Interventional Approaches to Acute Venous Thromboembolism

 

 Buy Article Permissions and Reprints

ABSTRACT

During the last decade, advances in minimally invasive technologies have spurred a renaissance in the aggressive treatment of venous thromboembolism (VTE) using percutaneous techniques. In this article, we outline the relative risks and benefits of endovascular VTE therapies, highlight clinical situations in which the benefits of endovascular treatment are likely to outweigh its risks, and provide an update regarding the specific new modalities that may be applied to VTE. Pharmacomechanical thrombolysis represents the most promising currently available method to treat VTE. However, pending demonstration that it actually improves VTE outcomes in randomized trials with long-term follow-up, a highly individualized approach to patient selection is recommended. At present, highly compromised patients with pulmonary emboli (PE) in whom systemic thrombolytic therapy has failed or is contraindicated are reasonable candidates for catheter-based PE interventions. Adjunctive pharmacomechanical catheter-directed deep venous thrombosis (DVT) thrombolysis is best indicated for the first-line treatment of patients with phlegmasia cerulea dolens, acute inferior vena cava (IVC) occlusion, and acute iliofemoral DVT after careful clinical assessment and a balanced discussion with the patient. It is hoped that multidisciplinary clinical trials with involvement by both interventionalists and pulmonary physicians will validate these techniques in the near future.

REFERENCES

• 1 Hirsh J, Hoak J. Management of deep vein thrombosis and pulmonary embolism: a statement for healthcare professionals.  Circulation. 1996;  93 2212-2245
  CrossrefPubMedGoogle Scholar
• 2 Bates S M, Ginsberg J S. Clinical practice: treatment of deep-vein thrombosis.  N Engl J Med. 2004;  351 268-277
  CrossrefPubMedGoogle Scholar
• 3 Brandjes D P, Buller H R, Heijboer H et al.. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis.  Lancet. 1997;  349 759-762
  CrossrefPubMedGoogle Scholar
• 4 Prandoni P, Lensing A W, Prins M H et al.. Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial.  Ann Intern Med. 2004;  141 249-256
  CrossrefPubMedGoogle Scholar
• 5 Kahn S R, Hirsch A, Shrier I. Effect of postthrombotic syndrome on health-related quality of life after deep venous thrombosis.  Arch Intern Med. 2002;  162 1144-1148
  CrossrefPubMedGoogle Scholar
• 6 Kahn S R, Ducruet T, Lamping D L et al.. Prospective evaluation of health-related quality of life in patients with deep venous thrombosis.  Arch Intern Med. 2005;  165 1173-1178
  CrossrefPubMedGoogle Scholar
• 7 Heit J A, Rooke T W, Silverstein M D et al.. Trends in the incidence of venous stasis syndrome and venous ulcer: a 25-year population-based study.  J Vasc Surg. 2001;  33 1022-1027
  CrossrefPubMedGoogle Scholar
• 8 Phillips T, Stanton B, Provan A, Lew R. A study of the impact of leg ulcers on quality of life: financial, social, and psychologic implications.  J Am Acad Dermatol. 1994;  31 49-53
  CrossrefPubMedGoogle Scholar
• 9 Bergqvist D, Jendteg S, Johansen L, Persson U, Odegaard K. Cost of long-term complications of deep venous thrombosis of the lower extremities: an analysis of a defined patient population in Sweden.  Ann Intern Med. 1997;  126 454-457
  CrossrefPubMedGoogle Scholar
• 10 Prandoni P, Lensing A W, Cogo A et al.. The long-term clinical course of acute deep venous thrombosis.  Ann Intern Med. 1996;  125 1-7
  CrossrefPubMedGoogle Scholar
• 11 Van Dongen C JJ, Prandoni P, Frulla M, Marchiori A, Prins M H, Hutten B A. Relation between quality of anticoagulant treatment and the development of the postthrombotic syndrome.  J Thromb Haemost. 2005;  3 939-942
  CrossrefPubMedGoogle Scholar
• 12 Ginsberg J S, Hirsh J, Julian J et al.. Prevention and treatment of postphlebitic syndrome: results of a 3-part study.  Arch Intern Med. 2001;  161 2105-2109
  CrossrefPubMedGoogle Scholar
• 13 Partsch H, Kaulich M, Mayer W. Immediate mobilization in acute vein thrombosis reduced post-thrombotic syndrome.  Int Angiol. 2004;  23 206-212
  PubMedGoogle Scholar
• 14 Nicolaides A N, Hussein M K, Szendro G, Christopoulos D, Vasdekis S, Clarke H. The relation of venous ulceration with ambulatory venous pressure measurements.  J Vasc Surg. 1993;  17 414-419
  CrossrefPubMedGoogle Scholar
• 15 Markel A, Manzo R A, Bergelin R O, Strandness D E. Valvular reflux after deep vein thrombosis: incidence and time of occurrence.  J Vasc Surg. 1992;  15 377-384
  CrossrefPubMedGoogle Scholar
• 16 Caps M T, Manzo R A, Bergelin R O, Meissner M H, Strandness D E. Venous valvular reflux in veins not involved at the time of acute deep vein thrombosis.  J Vasc Surg. 1995;  22 524-531
  CrossrefPubMedGoogle Scholar
• 17 Meissner M H, Manzo R A, Bergelin R O, Markel A, Strandness D E. Deep venous insufficiency: the relationship between lysis and subsequent reflux.  J Vasc Surg. 1993;  18 596-608
  CrossrefPubMedGoogle Scholar
• 18 Prandoni P, Frulla M, Sartor D, Concolato A, Girolami A. Venous abnormalities and the post-thrombotic syndrome.  J Thromb Haemost. 2005;  3 401-402
  CrossrefPubMedGoogle Scholar
• 19 Prandoni P, Lensing A WA, Prins M H et al.. Residual venous thrombosis as a predictive factor of recurrent venous thromboembolism.  Ann Intern Med. 2002;  137 955-960
  PubMedGoogle Scholar
• 20 Hull R D, Marder V J, Mah A F, Biel R K, Brant R F. Quantitative assessment of thrombus burden predicts the outcome of treatment for venous thrombosis: a systematic review.  Am J Med. 2005;  118 456-464
  CrossrefPubMedGoogle Scholar
• 21 O'Donnell Jr T F, Browse N L, Burnand K G, Thomas M L. The socioeconomic effects on an iliofemoral venous thrombosis.  J Surg Res. 1977;  22 483-488
  CrossrefPubMedGoogle Scholar
• 22 Delis K T, Bountouroglou D, Mansfield A O. Venous claudication in iliofemoral thrombosis: long-term effects on venous hemodynamics, clinical status, and quality of life.  Ann Surg. 2004;  239 118-126
  CrossrefPubMedGoogle Scholar
• 23 Goldhaber S Z, Buring J E, Lipnick R J, Hennekens C H. Pooled analyses of randomized trials of streptokinase and heparin in phlebographically documented acute deep venous thrombosis.  Am J Med. 1984;  76 393-397
  CrossrefPubMedGoogle Scholar
• 24 Comerota A J, Aldridge S C. Thrombolytic therapy for deep venous thrombosis: a clinical review.  Can J Surg. 1993;  36 359-364
  PubMedGoogle Scholar
• 25 Arnesen H, Hoiseth A, Ly B. Streptokinase or heparin in the treatment of deep vein thrombosis.  Acta Med Scand. 1982;  211 65-68
  PubMedGoogle Scholar
• 26 Elliot M S, Immelman E J, Jeffery P et al.. A comparative randomized trial of heparin versus streptokinase in the treatment of acute proximal venous thrombosis in an interim report of a prospective trial.  Br J Surg. 1979;  66 838-843
  CrossrefPubMedGoogle Scholar
• 27 Plate G, Eklof B, Norgren L, Ohlin P, Dahlstrom J A. Venous thrombectomy for iliofemoral venous thrombosis: 10-year results of a prospective randomized study.  Eur J Vasc Endovasc Surg. 1997;  14 367-374
  CrossrefPubMedGoogle Scholar
• 28 Giannitsis E, Katus H A. Risk stratification in pulmonary embolism based on biomarkers and echocardiography.  Circulation. 2005;  112 1520-1521
  CrossrefPubMedGoogle Scholar
• 29 Wan S, Quinlan D J, Agnelli G, Eikelboom J W. Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: a meta-analysis of the randomized controlled trials.  Circulation. 2004;  110 744-749
  CrossrefPubMedGoogle Scholar
• 30 Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism.  N Engl J Med. 2002;  347 1143-1150
  CrossrefPubMedGoogle Scholar
• 31 Goldhaber S Z, Visni L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER).  Lancet. 1999;  353 1386-1389
  CrossrefPubMedGoogle Scholar
• 32 McNamara T O, Fischer J R. Thrombolysis of peripheral arterial and graft occlusions: improved results using high-dose urokinase.  AJR Am J Roentgenol. 1985;  144 769-775
  CrossrefPubMedGoogle Scholar
• 33 Meyerovitz M F, Polak F J, Goldhaber S Z. Short-term response to thrombolytic therapy in deep venous thrombosis: predictive value of venographic appearance.  Radiology. 1992;  184 345-348
  PubMedGoogle Scholar
• 34 Semba C P, Dake M D. Iliofemoral deep venous thrombosis: aggressive therapy with catheter-directed thrombolysis.  Radiology. 1994;  191 487-494
  PubMedGoogle Scholar
• 35 Mewissen W M, Seabrook G R, Meissner M H, Cynamon J, Labropoulos N, Haughton S H. Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry.  Radiology. 1999;  211 39-49
  CrossrefPubMedGoogle Scholar
• 36 Parikh S R, Raabe R A, Motarjeme A, McNamara T O, Ho J W, Ferguson G S. Ultrasound-accelerated thrombolysis (UAT) for deep venous thrombosis (DVT): EKOS multicenter experience.  J Vasc Interv Radiol. 2006;  17(2 Pt 2) S49
  PubMedGoogle Scholar
• 37 Bjarnason H, Kruse J R, Asinger D A et al.. Iliofemoral deep venous thrombosis: safety and efficacy outcome during 5 years of catheter-directed thrombolytic therapy.  J Vasc Interv Radiol. 1997;  8 405-418
  PubMedGoogle Scholar
• 38 Sugimoto K, Hoffman L V, Razavi M K et al.. The safety, efficacy, and pharmacoeconomics of low-dose alteplase compared with urokinase for catheter-directed thrombolysis of arterial and venous occlusions.  J Vasc Surg. 2003;  37 512-517
  CrossrefPubMedGoogle Scholar
• 39 Castaneda F, Li R, Young K, Swischuk J L, Smouse B, Brady T. Catheter-directed thrombolysis in deep venous thrombosis with use of reteplase: immediate results and complications from a pilot study.  J Vasc Interv Radiol. 2002;  13 577-580
  PubMedGoogle Scholar
• 40 Razavi M K, Wong H, Kee S T, Sze D Y, Semba C P, Dake M D. Initial clinical results of tenecteplase (TNK) in catheter-directed thrombolytic therapy.  J Endovasc Ther. 2002;  9 593-598
  CrossrefPubMedGoogle Scholar
• 41 Mickley V, Shwagierek R, Rilinger N, Gorich J, Sunder-Plassman L. Left iliac venous thrombosis caused by venous spur: treatment with thrombectomy and stent implantation.  J Vasc Surg. 1998;  28 492-497
  CrossrefPubMedGoogle Scholar
• 42 Buller H R, Hull R D, Hyers T M, Prins M H, Raskob G E. Antithrombotic therapy for venous thromboembolic disease. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.  Chest. 2004;  126 401S-428S
  CrossrefPubMedGoogle Scholar
• 43 Vedantham S, Thorpe P E, Cardella J F for the CIRSE and SIR Standards of Practice Committees et al. Quality improvement guidelines for the treatment of lower extremity deep vein thrombosis with use of endovascular thrombus removal.  J Vasc Interv Radiol. 2006;  17 435-448
  CrossrefPubMedGoogle Scholar
• 44 Verstraete M, Miller G AH, Bounameaux H et al.. Intravenous and intrapulmonary recombinant tissue-type plasminogen activator in the treatment of acute massive pulmonary embolism.  Circulation. 1988;  77 353-360
  CrossrefPubMedGoogle Scholar
• 45 Tapson V F, Gurbel P A, Witty L A, Pieper K S, Stack R S. Pharmacomechanical thrombolysis of experimental pulmonary emboli: rapid low-dose intraembolic therapy.  Chest. 1994;  106 1558-1562
  CrossrefPubMedGoogle Scholar
• 46 Schmitz-Rode T, Kilbinger M, Gunther R W. Simulated flow pattern in massive pulmonary embolism: significance for selective intrapulmonary thrombolysis.  Cardiovasc Intervent Radiol. 1998;  21 199-204
  CrossrefPubMedGoogle Scholar
• 47 Kasirajan K, Gray B, Ouriel K. Percutaneous Angiojet thrombectomy in the management of extensive deep venous thrombosis.  J Vasc Interv Radiol. 2001;  12 179-185
  PubMedGoogle Scholar
• 48 Vedantham S, Vesely T M, Parti N, Darcy M, Hovsepian D M, Picus D. Lower extremity venous thrombolysis with adjunctive mechanical thrombectomy.  J Vasc Interv Radiol. 2002;  13 1001-1008
  PubMedGoogle Scholar
• 49 Uflacker R. Mechanical thrombectomy in acute and subacute thrombosis with use of the Amplatz device: arterial and venous applications.  J Vasc Interv Radiol. 1997;  8 923-932
  PubMedGoogle Scholar
• 50 Delomez M, Beregi J P, Willoteaux S, Bauchart J J, Janee d'Othee B, Asseman P et al.. Mechanical thrombectomy in patients with deep venous thrombosis.  Cardiovasc Intervent Radiol. 2001;  24 42-48
  CrossrefPubMedGoogle Scholar
• 51 Vedantham S, Vesely T M, Sicard G A et al.. Pharmacomechanical thrombolysis and early stent placement for iliofemoral deep vein thrombosis.  J Vasc Interv Radiol. 2004;  15 565-574
  PubMedGoogle Scholar
• 52 Bush R L, Lin P H, Bates J T, Mureebe L, Zhou W, Lumsden A B. Pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis: safety and feasibility study.  J Vasc Surg. 2004;  40 965-970
  CrossrefPubMedGoogle Scholar
• 53 Lin P H, Zhou W, Dardik A et al.. Catheter-direct thrombolysis versus pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis.  Am J Surg. 2006;  192 782-788
  CrossrefPubMedGoogle Scholar
• 54 Kim H S, Patra A, Paxton B E, Khan J, Streiff M B. Adjunctive percutaneous mechanical thrombectomy for lower-extremity deep vein thrombosis: clinical and economic outcomes.  J Vasc Interv Radiol. 2006;  17 1099-1104
  CrossrefPubMedGoogle Scholar
• 55 Cynamon J, Stein E G, Dym J, Jagust M, Binkert C A, Baum R A. A new method for aggressive management of deep vein thrombosis: retrospective study of the power pulse technique.  J Vasc Interv Radiol. 2006;  17 1043-1049
  CrossrefPubMedGoogle Scholar
• 56 Garcia M, Dignazio M, Kimbris G, Beeravolu A, Peters A, Veasey J. ATTACK-DVT: Angiojet and TPA thrombolysis: a closer look at combined therapy for the treatment of DVT.  J Vasc Interv Radiol. 2007;  18(1 Pt 2) S21
  PubMedGoogle Scholar
• 57 O'Sullivan G J, Lohan D G, Gough N, Cronin C G, Kee S T. Pharmacomechanical thrombectomy of acute deep vein thrombosis with the Trellis-8 isolated thrombolysis catheter.  J Vasc Interv Radiol. 2007;  18 715-724
  PubMedGoogle Scholar
• 58 Fava M, Loyola S, Flores P, Huete I. Mechanical fragmentation and pharmacologic thrombolysis in massive pulmonary embolism.  J Vasc Interv Radiol. 1997;  8 261-266
  PubMedGoogle Scholar
• 59 De Gregorio M A, Gimeno M J, Mainar A et al.. Mechanical and enzymatic thrombolysis for massive pulmonary embolism.  J Vasc Interv Radiol. 2002;  13 163-169
  CrossrefPubMedGoogle Scholar
• 60 Schmitz-Rode T, Janssens U, Duda S H, Erley C M, Gunther R W. Massive pulmonary embolism: percutaneous emergency treatment by pigtail rotation catheter.  J Am Coll Cardiol. 2000;  36 375-380
  CrossrefPubMedGoogle Scholar
• 61 Tajima H, Murata S, Kumazaki T et al.. Hybrid treatment of acute massive pulmonary thromboembolism: mechanical fragmentation with a modified rotating pigtail catheter, local fibrinolytic therapy, and clot aspiration followed by systemic fibrinolytic therapy.  AJR Am J Roentgenol. 2004;  183 589-595
  CrossrefPubMedGoogle Scholar
• 62 Siablis D, Karnabatidis D, Katsanos K, Kagadis G C, Zabakis P, Hahalis G. AngioJet rheolytic thrombectomy versus local intrapulmonary thrombolysis in massive pulmonary embolism: a retrospective data analysis.  J Endovasc Ther. 2005;  12 206-214
  CrossrefPubMedGoogle Scholar
• 63 Haskal Z J, Soulen M C, Huettl E A, Palevski H I, Cope C. Life-threatening pulmonary emboli and cor pulmonale: treatment with percutaneous pulmonary artery stent placement.  Radiology. 1994;  191 473-475
  PubMedGoogle Scholar
• 64 Comerota A J, Throm R C, Mathias S D, Haughton S, Mewissen M. Catheter-directed thrombolysis for iliofemoral deep venous thrombosis improves health-related quality of life.  J Vasc Surg. 2000;  32 130-137
  CrossrefPubMedGoogle Scholar
• 65 AbuRahma A F, Perkins S E, Wulu J T, Ng H K. Iliofemoral deep vein thrombosis: conventional therapy versus lysis and percutaneous transluminal angioplasty and stenting.  Ann Surg. 2001;  233 752-760
  CrossrefPubMedGoogle Scholar
• 66 Elsharawy M, Elzayat E. Early results of thrombolysis vs anticoagulation in iliofemoral venous thrombosis: a randomised clinical trial.  Eur J Vasc Endovasc Surg. 2002;  24 209-214
  CrossrefPubMedGoogle Scholar
• 67 Vedantham S, Rundback J H, Comerota A J et al.. Development of a research agenda for endovascular treatment of venous thromboembolism: proceedings from a multidisciplinary consensus panel.  J Vasc Interv Radiol. 2005;  16 1567-1573
  PubMedGoogle Scholar
• 68 Vedantham S, Millward S F, Cardella J F et al.. Society of Interventional Radiology Position Statement: treatment of acute iliofemoral deep vein thrombosis with use of adjunctive catheter-directed intrathrombus thrombolysis.  J Vasc Interv Radiol. 2006;  17 613-616
  CrossrefPubMedGoogle Scholar

Suresh VedanthamM.D. 

Interventional Radiology Section, Mallinckrodt Institute of Radiology

510 S. Kingshighway, Box 8131, St. Louis, MO 63110

Email: vedanthams@mir.wustl.edu