Catheter-Based Therapies and Other Management Strategies for Deep Vein Thrombosis and Post-Thrombotic Syndrome

Clinical Guidelines on Compression Therapy in Venous Diseases

BACKGROUND

In recent years, compression therapy has attracted gradually increasing clinical attention in lower extremity venous diseases. However, basic concepts and clear nomenclature, standard treatment methods, and consistent product standards for pressure equipment are lacking. Therefore, developing clinical guidelines for compression therapy is essential to improving the treatment of venous diseases.

METHODS

Our panel generated strong (Grade I), moderate (Grade IIa and IIb), and weak (Grade III) recommendations based on high quality (Class A), moderate quality (Class B), and low quality (Class C) evidence, using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach and the European Society of Cardiology (ESC) grading system.

RESULTS

The panels made 30 recommendations from current evidence, focusing on seven fields of lower extremity venous disease (venous thromboembolism, post-thrombotic syndrome, chronic venous insufficiency, varicose veins, hemangioma and vascular malformations, lymphedema, and venous ulcers) and 18 topics.

CONCLUSIONS

Of the 30 recommendations made across the 18 topics, 7 were strong (Grade I) and 17 were based on high quality (Class A) evidence, highlighting the need for further research of the use of compression therapy for .

Endovascular Strategy for Inferior Vena Cava Thrombosis Secondary to Deep Venous Thrombosis of the Lower Extremities: Early Experience From Two Centres

PURPOSE

To evaluate the safety, feasibility and technical aspects of endovascular treatments for inferior vena cava (IVC) thrombosis secondary to deep venous thrombosis of the lower extremities.

MATERIALS AND METHODS

A retrospective study of patients from two centres who received endovascular treatment for IVC thrombosis from January 2015 to December 2020. Under the protection of the IVC filter, all lesions were treated with manual aspiration thrombectomy (MAT) followed by catheter-directed thrombolysis (CDT). Technical aspects, complications, IVC patency, Venous Clinical Severity Score (VCSS) score and Villalta score were recorded during the follow-up observation.

RESULTS

Endovascular procedures including MAT and CDT were performed successfully in 36 patients (97.3%). The average duration of the endovascular procedure was 71 minutes (range: 35-152 min). To protect against fatal pulmonary artery embolism, 33 filters (91.7%) were deployed in the inferior renal IVC, while three patients (8.3%) received filter implantation in the retrohepatic IVC. No severe complications occurred during the procedure. In the follow-up observations, the cumulative primary and secondary patency rates in IVC were 95% and 100%, respectively. The patency rates for the iliac vein were as follows: a primary patency rate of 77% and a secondary patency rate of 85%. The average VCSS score was 5.9 ± 2.6, and the Villalta score was 3.9 ± 2.2. The rate of post thrombotic syndrome is 22% in our study as assessed by the villalta score (Villalta score>4).

CONCLUSIONS

Endovascular treatment for IVC thrombosis secondary to DVT of the lower extremities is feasible, safe, and effective. This strategy alleviates venous insufficiency and results in a high patency rate in IVC.

A systematic evaluation and meta-analysis of early prediction of post-thrombotic syndrome

Objective

Post-thrombotic syndrome (PTS) is the most common long-term complication in patients with deep venous thrombosis, and the prevention of PTS remains a major challenge in clinical practice. Some studies have explored early predictors and constructed corresponding prediction models, whereas their specific application and predictive value are controversial. Therefore, we conducted this systematic evaluation and meta-analysis to investigate the incidence of PTS and the feasibility of early prediction.

Methods

We systematically searched databases of PubMed, Embase, Cochrane and Web of Science up to April 7, 2023. Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of the included articles, and the OR values of the predictors in multi-factor logistic regression were pooled to assess whether they could be used as effective independent predictors.

Results

We systematically included 20 articles involving 8,512 subjects, with a predominant onset of PTS between 6 and 72 months, with a 2-year incidence of 37.5% (95% CI: 27.8-47.7%). The results for the early predictors were as follows: old age OR = 1.840 (95% CI: 1.410-2.402), obesity or overweight OR = 1.721 (95% CI: 1.245-2.378), proximal deep vein thrombosis OR = 2.335 (95% CI: 1.855-2.938), history of venous thromboembolism OR = 3.593 (95% CI: 1.738-7.240), history of smoking OR = 2.051 (95% CI: 1.305-3.224), varicose veins OR = 2.405 (95% CI: 1.344-4.304), and baseline Villalta score OR = 1.095(95% CI: 1.056-1.135). Meanwhile, gender, unprovoked DVT and insufficient anticoagulation were not independent predictors. Seven studies constructed risk prediction models. In the training set, the c-index of the prediction models was 0.77 (95% CI: 0.74-0.80) with a sensitivity of 0.75 (95% CI: 0.68-0.81) and specificity of 0.69 (95% CI: 0.60-0.77). In the validation set, the c-index, sensitivity and specificity of the prediction models were 0.74(95% CI: 0.69-0.79), 0.71(95% CI: 0.64-0.78) and 0.72(95% CI: 0.67-0.76), respectively.

Conclusions

With a high incidence after venous thrombosis, PTS is a complication that cannot be ignored in patients with venous thrombosis. Risk prediction scoring based on early model construction is a feasible option, which helps to identify the patient's condition and develop an individualized prevention program to reduce the risk of PTS.

Rheolytic thrombectomy using an AngioJet ZelanteDVT catheter or a Solent Omni catheter for patients with proximal vein thrombosis

PURPOSE

The present study aimed to investigate the preliminary safety and efficacy of rheolytic thrombectomy (RT) using an AngioJet Zelante DVT catheter or a Solent Omni catheter for acute proximal deep vein thrombosis (DVT).

MATERIAL AND METHODS

We conducted a retrospective review of 40 patients who were treated with an AngioJet RT between January 2019 and January 2021, and then the patients were divided into the ZelanteDVT group (n = 17) and the Solent group (n = 23). Data on demographics, clinical characteristics, technical success, clinical success, complications, and early follow-up were analysed.

RESULTS

No significant differences regarding demographics were detected (all p > .05). The technical success rates were both 100%. The ZelanteDVT group had a shorter duration of RT and a higher primary RT success than the Solent group (all p < .05), and the percentage of adjunctive catheter-directed thrombolysis (CDT) was 29.4% in the ZelanteDVT group, which was significantly lower than the 73.9% in the Solent group (p = .010). The clinical success rates for the ZelanteDVT group and Solent group were 100% (17/17) and 95.7% (22/23), respectively, and these values were high in the two groups (p > .05). Apart from transient macroscopic haemoglobinuria occurring in all the patients during the first 24 hours post-RT, none of the patients in either group suffered other procedure-related adverse events or major complications. Minor complications included bleeding events in 21.7% (5/23) of the patients in the Solent group and one (5.9%) patient in the ZelanteDVT group (p > .05). At 6 months, the frequency of PTS was 5.9% (1/17) in the ZelanteDVT group and 17.4% (4/23) in the Solent group (p > .05).

CONCLUSION

Both catheters are safe and effective in managing patients with proximal DVT, thus leading to improved clinical outcomes with few complications. The ZelanteDVT catheter was more effective than the Solent catheter in thrombectomy, thus allowing for faster extraction of the DVT with a shorter run time and lower proportions of patients with adjunctive CDT.

AngioJet rheolytic thrombectomy for the treatment of deep vein thrombosis in elderly patients: Increase the risk of acute kidney injury?

Objective

The objective of this study was to investigate the risk of acute kidney injury in elderly patients compared with nonelderly patients undergoing AngioJet rheolytic thrombectomy for treatment of acute deep vein thrombosis.

Methods

A retrospective review of all patients who underwent AngioJet rheolytic thrombectomy for the treatment of acute deep vein thrombosis between November 1, 2014 and August 1, 2022 was conducted. Their baseline demographics, comorbidities, clinical characteristics, procedural details, and postoperative course were reviewed.

Results

A total of 105 eligible patients were reviewed; 45 patients were in the elderly group, and 60 were in the nonelderly group. Except for age (p < 0.001), no significant differences regarding demographics were detected (p >0.05). Transient macroscopic hemoglobinuria occurred in all patients during the first 24 h post-AngioJet rheolytic thrombectomy. The overall morbidity of acute kidney injury in the two groups was 11.4%, and the nonelderly group had a similar rate of acute kidney injury (8.3%) to the elderly group (15.6%). None of the 12 patients progressed to dialysis within the postoperative period, and the mean acute kidney injury recovery time of the elderly group was 5.86 ± 1.57 days, which was longer than the 3.60 ± .89 days of the nonelderly group (p = 0.017).

Conclusion

The use of AngioJet rheolytic thrombectomy for the treatment of patients with acute deep vein thrombosis is associated with a potential risk of acute kidney injury, which seems to have a comparable rate in elderly and nonelderly patients. acute kidney injury in the elderly group tends to need a longer recovery time, which requires postoperative vigilance for this population.

Endovascular Management of Venous Thromboembolic Disease in the Oncologic Patient Population

PURPOSE OF REVIEW

Venous thromboembolic disease causes significant mortality and morbidity in the oncologic patient population. Recently, minimally invasive endovascular technologies have been developed as an adjunct to antithrombotic therapy for the management of DVT and PE. The current and potential roles for endovascular treatment of cancer-associated venous thromboembolism (VTE) will be reviewed in this article.

RECENT FINDINGS

The recent NCCN guidelines recommend endovascular therapy in patients eligible for therapeutic anticoagulation who present with life-, organ-, or limb-threatening thrombosis. However, symptomatic non-life-threatening VTE can negatively affect QOL and physical function, both of which have prognostic implications in the cancer population. Endovascular therapies have been shown to improve physical function and QOL in prospective trials performed in a non-oncologic patient population as well as small retrospective studies in the cancer population. In addition to treating life- and limb-threatening thrombosis, endovascular therapy for VTE can improve QOL and physical function in comparison to anticoagulation alone. Prospective trials are warranted to assess the benefit of endovascular therapy for quality of life-years, performance status, and overall survival in the oncologic patient population.

Pediatric May-Thurner Syndrome-Systematic review and individual patient data meta-analysis

BACKGROUND

The outcomes of deep vein thrombosis (DVT) in children with May-Thurner Syndrome (MTS) remain unclear.

OBJECTIVES

This systematic review and patient-level meta-analysis aims to describe the outcomes of children with MTS presenting with DVT.

METHODS

A systematic review of the published literature was performed. Data related to patients <18 years diagnosed with MTS and DVT was extracted. Risk of bias was assessed using the Murad criteria. Outcomes included vessel patency post-treatment, DVT recurrence, and post-thrombotic syndrome (PTS). Predictive and explanatory models were developed for these outcomes.

RESULTS

In total, 109 cases were identified (age range 4-17 years; 77 females) in 28 studies; 75% of patients had ≥1 additional risk factor for DVT. PTS was seen in 61% of patients, DVT recurrence in 38%, and complete vessel patency post-treatment in 65%. The models developed to predict and explain PTS performed poorly overall. Recurrent thrombosis (adjusted for age and patency) predicted PTS (odds ratio [OR] 3.36, 95% confidence interval [CI] 1.28-8.82). DVT management strategies (adjusted for age and DVT characteristics) predicted vessel patency (OR 2.10, 95% CI 1.43-3.08). Lack of complete vessel patency (adjusted for age and thrombophilia) predicted recurrent DVT (OR 2.70, 95% CI 1.09-6.67). Sensitivity analyses showed the same direction of effects for all outcomes.

CONCLUSIONS

PTS and DVT recurrence occur frequently in pediatric MTS. PTS prediction is complex and it was not possible to identify early predictors to guide clinical practice. Use of imaging-guided therapy and thrombus burden predicted venous patency, and lack of patency predicted DVT recurrence.

Surgical Considerations in the Treatment of Axillary-Subclavian Venous Thrombosis in the Era of COVID-19

PURPOSE

Traditional treatment of axillary-subclavian venous thrombosis is resource intensive due to the need for advanced nursing care and increased utilization of intensive care units for thrombolysis procedures. We recently encountered this in the management of 2 patients with effort-induced upper extremity venous thrombosis following COVID-19 infection and offer a treatment paradigm for consideration.

CASE REPORTS

A 30-year-old presented with 2 weeks of left upper extremity symptoms following COVID-19 infection. Duplex ultrasound demonstrated axillary-subclavian venous thrombosis and venogram confirmed total occlusion of the axillary and subclavian veins with profuse collaterals around the occlusion. Suction thrombectomy was performed successfully and veins remained patent at 6 month follow up. The patient declined first rib resection and stopped lifting weights. A 16-year-old presented with 4 days of right arm symptoms 1 month after testing positive for COVID-19. Duplex ultrasound revealed acute axillary and subclavian vein thrombosis and she underwent successful thrombectomy followed by balloon angioplasty with improvement in symptoms.

CONCLUSION

The pandemic has strained health care resources such that the treatment of non-life-threatening conditions must be triaged to conserve resources. While axillary-subclavian venous occlusion is usually not life-threatening, timely treatment leads to decreased morbidity and better outcomes. Percutaneous aspiration and thrombectomy without adjunctive thrombolysis may be of benefit in reducing healthcare resource utilization while still achieving good outcomes during the COVID pandemic and beyond.

Prevalence and predictors of alternative diagnoses on whole-leg ultrasound negative for acute deep venous thrombosis

Background

To investigate the prevalence, spectrum, and predictors of alternative diagnoses explaining leg symptoms in patients negative for suspected acute deep venous thrombosis (DVT), which can be detected with whole-leg ultrasound.

Methods

We retrospectively analyzed a cohort of 789 patients (median age 70 years, 50.6% women) evaluated with a whole-leg ultrasound examination for suspected acute DVT within one year. All findings in the radiology report were analyzed and electronic chart review was performed to collect clinical information.

Results

Ultrasound was negative for acute DVT in 531 patients (67.3%). Among these, alternative diagnoses explaining leg symptoms were seen in 349 patients (65.7%). The most frequent alternative diagnoses were chronic venous insufficiency (147 patients, 27.7%), followed by lymphedema (48 patients, 9.0%) and chronic post-thrombotic changes (41 patients, 7.7%). Patients with alternative diagnoses were older (median 71 vs. 66 years, p = 0.0226), as well as more likely to present with leg swelling (39.5% vs. 23.1%, p = 0.0002), difference in leg circumference (25.5% vs. 14.8%, p = 0.0055) and redness (7.7% vs. 2.7%, p = 0.0213) than patients without alternative diagnosis. Independent predictors of finding alternative diagnoses on whole-leg ultrasound were older age (odds ratio 1.014 per year, p = 0.0119), leg swelling (OR 1.949, p = 0.0020) and history of previous DVT (OR 2.235, p = 0.0154).

Conclusions

Alternative diagnoses explaining leg symptoms can be detected on whole-leg ultrasound in two thirds of patients with no evidence of acute DVT. Our data supports performing a comprehensive ultrasound evaluation beyond the venous system, particularly, in older patients, who present with leg swelling and a past history of DVT.