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.

Safety and Efficacy of Aspiration Thrombectomy or Pharmacomechanical Thrombectomy after Catheter-Directed Thrombolysis for the Treatment of Acute Iliofemoral Deep Vein Thrombosis

PURPOSE

To evaluate the safety and efficacy of additional aspiration thrombectomy (AT) or pharmacomechanical thrombectomy (PMT) after catheter-directed thrombolysis (CDT) for the treatment of acute iliofemoral deep vein thrombosis (AIFDVT).

MATERIALS AND METHODS

Between May 2017 and December 2018, 40 patients with AIFDVT were enrolled. Twenty underwent AT after CDT (CDTAT), while the remaining 20 underwent PMT using an AngioJetTM device after CDT (CDTPMT). Thrombus clearance was assessed using computed tomography venography at 1 week after the procedure, as follows: grade I, ≤50%; grade II, 51% to 75%; grade III, >75%. Grade III was considered a successful outcome. Treatment outcomes (thrombus clearance, thrombolytic therapy duration, urokinase dose, major complications, residual filter thrombosis, and Villalta score) were compared between the groups.

RESULTS

Successful thrombus clearance was achieved in 95% of the patients in both groups. Significant decreases in the thrombolytic therapy duration (P=0.018) and urokinase dose (P=0.014) were noted in the CDTPMT group. Major complications were not noted in both groups. Residual filter thrombi >10 mm were found in 6 filters in the CDTAT group and in 1 filter in the CDTPMT group (P=0.038). The Villalta scores at 6 months were 1.47±1.24 and 1.12±0.92 in the CDTAT and CDTPMT groups, respectively (P=0.372).

CONCLUSION

Both methods may be safe and effective management options for patients with AIFDVT. CDTPMT can reduce urokinase dosage, time and remained filter thrombus compared to CDTAT. Studies conducted in the future should compare the effects of overnight CDT followed by PMT with those of single-session PMT on patients with AIFDVT.

A Swine Model of Filter-Assisted Caval Thrombosis for Endovascular Thrombectomy Using AngioJet

To assess the feasibility of creating swine model of filter-assisted caval thrombosis and to evaluate the efficacy in removing clot in this model using rheolytic thrombectomy. The model was created by implanting a filter into the inferior vena cava followed by injection of autologous thrombus. Rheolytic thrombectomy was performed for all models to remove the clot. The success rate of model creation and the efficacy of clot removal were analyzed. The success rate of model creation was 100% (15/15). Following rheolytic thrombectomy, 3 of 5 pigs attained complete clot removal in a 7-day-old model, while no pigs attained complete clot removal in 14- and 21-day-old models. Creating a filter-related caval thrombosis model in swine is technically feasible and can be used to mimic a clinical episode of caval thrombosis from acute phase to chronic occlusion. Rheolytic thrombectomy can be used to remove filter-related thrombosis that aged less than 14 days. Graphical Abstract Swine Model of Filter-Assisted Caval Thrombotic Occlusion.

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.

Safety and efficacy of pharmacomechanical thrombolysis for acute and subacute deep vein thrombosis patients with relative contraindications

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.

Management of Chronic Deep Vein Thrombosis in Women

Chronic deep vein thrombosis (DVT) affects hundreds of thousands of women in the United States. Chronic DVT can lead to pain, edema, venous ulcers, and varicosities. While there are limited data regarding the management of chronic DVT, several interventional radiology groups aggressively treat chronic DVT to aid patient symptom resolution. Recanalization of occluded veins and venous stenting re-establishes deep vein flow and decreases venous hypertension.

The Role of Pharmacomechanical Endovascular Intervention for Iliofemoral Vein Thrombosis Compared to Conventional Anticoagulation Therapy

Although anticoagulation therapy is the primary treatment for deep vein thrombosis (DVT), it has not been associated with the rapid recanalization of the venous occlusion. Moreover, it is associated with long-term disability due to post-thrombotic syndrome (PTS). In contrast, pharmacomechanical endovascular intervention (PMI) results in more rapid clinical improvement in DVT patients, but there are few reports on its long-term outcomes. This retrospective study evaluated the clinical effectiveness of PMI compared to conventional anticoagulation therapy (ACA) for acute and subacute iliofemoral DVT. We reviewed the medical records of 102 patients with iliofemoral DVT. A total of 46 patients for ACA and 56 patients for PMI were enrolled. We analyzed the clinical differences between the PMI and ACA groups by comparing the clinical signs, residual DVT free-rate, and PTS-free rate. There were no statistically significant differences in the demographic characteristics and risk factors except age between the groups (age: ACA, 52.0 ± 18.0 years; PMI, 59.0 ± 17.0 years; P = 0.035). The 1-, 3-, and 5-year residual DVT-free rate (ACA = 84.7%, 71.6%, and 46.0%; PMI = 82.1%, 76.8%, and 76.8%, respectively; P = 0.235) was not significantly different. However, the 1-, 3-, and 5-year PTS-free rate was significantly different (ACA = 93.5%, 74.0%, and 55.7%; PMI = 92.9%, 90.0%, and 90.0%, respectively; P = 0.019). There was no significant difference in the rate of other complications. PMI showed a lower incidence of PTS during the follow-up period. Therefore, PMI should be considered as an effective therapeutic modality for patients with iliofemoral DVT.

Etiology and treatment of acute inferior vena cava thrombosis

Inferior vena cava thrombosis (IVCT) is a rare but severe disease that is associated with a high rate of mortality. IVCT can be categorized into primary versus secondary thrombosis dependent upon the underlying pathophysiology. The diagnosis includes both clinical probability assessment as well as the imaging evaluation. The optimal therapeutic strategy remains the target of continued research. Although anticoagulation therapy remains fundamental in treating IVCT, its inherent limitations have led to the use of minimally invasive, endovascular treatment options, including transcatheter thrombolysis, mechanical thrombectomy or a combination of these techniques. This review focuses on the etiology, diagnostic assessment, and endovascular treatment options for IVCT.

NMMHC IIA inhibition impedes tissue factor expression and venous thrombosis via Akt/GSK3β-NF-κB signalling pathways in the endothelium

Non-muscle myosin heavy chain IIA (NMMHC IIA) has been shown to be involved in thrombus formation and inflammatory microparticle release in endothelial cells. However, the role of NMMHC IIA in regulating the expression of tissue factor (TF) and deep venous thrombosis remains to be elucidated. In the present study, endothelial cells were stimulated with tumour necrosis factor-α (TNF-α) to induce TF expression. Pretreatment with the NMMHC II inhibitor blebbistatin suppressed the mRNA and protein expressions as well as the procoagulant activity of TF in a dose-dependent manner. Blebbistatin enhanced Akt and GSK3β phosphorylation and inhibited NF-κB p65 nuclear translocation and IκBα degradation. These observations were similar to the effect of CHIR99021, a GSK3β inhibitor. TF downregulation by blebbistatin was antagonised by the PI3K inhibitor, wortmannin. Furthermore, siRNA knockdown of NMMHC IIA, but not IIB or IIC, inhibited TF expression, activated Akt/GSK3β and suppressed NF-κB signalling pathways, whereas the overexpression of NMMHC IIA increased TF expression. The binding of NMMHC IIA and TNF receptor 2 mediated signal internalisation in TNF-α-stimulated endothelial cells. Importantly, blebbistatin decreased endothelium NMMHC IIA and TF expression, deactivated GSK3β by inducing its phosphorylation, suppressed p65 nuclear translocation, and inhibited thrombus formation in a mouse deep venous thrombosis model.Our findings provide solid evidence that inhibition of NMMHC II, most likely NMMHC IIA, impedes TF expression and venous thrombosis via Akt/GSK3β-NF-κB signalling pathways in the endothelium both in vitro and in vivo. NMMHC IIA might be a potential novel target for the treatment of thrombotic disorders.

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.

Isolated pharmaco-mechanical thrombectomy (IPMT) for the endovascular treatment of acute axillofemoral graft occlusion

Since the long-term patency of axillofemoral (AXF) grafts is inferior to aorto-bifemoral (ABF) grafts, limb salvage procedures are crucial in this group of patients. Emerging endovascular devices have helped in the successful restoration of flow for acute limb ischemia in both native arteries as well as bypass grafts. One such device, the Trellis thrombectomy system is being used more frequently in this setting. The device has previously been used in veins, native arteries, and rarely in aortofemoral grafts. We present its first successful use for the treatment of occluded AXF bypass graft. The use of this device helped to isolate the treatment zone in the occluded graft, which allowed the use of a lower dose of thrombolytics, less systemic release of thrombolytics, and less distal embolization. Resolution of extensive clot burden was achieved and, with subsequent stenting of the graft at the distal anastomotic site, arterial flow to the leg through the AXF graft was restored and a revision surgery was avoided.