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Complications/Special Considerations
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Fig. 8.9 Stent strut preventing oversheathing of the
entire filter/stent complex.
are recognized immediately, a small percentage
59
are found on subsequent follow-up.
It is important to recognize these events early and attempt
retrieval of the misplaced stent due to the vascular
complications that could occur, leading to more
difficult recanalization as well as iliofemoral/iliocaval thrombosis. Other serious complications due
to vascular stent migration include pulmonary
infarctions following migration into the pulmonary arteries or myocardial injury as a result of
stents migrating into the right ventricle.
60
A case series was published by Gabelmann et al
looking at percutaneous retrieval techniques used
for 28 patients with maldeployed or migrated en-
61
dovascular stents.
The retrieval methods used in
these patients included balloon catheters, gooseneck snares, grasping forceps, as well as the placement of additional stents to effect ively oppose the
misplaced stent to the vessel wall. Twenty-six of
the 28 cases were recognized immediately and retrieved. The two stents not recognized immediately were transjugular intrahepatic portosystemic
shunt (TIPS) stents discovered after 2 and 10 days
Fig. 8.10 (a) Snare attached to the free-floating stent in the inferior vena cava (IVC). (b) A 24 mm × 7 cm Wallstent
placed in the IVC crushing the stent against the caval wall.
101
Interventional Approaches to Recanalization of Chronic Central Venous Occlusions
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and no percutaneous retrieval techniques were
attempted. These stents remained in the pulmonary
artery of the left lobe of the lung and were followed
over a mean of 42 months with no adverse consequences. It is the authors’ opinion that if a stent/filter
can be retrieved easily, it should be done. However,
if there are risk factors that put the patient at an
unacceptable risk, it should be either crushed or left
in place provided the patient is not symptomatic.
8.7 Clinical Data and Outcomes
We included in our summary of clinical outcomes
large studies of > 30 patients with follow-up durations > 2 years after recanalization for thrombotic
central CTOs in the iliocaval and iliofemoral segments (▶ Table 8.3).
The majority of the lesions in these studies were
documented as older than 6 months on recanalization and all patients met a CEAP criteria of at least
C ≥ 3. Technical success is defined here as restoration
of venous f low on final venogram after recanalization and stent placement. This included if there was
reduction in blood flow or collateralization on initial
venogram. Technical success rates for all studies
analyzed were high (83–95%). Patency rates are the
major determining factors when it comes to clinical
success and reinterventions, and understanding
their definitions is important in reporting clinical
outcomes. Primary patency is defined as < 50% restenosis on follow-up without any reinterventions.
Primary assisted patency is confirmed patency on
follow-up after reintervention (e.g., angioplasty) to
maintain patency. Finally, secondary patency is
defined as reestablishment of flow with angioplasty,
thrombolysis, or stent placement after reocclusion
of the previously treated vein segments. A major
distinction is made in primary patency rates between nonthrombotic and postthrombotic limb recanalization. One of the largest studies to date by
Neglén et al in 2007 looked at 982 limbs for obstructive iliac vein lesions that were treated by stenting.
Only 6% of these had iliac veins that required recanalization. In this group, the occlusion rate was much
higher than that of nonocclusive iliac vein stenosis
(24 vs. 3%). The focus of this chapter is specifically
on central CTO recanalization; therefore, nonocclusive stenosis was not included in this review.
Clinical success is defined as significant reduction of symptoms during the duration of follow-up
of the studies. These include reduction in pain and
swelling, resolution of venous ulcers, and quality-oflife metrics. A good metric, as stated before, to monitor clinical process is by using a venous-specific
quality-of-life questionnaire combined with the
Villalta score. Of the studies included, only Ye et al
used the Villalta scoring system and comparison of
quality-of-life metrics is difficult without a standardized reporting format (▶ Table 8.4). An important
finding from these studies is that limbs of patients
who had bilatera l stenting had a higher frequency of
reocclusion (57 vs. 27%). Other factors associated
with stent occlusions included prior thrombosis,
male sex, recent trauma, and age < 50 years.
65
Table 8.3 Clinical outcomes from recanalization in central CTOs
Study Treated limbs Clinical outcomes
Kölbel et al
Raju and Neglén
Rosales et al
Ye et al
Murphy et al
Abbreviations: CTO, chronic total occlusion; PTS, postthrombotic syndrome; VCSS, Venous Clinical Severity Score.
62
63
47
64
102
57 75% overall improvement in symptoms (limb swelling and pain combined)
40
139 Pain and swelling improvement in 79 and 66%, ulceration healing in 56%, and
32 Pain and swelling improvement in 94% (combined), ulceration healing in 57%,
112 Pain and swelling improvement 72 and 70%, ulceration healing in 78% (36/
60 Pain and swelling improvement in 91 and 83%, ulceration healing in 78%,
improvement in all quality-of-life metrics by CVIQ
VCSS in C3/C6 patients 9 (5–12) and 21 (18–29) pre-op and 1 (0–11) and 7
(6–14) post-op
46), total Villalta PTS score 22 pre-op and 9.3 post-op
VCSS 8.4 ± 5.1 pre-op and 3.9 ± 3.2 post-op
References
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Table 8.4 The Villalta scale
Symptoms scored
by the patient
Signs scored by caregiver
(nurse/physician)
Pain Pretibial edema
Cramps Skin induration
Heaviness Hyperpigmentation
Paresthesia Redness
Itching Venous ectasia
Pain on calf compression
Ulcer is scored as present or absent
Note: All symptoms and signs are scored from 0
(absent) to 3 (severe) and summarized to produce a
total score ranging from 0 to 33. A total score of ≥5
points corresponds to any grade of postthrombotic
syndrome (PTS), 5 to 14 points to mild/moderate
PTS, and ≥15 points or the presence of a venous
ulcertoseverePTS.Ascoreoflessthan5indicates
no PTS.
Source: Semin Thromb Hemost 2017; 43(05): 500-504.
The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis ( ATTRACT) trial compared pharmacomechanical
CDT (PCDT) to AC alone, measuring the VCSS and the
Villalta PTS score as outcomes at up to 2 years’
follow-up. While there was no significant difference
in the development of PTS between groups, the
severity of sympt oms as determined by mean VCSS
and Villalta scores was significantly lower in the
PCDT group at all follow-up visits (p ≤ 0.01) except
for the VCSS scores at 24 months (p = 0.03). PCDT
was associated with a significantly higher major
bleedriskof1.7%comparedto0.3%onACalone;
however, no patients in either arm suffered intracranial bleeds.
62
A recent subgroup analysis of ATTRACT patients
with acute iliofemoral DVT demonstrated that
PCDT had a greater reduction in acute pain and
swelling symptoms (p< 0.01) and increased venous
disease-specific quality of life as measured by
VEINES-QOL scores (p = 0.029). There was no significant difference in bleed risk or recurrent VTE.
63
The findings of the ATTRACT trial and its subgroup
analysis suggest that PCDT is an effective method
to reduce symptom severity and improve quality
of life in patients with acute iliofemoral DVT.
8.8 Conclusion
Recanalization of central chronic venous occlusions
(CTOs) is a technique that has been gaining increasing popularity over the past 10 to 15 years with the
advancements in endovascular techniques. Therefore, proper understanding of the tools and techniques used by interventional radiologist to set up a
successful practice that includes DVT interventions
is essential. Quality of life can be significantly improved in patients who suffer with PTS if they are
managed appropriately from initial intervention
using the strategies described in this chapter.
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Chapter 9
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Pulmonary Embolism
9.1 Clinical Assessment:
Massive versus Submassive 109
9.2 Medical/Systemic
Treatment of PE:
Anticoagulation and
Thrombolysis 109
9.3 Pharmacologic
Catheter-Directed Lysis 111
References 113
9
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9 Pulmonary Embolism
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Mina S. Makary, Alexander Y. Kim, Mamdouh Khayat, and Joshua D. Dowell
Keywords: pulmonary embolism, mechanical
thrombectomy, lysis
9.1 Clinical A ssessment: Massive
versus Submassive
Most patients presenting with pulmonary embolism (PE) often have nonspecific symptoms such as
dyspnea and chest pain, while some may experience pleuritic chest pain, tachycardia, fevers, and
hemoptysis. Regardless of the presentation, the
clinical evaluation of a patient presenting with
acute PE should be centered on imaging findings
and hemodynamic stabilit y. Perfusion/ventilation
nuclear medicine scans have been the diagnostic
tool of choice to diagnose PE. This has largely been
replaced in recent years with pulmonary computed tomography (CT) angiography due to its diagnostic accuracy, speed, clot burden assessment,
and associated cardiac effects (▶ Fig. 9.1). The role
of a diagnostic pulmonary angiography is limited
due to its invasive nature but does allow for diagnostic confirmation and direct measurement of
pulmonary arterial pressures prior to catheterbased treatment (▶ Fig. 9.2).
Once the diagnosis of PE is made, hemodynamic
stability dictates treatment approaches and is generally used to stratify the PE as massive, submassive,
or low risk.
instability with systolic blood pressure < 90 mm Hg
1
Massive PE is defined by hemodynamic
for > 15 minutes or requiring inotropic support,
cardiac arrest, pulselessness, or persistent profound
bradycardia (< 40 beats per minute). In contrast, submassive PE is characterized by hemodynamic stability with a systolic blood pressure ≥ 90 mm Hg, but
clinical evidence of right ventricular (RV) dysfunction including the right ventricle-to-left ventricle
(RV/LV) ratio of > 0.9 on CT or echocardiogram
(▶ Fig. 9.3), electrocardiogram changes, and/or laboratory values indicative of heart failure or myocardial
injury. Stable, low-risk PE occurs in patients who are
normotensive and are without RV dysfunction. The
more severe the patient’s presentation, including
acute-onset hypotension, syncope, hypoxemia, or
even cardiac arrest, the higher likelihood the PE is
massive; therefore, higher clinical suspicion and
prompt evaluation should be pursued.
1,2
9.2 Medical/Systemic Treatment
of PE: Anticoagulation and
Thrombolysis
Anticoagulation is the core therapy for patients
with acute PE. Anticoagulation agents are thought
to “stabilize” thrombus and inhibit further propagation of the clot. It should be initiated immediately following the diagnosis of PE or empirically
in the setting of high clinical suspicion for PE, unless a known contraindication is present. Systemic
intravenous fractionated heparin, subcutaneous
unfractionated low-molecular-weight heparin, or
Fig. 9.1 (a,b) Axial and coronal views of pulmonary computed tomography angiography (CTA) demonstrating large
central pulmonary emboli.
109
Pulmonary Embolism
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Fig. 9.2 (a,b) Pulmonary angiogram
demonstrating central filling defects in
bilateral pulmonary arteries consistent
with pulmonary embolism.
Fig. 9.3 Right ventricle-to-left ventricle (RV/LV) ratio > 0.9
in patient with bilateral pulmonary embolism (PE).
subcutaneous fondaparinux are the mainstay systemic therapies. Any of these agents is used to
“bridge” patients while a concurrent oral anticoagulant agent such as warfarin reaches therapeutic
3,4
levels.
Newer oral agents are also now available
in the market and are often used as alternatives to
warfarin including apixaban (Eliquis, Bristol-Myers
Squibb/Pfizer), rivaroxaban (Xarelto, Janssen),
edoxaban (Savaysa, Daiichi Sank yo), and dabigatran etexilate (Pradaxa, Boehringer Ingelheim).
Anticoagulant drug choice should be based on
bleeding risk, reversal agent availability, and cost.
Anticoagulation alone is typically sufficient for
patients with stable, low-risk PE.
For patients presenting with massive PE, thrombolytic agents have been shown to be more effective
in diminishing clot burden compared to systemic
anticoagulants alone.
7
Unlike anticoagulants, which
are used to prevent further thrombus formation,
thrombolytics actively dissolve blood clots. These
drugs cleave the inactive plasminogen into its active
form: plasmin. Plasmin then breaks cross-links between fibrin molecules, which provide the underlying structure of blood clots. The most commonly
used thrombolytic is tissue plasminogen activator
(tPA), but other available U.S. Food and Drug
Administration (FDA) approved thro mbolytics for
PE treatment include streptokinase, urokinase,
5
and alteplase (Activase, Genentech).
Typically, the
drug is administered as a peripheral intravenous
3,8
infusion over a 2-hour period.
Per the latest
guidelines by the American Heart Association
(AHA), the American College of Chest Physicians
(ACCP), the European Heart Association (EHA), and
the American College of Emergency Physicians
(ACEP), thrombolytic therapy is recommended for
patients presenting with acute massive PE, which
accounts for 5% of patients.
1,2,9,10,11
The role of thrombolytics in submassive PE
treatment remains a controversial point of debate.
The multicenter, double-blind, placebo-controlled
Pulmonary Embolism Thrombolysis Trial (PEITHO)
trial assessed 1,005 patients with submassive PE
treated with tenecteplase versus placebo along
5
with unfractionated heparin. The study met its
primary endpoint of demonstrating statistically sig-
6
nificant decrease in all-cause mortality or hemodynamic decompensation (2.6 vs. 5.6%, p = 0.02), in
favor of the tenecteplase group. However , tenecteplase use was associa t ed with increased rates of
major bleeding complication including intracranial
hemorrhage (2.4 vs. 0.2%, p = 0.004). Other trials
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