treatment. Here we report the case of a 47-year-old male who sustained severe trauma during a car accident. After having a prophylactic retrievable inferior vena cava filter placed, he developed caval thrombosis with progression to phlegmasia cerulea dolens. He was successfully treated with a combination of surgical thrombectomy of the lower extremity veins and catheter-assisted thrombectomy of the iliac veins and inferior vena cava, in the setting in which an initial attempt at balloon thrombectomy of the iliac veins and inferior vena cava failed. He was discharged from the hospital in stable condition and on follow-up visits had full resolution of symptoms. Ultrasound evaluation showed no residual venous clot. The presented case illustrates how the use of catheter-assisted thrombectomy alleviated the need for a laparotomy and direct caval evacuation of the thrombus and provided a timely and effective treatment of phlegmasia cerulea dolens with impending gangrene.

Manual Aspiration Thrombectomy with Stent Placement: Rapid and Effective Treatment for Phlegmasia Cerulea Dolens with Impending Venous Gangrene

Phlegmasia cerulea dolens is an uncommon but potentially life-threatening complication of acute deep vein thrombosis. It is an emergency and delay in treatment may cause death or loss of the patient's limb. Surgical thrombectomy is the recommended treatment in venous gangrene. Catheter-directed intrathrombus thrombolysis has been reported as successful, but it may require a lengthy infusion. Manual aspiration thrombectomy may clear the entire thrombus with no need for thrombolytic administration and provide rapid and effective treatment for patients with phlegmasia cerulea dolens with impending venous gangrene.

Use of the Arrow Percutaneous Thrombectomy Device and Transjugular Liver Biopsy Cannula for Mechanical Thrombectomy of the Inferior Vena Cava in a Patient with Budd-Chiari Syndrome

A 33-year-old woman with Budd-Chiari syndrome and hypercoagulability was sequentially treated with the placement of hepatic vein stents and transjugular intrahepatic portosystemic shunts (TIPS), all of which repeatedly thrombosed. Four months after TIPS revision with an endoprosthesis, a large inferior vena cava (IVC) thrombus developed caudal to an IVC stenosis. A percutaneous thrombectomy device was introduced coaxially through a transjugular liver biopsy cannula to extend its effective diameter range of attack and was steered within the IVC to successfully clear the thrombus. The condition recurred 9 months later, and the technique was repeated successfully. At subsequent 12-month follow-up, the IVC remains patient and symptoms resolved. This combination of cannula and percutaneous thrombectomy device proved essential in facilitating successful mechanical thrombectomy of the IVC.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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