Catheter-Directed and Pharmacomechanical Thrombolysis for the Treatment of Acute Iliofemoral Deep Venous Thrombosis
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Introduction
The majority of physicians treat patients with iliofemoral deep venous thrombosis (DVT) with anticoagulation alone, despite a growing body of evidence that these patients suffer more severe postthrombotic morbidity and higher recurrence rates than patients with infrainguinal DVT. Although there have been enormous advances in anticoagulation therapy (e.g., low-molecular-weight heparins, pentasaccharides, and direct thrombin inhibitors), these agents serve to limit the progression of thrombosis and, with proper duration of therapy, reduce recurrence. However, anticoagulants are not designed to remove existing thrombus from the deep venous system.
Acute iliofemoral DVT is associated with significant postthrombotic morbidity.1–3 Treatment that removes the thrombus from the iliofemoral venous system and restores patency appears to improve the patient’s clinical condition and reduces long-term postthrombotic morbidity.4–7 Treatment methods have evolved over time from systemic anticoagulation alone to catheter-directed thrombolysis to pharmacomechanical thrombolytic therapy. With each advance in treatment, there appears to be more effective thrombus resolution, reduction of postthrombotic morbidity, and overall improvement in the health of patients following acute DVT.
The latest American College of Chest Physicians (ACCP) evidenced-based clinical practice guidelines echo the importance of treatment designed to eliminate the thrombus in patients with extensive acute proximal DVT. Kearon et al4 state that “in selected patients with extensive acute proximal DVT (iliofemoral DVT, symptoms for < 14 days, good functional status, life expectancy of ≥ 1 year) with low risk of bleeding, catheter-directed thrombolysis may be used to reduce acute symptoms and postthrombotic morbidity if appropriate expertise and resources are available (Grade 2B).” They also added that “pharmacomechanical thrombolysis in preference to CDT alone may be performed to shorten treatment time (Grade 2C).”
Understanding Postthrombotic Venous Disease
The pathophysiology of primary versus postthrombotic venous disease is often unappreciated by many physicians. Consequently, the importance of thrombus removal for the prevention of postthrombotic morbidity, especially in patients with iliofemoral DVT, has been undervalued. The pathophysiology of chronic venous disease (CVD) is ambulatory venous hypertension, which is defined as an elevated venous pressure during exercise.5 Shull et al measured ambulatory venous pressures in a cohort of patients who had iliofemoral DVT 3–5 years earlier. Using a threshold of ≤ 30 mmHg to quantify normal venous pressure, they reported that the combination of luminal occlusion and popliteal valve incompetence resulted in the highest ambulatory venous pressures (85 ± 14 mmHg). Studies have consistently demonstrated that patients with chronic venous obstruction have the most severe postthrombotic morbidity.5,6 Although this is generally true for all segments of the venous system, patients who have multisegment venous involvement17,8 and iliofemoral obstruction suffer the most profound morbidity.
Akesson et al2 showed that 95% of patients with iliofemoral DVT treated with anticoagulation alone had ambulatory venous hypertension at 5 years, and 90% suffered symptoms of CVD. During this relatively short follow up, 15% of patients had already developed venous ulceration and another 15% had debilitating symptoms of venous claudication. In 39 exercised patients with iliofemoral DVT who were treated with anticoagulation, Delis et al3 found that 40% complained of venous claudication. All but one patient complained of chronic symptoms of heaviness, swelling, pruritus, pain, and itching.
Benefits of Thrombus Removal
It has become increasingly evident that early thrombus resolution (by whatever means) after the onset of acute DVT is associated with improved outcomes. Experimental observations, natural history studies of acute DVT treated with anticoagulation, venous thrombectomy data, and observations following both systemic and catheter-directed thrombolysis confirm that a strategy of thrombus removal reduces postthrombotic morbidity.
Experimental observations of acute DVT in canine models demonstrated that thrombolysis preserves endothelial function by preserving ADP-mediated relaxation and valve competence immediately, and at 4 weeks after therapy, compared with placebo. There was less residual thrombus in veins treated with a plasminogen activator, increasing the likelihood that the vein’s structural integrity would be maintained.9,10 Valve function was frequently preserved in humans with acute DVT who were treated with anticoagulation alone and had spontaneous lysis occur early (< 90 days).11–13
Early trials of thrombolytic therapy for acute DVT infused plasminogen activators systemically. Cumulative results of these trials demonstrated that although 45% of patients had substantial or complete lysis, most patients did not.14 However, those patients who had their thrombus successfully lysed had a significant reduction in postthrombotic morbidity and enjoyed preservation of venous valve function. Goldhaber et al15 reviewed outcomes from 8 randomized trials of systemic streptokinase infusion for patients with acute DVT; they found that moderate or significant lysis was achieved almost three times more frequently in patients treated with thrombolysis than in those receiving anticoagulation alone. Unfortunately, systemic lytic therapy was associated with more bleeding complications.
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Wow! Excellent information. It is September 2011 when I am writing this, and after suffering from a DVT four feet long, and being told by almost every health practicioner that there is only one traditional treatment: anticoagulents and time, up to months, for natural dissolvement of clot...
then My kind doctor, Roger Brockbank, of Tri-City Medical in Lindon Utah, directed me to an actual clot removal treatment.
My first thought when diagnosed with dvt, was there must be a roto-rooter therapy that can break-up and remove this massive clot. Bouts of extreme pain took me back to the emergency room and so forth several times.
Bottom LIne:
Pharmacomechanical catheter directed thrombolysis !! Ya, baby! In goes a catheter, into the clotted vein, pushed through to end of clot, or to a certain length segment, a balloon is placed and inflated , to block passage of any dissolved clot, retract catheter and place another balloon at some start point, thus isolating a section of the clotted vein from flow through. Then the catheter delivers a clot dissolving agent, to soften/dissolve the clot. then through a mechanical means, perhaps the high speed spinning of catheter?, the clot is pulverized. Then the catheter sucks out the material. Sections are repeated until the whole length is treated, etc.
Voila: advantage of clot dissolution/ advantage of mechanical means of break-up and reduction to 'dust' / removal of the nasty material!!, then jobsite clean-up. Now that is the common sense of an evolved procedure!
I am looking forward to my procedure tommorrow!
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