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

ACR Appropriateness Criteria® Lower Extremity Chronic Venous Disease

Lower extremity venous insufficiency is a chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis or extrinsic venous obstruction. Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million males and 22 million females 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly. Various diagnostic and treatment strategies are in place for lower extremity chronic venous disease and are discussed in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Single-Session Percutaneous Mechanical Thrombectomy for Acute and Subacute Deep Vein Thrombosis: Clinical Outcomes and Predictive Factors of Recurrence

Objectives

To evaluate the efficacy and safety of single-session percutaneous mechanical thrombectomy (PMT) for deep vein thrombosis (DVT), to compare clinical outcomes and recurrences between acute and subacute DVT, and to identify factors predicting recurrence.

Materials and Methods

From January 2018 to March 2021, 100 consecutive patients (age: 64.64 ± 17.28 years; male, 42%) with symptomatic DVT who underwent single-session PMT were enrolled for this study. These patients were divided into an acute DVT group (< 14 days, n = 75) and a subacute DVT group (15-28 days, n = 25).

Results

A large-bore aspiration thrombectomy was used in 80 (80%) cases, Angiojet (Boston Scientific, Marlborough, MA, USA) device in one (1%) case, and a combination of both techniques in 19 (19%) cases. The anatomic success rate was 97% and the clinical success rate was 95%. There were no major complications. Clinical outcomes were not different between the two groups. The recurrence-free survival rate in the acute DVT group was significantly (p = 0.015) better than that in the subacute DVT group. The anatomic success (HR, 52.3; 95% CI, 3.82-715.21; p = 0.003) and symptom duration (HR, 17.58; 95% CI, 1.89-163.34; p = 0.012) were predictive factors associated with recurrence.

Conclusions

Single-session PMT is safe and effective for immediate symptom relief in acute and subacute DVT patients. However, recurrence occurred more frequently in patients with subacute DVT than in those with acute DVT. Anatomic success of the procedure and duration of symptoms were independent predictors of DVT recurrence.

Multi-factor analysis of failure for modified single-session Angiojet rheolytic thrombectomy in treatment of acute iliofemoral venous thrombosis from iliac vein compression syndrome

PURPOSE

To explore the risk factors of failure for modified single-session Angiojet rheolytic thrombectomy combined with directed iliac vein stenting, directed filter retrieval in the treatment of iliac vein compression with iliofemoral vein thrombosis.

METHODS

During September 2017 to September 2021, 278 patients with DVT were retrospectively analyzed and 203 were eligible for inclusion. All patients were tried to take modified single-session Angiojet rheolytic thrombectomy combined with directed iliac vein stenting, directed filter retrieval treatment. The perioperative factors were analyzed between groups: group 1-modified single-session therapy succeed, and group 2-modified single-session therapy failed. The high risk factors of failure group were evaluated by logistic regression analysis.

RESULTS

48 patients failed in modified single-session therapy, up to 23.64%. Single factor analysis indicated that there were five independent risk factors related with the failure (p < 0.05), including course of disease longer than 7 days, lumbar degeneration-related iliac vein compression syndrome (dIVCS), antegrade vein access, balloon-assisted cracking thrombus, and suction time. Logistic regression analysis indicated that course of disease longer than 7 days (OR = 19.642.95%CI:6.776∼56.933), dIVCS (OR = 11.586.95%CI:4.016∼33.427) were high risk factors for modified single-session therapy failed, antegrade vein access (OR = 0.171.95%CI:0.047∼0.614) and balloon-assisted cracking thrombus (OR = 0.157.95%CI:0.045∼0.542) were protective factors for therapy failure (p < 0.05).

CONCLUSIONS

Long course of disease and dIVCS are the high risk factors for failure of modified single-session Angiojet rheolytic thrombectomy combined with directed iliac vein stenting, directed filter retrieval in the treatment of iliac vein compression syndrome (IVCS). But, antegrade vein access and balloon-assisted cracking thrombus intraoperatively may improve the success rate of modified single-session treatment.

A unique case of hypoplastic inferior vena cava leading to bilateral iliofemoral venous outflow obstruction and review of literature

Venous thromboembolism (VTE) is a common cardiovascular disease associated with high rates of morbidity and mortality whereas it induces substantial health care costs and increased use of resources. The current standard of treatment for acute deep vein thrombosis (DVT) is anticoagulation, although revascularization can be considered in younger patients with severe symptoms and extensive thrombus burden to prevent long-term sequalae of VTE (eg, recurrent DVTs, post-thrombotic syndrome post-pulmonary embolism syndrome, and chronic thromboembolic pulmonary hypertension). A rare cause of VTE is anomalous development of the inferior vena cava (IVC) and can challenge endovascular revascularization. This case report describes a case of hypoplastic supra hepatic IVC, associated with distal IVC occlusion and bilateral lower extremity DVTs treated successfully with suction thrombectomy and on table only thrombolysis, avoiding the higher risk for major bleeding, intensive care unit admission and prolonged hospitalization associated with prolonged tissue plasminogen activator infusion.

Application of manual aspiration thrombectomy in the treatment of deep vein thrombosis in cancer patients: Descriptive retrospective cohort study

OBJECTIVES

To determine the outcomes and feasibility of endovascular treatment, mainly based on manual aspiration thrombectomy (MAT) with adjunctive percutaneous balloon angioplasty with or without stent deployment, for treatment of symptomatic ilio-femoral deep vein thrombosis (IFDVT) in cancer patients.

MATERIALS AND METHODS

In this retrospective cohort study, 135 consecutive patients (56 men; mean age, 63 years; 149 limbs) with acute (n = 113; 83.7%) and subacute to chronic (n = 22; 16.3%) symptomatic IFDVT underwent MAT-based endovascular treatment. Among them, adjunctive balloon angioplasty and stent placement was performed in 94 patients. Technical and clinical success regarding stage and cause of DVT was assessed.

RESULTS

Technical success (complete thrombus removal without residual thrombus or stenosis) was achieved in 89.6%, and subjective symptom improvement was stated by 71.5% of treated patients. The primary patency rates were 88.1%, 81.6%, 76.0%, 74.1% and 69.1% at 1, 3, 6, 12, and 30 months, respectively. Recurrent IFDVT occurred in 19.3% (26/135) of patients, 0.79 cases per patients-years of follow up. According to the analysis by causes of IFDVT, recurrence rate was 19.3% (11/57), 21.2% (12/57), and 14.3% (3/21) in unknown, compression/invasion of the vein by cancerous mass, and May-Thurner syndrome groups, respectively (p = 0.798). No procedure-related complication developed.

CONCLUSIONS

Endovascular treatment based on MAT is a feasible treatment option with favorable outcomes and minimal risk of complication in cancer patients with symptomatic IFDVT.

Two New Methods of Supine Venographically Guided Popliteal Vein Puncture: A Retrospective Study

OBJECTIVE

Presently, the prone position is necessary for popliteal vein puncture access, but it makes the patients uncomfortable and does not allow traditional femoral or jugular access. To address these deficiencies, this study introduces two new methods, anterior and medial access carried out in the supine position.

METHODS

Venous interventions with punctures in the popliteal vein of 120 limbs in 97 patients were performed during the period from February 2017 to April 2019. After puncture, venographic guidance was achieved by dorsal vein injection of contrast medium. Interventional therapy was performed after puncture and insertion of the introducer sheath.

RESULTS

In all, 120 limbs were punctured in the popliteal vein, with technical success in 118 (98.3% in total) cases: 100%, 96.1%, and 100% successful punctures in, respectively, 32 anterior, 49 medial, and 37 posterior access cases. A comparison of the three groups revealed that the fluoroscopy time and duration of puncture were longer in the medial and anterior access groups than in the posterior access group. The rate of intra-operative and post-operative complications was 7.5% (9/120), with no statistically significant difference between the three access groups. Compared with the pre-operative median score of 2.5, the post-operative SVS (Society of Vascular Surgery) score of the popliteal vein was reduced to 1.5 in the anterior and 0.5 in the medial groups.

CONCLUSION

Medial and anterior puncture of the popliteal vein in the supine position can be used as a safe alternative in venous endovascular therapy. The two new methods can mitigate frailty or respiratory problems resulting from the prone position and facilitate traditional femoral and jugular access.

A retrospective comparison of thrombectomy followed by stenting and thrombectomy alone for the management of deep vein thrombosis with May-Thurner syndrome

OBJECTIVE

To summarize the clinical results of thrombectomy with stenting (TBS) in patients with deep venous thrombosis (DVT) secondary to May-Thurner syndrome (MTS) compared with the outcomes in patients treated with thrombectomy alone (TB).

METHODS

A retrospective observation of patients with proximal DVT secondary to MTS was conducted in our institution. Patients accepted treatment including either catheter-directed TBS or TB. The complications and stent patency rates were recorded after treatments. The clinical results were assessed in both groups. The independent predictors for in-stent restenosis were further calculated in this study.

RESULTS

We included 372 patients with DVT secondary to MTS. Two hundred twenty-one patients received treatment with thrombectomy with TBS and 151 with TB. A longer mean procedure time (65.1 ± 13.9 minutes vs 49.5 ± 15.7 minutes; P < .001) and higher venous perforation rate (23 patients vs 5 patients; P = .011) were observed in the TBS group than in the TB group. The median follow-up time was 34 months. The patency rates in the TBS group at 36 months were as follows: primary patency rate of 74.0% and secondary patency rate of 92.1%. Independent predictors for restenosis included visible remaining collateral vessels (hazard ratio [HR], 1.12-3.29; P = .02), residual thrombus (HR, 1.40-4.38; P = .002), and tapered iliac vein (HR, 1.26-4.06; P = .006). Clinical results, including Venous Clinical Severity Scores (TBS, 8.0 ± 3.0; TB, 11.4 ± 3.2), Chronic Venous Insufficiency Questionnaire score (TBS, 76.4 ± 4.0; TB, 83.1 ± 4.6), Villalta scores (TBS, 3.8 ± 1.7; TB, 6.6 ± 3.2), and edema scores (TBS, 0.7 ± 0.7; TB, 1.6 ± 0.6), improved significantly in the TBS group.

CONCLUSIONS

TBS is effective and feasible for patients with proximal DVT secondary to MTS. Furthermore, compared with TB, additional stenting might be effective in improving the venous clinical results at follow-up observations.

Percutaneous Venous Interventions in The Pulmonary Vascular, Central and Peripheral Venous Systems: How to Recognize, Avoid and Treat Complications

Endovascular treatment of venous disease encompasses a broad range of interventions. Both central and peripheral venous interventions can range from the simple to the complex which increases the need for proper patient selection, procedural planning and technical proficiency. The following article will discuss the importance of avoiding, recognizing and addressing complications associated with venous interventions. Our goal is to raise awareness and educate to help the reader improve performance.

Midterm Outcomes of Pharmacomechanical Thrombectomy in the Treatment of Lower Extremity Deep Vein Thrombosis With a Rotational Thrombectomy Device

Background:

The purpose of this study was to assess the safety and efficacy with midterm outcomes of pharmacomechanical thrombectomy (PMT) performed by using a relatively new thrombectomy device in the treatment of lower extremity deep vein thrombosis (DVT).

Methods:

Between February 2014 and February 2016, a total of 46 patients with lower extremity DVT were treated with PMT by using Cleaner rotational thrombectomy system. Preprocedural, intraprocedural, postprocedural, and follow-up records of patients were collected and retrospectively analyzed.

Results:

Mean age of patients was 50.5 (14.8) years, and 58.7% of them were female. Technical success rate of procedure was 91.3%. Mean procedure time was 81.8 (40.3) minutes. Early clinical improvement was observed in all patients with successful treatment. No serious adverse event related to procedure and mortality was observed. Mean follow-up time was 16.0 (7.9) months. Reocclusion was observed in 7 (17.5%) patients during the follow-up period. Venous patency rates of patients at 1-, 3-, 6-, and 12-month follow-up visits were 95%, 92.5%, 89.7%, and 79.5%, respectively. Mild, moderate, and severe postthrombotic syndrome were observed in 8 (20%) patients, 4 (10%) patients, and 1 (2.5%) patient, respectively. Postthrombotic syndrome–free survival rate was 67.5%.

Conclusion:

Cleaner rotational thrombectomy system appears to be safe and effective in the treatment of lower extremity DVT. Further larger randomized studies are needed to determine the long-term outcomes of this treatment modality.