Device and Imaging-Specific Volumetric Analysis of Clot Lysis After Percutaneous Mechanical Thrombectomy for Iliofemoral DVT

Abstract

IVUS is superior to venography for detection of residual thrombus and underlying venous pathology after pharmacomechanical thrombectomy. While greater clot lysis was seen with the AngioJet system, both the AngioJet and Trellis devices resulted in excellent clinical clot lysis.

Quality Improvement Guidelines for the Treatment of Lower-Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal

“…An important positive trend is the fact that clinical follow-up beyond 1 year after the procedure was documented in 25 (19,21,22,(25)(26)(27)(28)(29)(30)(31)(32)(36)(37)(38)(39)(40)(41)(43)(44)(45)(46)(47)(48)(49)(50) of 28 (19,21,22,(25)(26)(27)(28)(29)(30)(31)(32)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)…”

“…To determine safety and efficacy thresholds for this review, the committee reviewed more than 200 articles and ultimately selected 30 studies that met the following criteria: (i) English-language publication from 2004-2013; (ii) reported on the endovascular thrombolytic treatment of patients with lower extremity DVT using pharmacologic CDT or PCDT; (iii) included mainly acute DVT cases; and (iv) included a prospective data collection or a retrospective review of data on at least 25 treated patients (19)(20)(21)(22). Of these 30 studies, 17 reported thrombus removal as a percentage based on review of pre-and posttreatment venograms (19,20,23,(28)(29)(30)(31)(32)35,38,(40)(41)(42)(45)(46)(47)50). In these studies, removal of more than 50% thrombus was reported in 91.8% of the 1,046 treated patients.…”

“…However, substantial rates of early recurrent thrombosis have been reported in nonrandomized studies. In the committee's review, 14 studies (19,25,26,29,35,(37)(38)(39)(42)(43)(44)46,48,50) directly reported the frequency of early (1-3 mo after treatment) recurrent thrombosis, and this information could be closely estimated from an additional six studies (30)(31)(32)40,45,47). Early recurrent thrombosis was observed in 9.1% of the 1,131 patients treated in these 20 studies.…”

“…When the observed rate of early treatment success prompts an internal quality review, we suggest attention to the following items: it should be confirmed that (i) the treated population consisted primarily of patients with acute DVT; (ii) intrathrombus drug delivery was accomplished, as systemic thrombolysis and flow-directed thrombolysis are not as effective as intrathrombus CDT (51); (iii) therapeutic-level anticoagulation (heparin-based therapy for patients without contraindications) was provided during the on-table procedural manipulations and after procedure completion (unfractionated heparin may be continued or halted briefly for sheath removal, but complete reversal of its effect is rarely desired) and that heparin-based therapy was given during the infusion CDT component of the treatment (if applicable); and (iv) flow-limiting obstructive lesions (eg, stenosis from iliac vein compression syndrome or other cause, or residual thrombus) were sought and appropriately treated with balloon angioplasty and/or stent placement (1,15,38,52,53). Failure to address such lesions has been associated with high rates of treatment failure or early recurrent thrombosis after thrombus removal procedures, and improved outcomes have been observed in patients treated with left-sided DVT in whom stents were placed (15,19,20,52).…”

May–Thurner syndrome and other obstructive iliac vein lesions: Meaning, myth, and mystery

“…It should also be noted that residual intraluminal thrombus is a common 'obstructive lesion' in patients who have undergone thrombolysis for DVT: in one study, IVUS identified residual thrombus in 36% of patients who were felt to have normal post-thrombolysis venograms. 31 On the other hand, it is very important to note that the true clinical significance of many of the abnormalities that have been described on IVUS (especially those that are entirely occult on venography) has not been established. While lesions that clearly cause severe persistent narrowing or deform the internal architecture of the vein are likely to be significant, lesser degrees of stenosis may or may not account for an individual patient's symptoms, especially when the structure of the vein wall and lumen appear otherwise normal.…”