Catheter-Directed and Pharmacomechanical Thrombolysis for the Treatment of Acute Iliofemoral Deep Venous Thrombosis
- Volume 6 - Issue 3 - May/June 2009
- Posted on: 6/5/09
- 1 Comments
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Anthony J. Comerota, MD, FACS, FACC, Nina Grewal, MD
Quality-of-life results were directly related to the initial success of thrombolysis. Patients with successful thrombus resolution reported a significantly better health utilities index, improved physical functioning, less stigma of CVD, reduced health distress, and fewer overall postthrombotic symptoms. Patients in whom catheter-directed thrombolysis failed had similar outcomes to patients treated with anticoagulation alone. These efficacy data combined with the observed reduction in complications with intrathrombus infusion of plasminogen activators offer a sound argument for the management of patients with iliofemoral DVT with catheter-directed thrombolysis. Subsequently, a randomized trial was performed by Elshawary et al,27 comparing catheter-directed thrombolysis to anticoagulation alone. These authors demonstrated that catheter-directed thrombolysis resulted in significantly better outcomes at 6 months. This was measured by restoration of patency of 72% in lytic group versus 12% in the anticoagulation-only group and by evidence of venous reflux in 11% of patients lysed versus 41% of patients receiving anticoagulation alone.
Assuming patients are properly managed with anticoagulation, thereby avoiding recurrent DVT, this 6-month observation should reflect their long-term outcome.
Now that it has been established that catheter-directed thrombolysis can be performed safely with minimal systemic complications, the next question becomes whether the risk of bleeding complications may be further decreased. An interesting therapeutic approach was reported by Chang et al28 when they used repeated intrathrombus bolus dosing of rt-PA in 12 lower extremities of 10 patients with acute DVT. They infused rt-PA intrathrombus using the pulse-spray technique and no more than 50 mg per treatment. Following the pulse-spray bolus, patients were returned to their rooms and brought back the following day for repeat phlebographic evaluation and repeat infusion, if necessary. Treatment was repeated up to four times. Eleven of the 12 extremities had significant or complete lysis and one had 50–75% lysis. Although the average total dose of rt-PA was 106 mg, bleeding complications were minor, and no patient dropped their hematocrit more than 2%. This intriguing technique deserves further study to evaluate its applicability to the general population of DVT patients.
Preserving venous valve function and luminal patency is the goal of all strategies of thrombus removal for acute DVT. Generally, the preferred method has been catheter-directed thrombolysis, but adding mechanical methods as an adjunct to catheter-directed lytic therapy is quickly setting a new standard for catheter-based treatment of acute DVT.29–31 However, using percutaneous mechanical thrombectomy alone is less successful than catheter-directed thrombolysis, and there appears to be a higher incidence of embolic complications with mechanical thrombectomy. In a prospective evaluation of pulse-spray pharmacomechanical thrombolysis of clotted hemodialysis grafts,32 it was found that PE (documented by ventilation perfusion scan) occurred in 18% of patients treated with a plasminogen activator pulse-spray solution versus 64% of patients treated with a heparinized saline pulse-spray solution (P = .04). Since clotted hemodialysis grafts are in direct communication with the venous circulation, they can be considered similar to proximal veins with acute DVT treated with mechanical thrombus disruption alone (in terms of embolic potential). Observations would likely be magnified when treating larger venous thromboses. This is an important concept, suggesting that mechanical intervention without protection and without adding plasminogen activators will increase the risk of embolization.
This concept was reinforced by Greenberg et al,33 who, in an experimental model, evaluated mechanical, pharmacomechanical, and pharmacologic thrombolysis. Their findings, consistent with anecdotal clinical observations, as well as the results reported by Kinney et al,32 demonstrated that pulse-spray mechanical thrombectomy alone was associated with the largest number and greatest size of distal emboli. When urokinase was added to the pulse-spray solution, the embolic particles diminished in number and size and the speed of lysis increased while time-to-reperfusion shortened. Catheter-directed thrombolysis alone was associated with the slowest time-to-reperfusion but the fewest distal emboli. In general, mechanical thrombectomy alone is generally inadequate. Hemolytic complications of rheolytic mechanical thrombectomy are common and occasionally can result in anemia and renal dysfunction.
One of the more promising pharmacomechanical treatment options for patients with acute iliofemoral DVT is isolated segmental pharmacomechanical thrombolysis (ISPMT), which uses the Trellis Peripheral Infusion System (Bacchus Vascular, Santa Clara, California). The Trellis is a hybrid catheter that isolates the segment of thrombosed vein between two occluding balloons and infuses a small dose of a lytic agent into the target segment. The intervening catheter assumes a spiral configuration which, when activated, spins at approximately 1500 revolutions per minute for 15 to 20 minutes. Following aspiration of the liquefied and fragmented thrombus, the treated vein segment is re-evaluated and re-treated, if necessary. Once the vein is cleared of thrombus, the catheter is repositioned to treat the next thrombosed segments. Phlebographic evaluation of the result is performed before treating additional segments of the thrombosed vein.
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