Catheter-Directed Thrombolytic Therapy for Massive and Submassive Pulmonary Embolus: A Community Hospital Experience

Abstract

Background: Traditional treatment of deep venous thrombosis (DVT) with therapeutic anticoagulation has been increasingly challenged by aggressive percutaneous treatment using ultrasound-accelerated catheter directed thrombolysis (US-CDT) or percutaneous pharmacomechanical thrombectomy (PMT). These techniques have been promoted to improve thrombus removal, prolong venous patency, prevent venous insufficiency, and reduce postthrombotic syndrome. This study reviews midterm results using these endovascular techniques for both acute and chronic DVT.Methods: A retrospective chart review was performed on patients treated for acute or chronic DVT with US-CDT and/or PMT. Charts were reviewed for patient demographics, symptoms and time course of venous thrombosis, anticoagulation regimen, underlying prothrombotic disorders, operative details, and postoperative outcomes. Intraoperative venography and intravascular ultrasound (IVUS) quantified clot response to therapy. Duplex ultrasound defined the pre-and postoperative extent of venous thrombosis, venous patency, and valvular function.Results: Between October 1, 2002 and September 30, 2010, eightyseven patients were treated for iliofemoral (n ϭ 48), iliofemoropopliteal (n ϭ 15), femoropopliteal (n ϭ 17), or subclavian (n ϭ 7) venous thrombosis. Mean age was 45.8 years (range, 15-78 years) and 27 patients (31%) had a documented history of hypercoaguable state. IVUS confirmed May-Thurner syndrome in 34 patients (39%). Fifty-nine patients (68%) were treated for acute symptoms; the mean time to intervention from symptom onset was 7.0 days (range, 1-14 days). The remaining 28 patients (32%) had severe chronic symptoms and were treated at a mean of 8.6 months (range, 1.5-36 months) after DVT diagnosis was made. Patients were treated with PMT (n ϭ 52, 58%), US-CDT (n ϭ 14, 16%), or both (n ϭ 22, 25%). Adjunctive procedures, including percutaneous transluminal angioplasty alone or with stent placement, were required in 59% (n ϭ 35) of acute patients and in 96% (n ϭ 27) of chronic patients (P ϭ.09). A significant decrease in clot burden (Ͼ50%) or complete clot lysis was achieved in 79 of 87 patients (91%). Three patients (3.4%) had postoperative bleeding events requiring blood transfusion; there were no occurrences of intracranial hemorrhage or clinically significant pulmonary embolism. At a mean follow-up of 3.8 years (range, 1-8.9 years), venous patency was present in 55 of 59 acute patients (93%) and in 23 of 28 chronic patients (82%)( P ϭ .14). However, of the 80 lower extremities treated, valve function was preserved in 41 of 52 (79%) acute patients versus only 11 of 28 (39%) chronic patients (P Ͻ .001).Conclusions: Ultrasound-accelerated thrombolysis or percutaneous mechanical thrombectomy used alone or in tandem for treatment of acute and chronic deep venous thrombosis improves symptoms in the involved limb and maintains venous patency at midterm follow-up. Valvular function in the lower extremity is better preserved when sufficient treatment is provided acutely after the ons...