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discomfort or distal leg so tissue damage. Our ability to
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identify and quantitate venous obstruction is so poor that
there is widespread underappreciation regarding the importance of the contribution of obstruction to postthrombotic
morbidity.
Unfortunately, physiologic testing on the venous side of
the circulation has not kept pace with similar advances on
the arterial side of the vascular tree. Vascular laboratories
have traditionally (and paradoxically) tested the hemodynamics of venous obstruction with patients in the resting,
supine position with their legs elevated, which is the standard position for measuring maximum venous out ow, the
commonly accepted test for venous obstruction. However,
the pathophysiology of chronic venous disease is de ned in
the upright, exercising patient, with increased arterial in ow
stressing venous return. Phlebograms of postthrombotic
recanalized veins frequently document patency, and noninvasive studies may indeed show normal maximal venous
out ow values, giving the mistaken impression that venous
obstruction contributes little to postthrombotic morbidity.
is is clearly illustrated by the patient represented in
Figure46.1, who had iliofemoral DVT 10years earlier and
was su ering with severe postthrombotic syndrome and a
venous ulcer. Noninvasive testing demonstrated that the
patient had valvular incompetence but a normal 3-s maximal venous out ow. An ascending phlebogram was interpreted as “the classic tree-barking appearance of chronic
venous disease. ere is no evidence of venous obstruction.”
e following day the patient underwent a classic Linton
procedure, which included femoral vein ligation with division just below its junction with the profunda femoris
vein. Across-section of the divided femoral vein is shown
in Figure49.1, along with its corresponding level on the
Figure46.1 Chronic venous disease in a patient who had iliofemoral DVT
10years earlier. e patient su ered with the postthrombotic syndrome
leading to multiple hospitalizations due to venous ulcers. Ascending
phlebography showed chronic venous disease with “no evidence of
obstruction.” An IPG was normal. Aclassic Linton procedure, which
includes ligation of the femoral vein distal to its junction with the
profunda, was performed, showing recanalization of the femoral vein
with signi cant luminal obstruction.
ascending phlebogram. e vein shows multiple recanalization channels and substantial luminal obstruction. is
severity of luminal obstruction becomes hemodynamically important in the exercising limb, in which substantial
increases in arterial ow occur as a result of exercise. With
exercise, venous out ow becomes restricted by the luminal obstruction, signi cantly contributing to ambulatory
venous hypertension. Of course, the valves within these
diseased veins are destroyed, and patients also have valvular
i n c o m p e t en c e .
It makes intuitive sense that eliminating the acute
thrombus leading to the persistent venous obstruction
would bene t patients over the long term, and indeed it
does. Furthermore, thrombus extraction not only eliminates
venous obstruction but also preserves valvular function.
BENEFITS OF THROMBUS
REMOVAL
ere is increasing evidence that thrombus removal or
early thrombus resolution a er acute DVT is associated
with improved outcomes. Bene ts of thrombus removal
derive from data generated from experimental animal studies, ndings from natural history studies of acute DVT
treated with anticoagulation, venous thrombectomy data,
and observations following systemic and catheter-directed
thrombolysis.
6
Cho and colleagues
and Rhodes and associates 7 have
used a canine experimental model of acute DVT to compare
the results of thrombolysis versus placebo and mechanical
thrombectomy. ey demonstrated that thrombolysis with
urokinase preserves endothelial function and valve competence, both immediately and at 4 weeks a er therapy. ere
was less residual thrombus in veins treated with urokinase,
thereby preserving the vein’s structural integrity.
e aforementioned experimental observations
translated into clinical outcome when the University of
Washington investigators performed a natural history
8–11
study of acute DVT treated with anticoagulation.
is
NIH-supported e ort resulted in observations indicating
that persistent obstruction of proximal veins was associated
with distal valve incompetence. e combination of venous
obstruction and valve incompetence was associated with
the most severe postthrombotic morbidity. Spontaneous
clot lysis naturally restored venous patency. If spontaneous
lysis occurred early (within 90days), valve function was frequently preserved.
e initial trials of thrombolytic therapy for acute
DVT involved systemic administration of the plasminogen activators. e cumulative results of these trials demonstrated that although 45% of patients had substantial
12
or complete lysis, the majority did not.
ose whose clot
was successfully lysed had a signi cant reduction in postthrombotic morbidity and preservation of venous valve
388 • VENOUS THROMBOEMBOLISM
function. Goldhaber et al. 13 reviewed the results from
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eight trials of systemic streptokinase treatment for acute
DVT and found that moderate or signi cant thrombolysis was achieved almost three times more frequently among
patients treated with thrombolytic therapy than among
patients treatedwith anticoagulation alone. However, there
was nearly a four-fold increased risk of major bleeding in
those receiving thrombolytic therapy, thereby focusing the
attention of clinicians on the hemorrhagic morbidity of
lytics rather than their potential for long-term bene t.
e long-term e cacy of thrombus removal in patients
with acute iliofemoral DVT was further substantiated by
the Scandinavian investigators who performed a randomized trial of iliofemoral venous thrombectomy with an
arteriovenous stula (AVF) and anticoagulation versus anti-
14–16
coagulation alone.
Follow-up at 6months, 5years, and
10years demonstrated clear bene t in patients randomized
to venous thrombectomy. Early thrombus removal resulted
in improved patency of the iliofemoral venous system,
lower venous pressures, less edema, and fewer postthrombotic symptoms.
ese observations, extending from the basic research
laboratory through systemic thrombolysis and operative
venous thrombectomy, support the concept that thrombus
removal in patients with acute iliofemoral DVT results in
signi cantly less postthrombotic morbidity. Unfortunately,
the favorable results of contemporary venous thrombectomy have not led to much enthusiasm for the operative
procedure in the United States. Additionally, physicians are
unwilling to accept the higher risk of bleeding complications with lytic therapy; therefore, systemic thrombolysis
for acute DVT is infrequently used and not recommended,
which is appropriate in light of the improved results with
catheter-directedlysis.
INTRATHROMBUS
CATHETERDIRECTED
THROMBOLYSIS
R A T I O N A L E
e mechanism by which thrombolysis results in clot dissolution is the activation of brin-bound plasminogen.
17
When circulating GLU-plasminogen binds to brin, it is
modi ed to LYS-plasminogen, which has greater a nity for plasminogen activators. When delivered into the
thrombus, a plasminogen activator e ciently activates
LYS-plasminogen. e intrathrombus delivery protects
the plasminogen activator from neutralization by circulating plasminogen activator inhibitors and also protects the
resultant plasmin from neutralization by circulating alpha
2-antiplasmins.
Catheter-directed techniques that deliver the plasminogen activator into the thrombus theoretically can accelerate
thrombolysis, which increases the likelihood of a successful
outcome. By reducing the overall dose and duration of infusion of the plasminogen activator, it is reasonable that complications will be minimized.
R E S U L T S
Numerous reports have emerged supporting favorable
outcomes of catheter-directed thrombolysis for acute
18–25
DVT.
ree of the larger reports demonstrate approximately an 80% success rate (see Table46.1). Initial success
rates might have been higher had treatment been restricted
to only patients with acute iliofemoral DVT. However,
patients who had more distal and chronic venous thrombosis were included, resulting in a lower overall success rate. In
these three studies, 422 patients were treated with remarkably consistent rates of success and complications.
Catheter-directed urokinase was used in each of these studies. Underlying iliac vein stenoses were treated with balloon angioplasty, stenting, or both to achieve unobstructed
venous drainage into the vena cava and reduce the risk of
recurrent thrombosis (see Figure46.2).
Major bleeding occurred in 5 to 10% of cases, with the
majority resulting from puncture site bleeding. Intracranial
bleeding was rare, occurring in only three patients in the
19
National Venous Registry.
is resulted in the death of
one patient. Pulmonary embolism (PE) occurred in 1% of
18
patients in the series reported by Bjarnason etal.
and the
National Venous Registry, and fatal PE occurred in only
one out of the 422 patients. erefore, death as a result of
catheter-directed thrombolysis wasrare.
Since 2000, most patients treated with catheter-directed
thrombolysis were managed with urokinase. Since urokinase
was removed from the market, catheter-directed alteplase
and reteplase have demonstrated similarly good results.
An interesting new therapeutic approach was reported
23
by Chang etal.
when they used intrathrombus bolus dosing of rtPA in twelve lower extremities of ten patients with
acute DVT. ey infused rtPA intrathrombus using the
pulse-spray technique and no more than 50 mg per treatment. A er the pulse-spray bolus, patients were returned to
their rooms and brought back the following day for repeat
venographic examination. Continuous infusion was not
used. Patients had treatment repeated for up to four daily
sessions. Results were excellent; eleven lower extremities
had signi cant or complete lysis, and the remaining leg had
50 to 75% lysis. Although the average total dose of rtPA was
106 mg, bleeding complications were minor, and no patient
had a decrease in hematocrit more than 2%. is technique
is deserving of further study to evaluate whether others can
obtain similarly good results.
A further analysis of the patients treated in the National
19
Venous Registry
o ers important clinical insight into
catheter-directed thrombolysis for patients with acute
DVT. Of the 287 patients treated in both academic and
18–20
22–25
THROMBOLYTIC THERAPY FOR ACUTE VENOUS THROMBOSIS • 389
Table46.1 RESULTS OF CATHETERDIRECTED THROMBOLYSIS WITH
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UROKINASE IN THREE CONTEMPORARY SERIES:EFFICACY AND
COMPLICATIONS
BJARNASON
E cacy
Initial Success
Iliac
Femoral
Primary Patency at 1 yr
Iliac
F e mo r a l
Iliac Stent:Patency at 1 yr
+ S t e n t
– St e n t
Complications
Major Bleed
Intracranial Bleeding
Pulmonary Embolism
Fatal Pulmonary Embolism Death
Secondary to Lysis
*Death due to multiorgan system failure 30 d post lysis, though not related to lytic therapy.
community centers, 66% had acute DVT, 16% had chronic
DVT, and 19% had an acute episode superimposed on a
chronic condition. Seventy-one percent of the patients
presented with iliofemoral DVT and 25% with femoropopliteal DVT. Catheter-directed thrombolysis with
intrathrombus infusion of urokinase was the preferred
approach. However, some patients were treated with urokinase infused into a foot vein, which was essentially systemic
thrombolysis. Phlebographic evaluation showed that 31%
of patients had complete lytic success and 52% had 50 to
99% lytic success. In 17% of patients, less than 50% of the
thrombus was dissolved. When urokinase was not infused
intrathrombus, success rates fell dramatically. In the subgroup of patients with acute, rst-time iliofemoral DVT,
65% of the patients enjoyed complete clotlysis.
During follow-up, thrombosis-free sur vival was observed
in 65% at 6months and in 60% at 12months. ere was a
signi cant correlation (P < 0.001) of thrombosis-free survival with the results of initial therapy. Seventy-eight percent of patients with complete clot resolution had patent
veins at 1year, compared with only 37% of those in whom
less than 50% of the clot was dissolved. Interestingly, in
the subgroup of patients with acute, rst-time iliofemoral
DVT who had successful thrombolysis, 96% of the veins
remained patent at 1year. In addition to sustained patency,
early success directly correlated with valve function at
6months. Sixty-two percent of patients with less than 50%
thrombolysis had venous valvular incompetence, whereas
72% of patients who had complete lysis had normal valve
function (P <0.02).
e large database of the National Venous Registry
o ered an opportunit y to objectively evaluate the long-term
E T A L .
N = 77
79%
63%
40%
63%
40%
54%
75%
5%
0%
1%
0%
0%
MEWISSEN
19
E T A L .
N=287
83%
64%
47%
64%
47%
74%
53%
11%
<1%
1%
0.2%
0.4%
18
COMEROTA
20
E T A L .
N=58
84%
78%
–
78%
–
89%
71%
9%
0%
0%
0%
0% (? 2%)*
impact of catheter-directed thrombolysis on patients with
iliofemoral DVT. Since the National Venous Registry collected data only on patients treated with thrombolytic
therapy, a contemporary cohort of patients with iliofemoral DVT treated with anticoagulation in the same institutions was identi ed. All anticoagulated patients were
candidates for lytic therapy but were treated with anticoagulation alone due to physician preference. Avalidated
quality-of-life (QOL) questionnaire was used to query
patients at 16 and 22 months post treatment. Of the
ninety-eight patients studied, sixty-eight were treated with
catheter-directed lysis and thirty treated with anticoagulation alone. ose treated with catheter-directed thrombolysis reported a signi cantly better QOL than those treated
with anticoagulation alone. e QOL results were directly
related to the initial success of thrombolysis. Patients who
had a successful lytic outcome reported a signi cantly better Health Utilities Index, better physical functioning, less
stigma of chronic venous disease, less health distress, and
fewer overall postthrombotic symptoms. Patients in whom
catheter-directed thrombolysis failed had similar outcomes
to patients treated with anticoagulation alone. ese e cacy data combined with the observed reduction in complications o er a sound argument for the management
of patients with iliofemoral DVT with catheter-directed
thrombolysis.
A small, randomized trial performed by Elsharawy
26
demonstrated that catheter-directed thromboly-
et al.
sis versus anticoagulation alone o ered signi cantly better outcomes at 6months. Assuming patients are properly
managed with anticoagulation, the 6-month observations
should re ect their long-term outcome.
390 • VENOUS THROMBOEMBOLISM
A B
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C D
Figure46.2 (A) Initial phlebogram (prone iliocavagram) of a patient with extensive iliofemoral DVT who presented with a swollen, painful le leg.
Using ultrasound guidance, the catheter was positioned into the thrombus of the iliofemoral segment. Aplasminogen activator (t-PA) was infused at
1 mg/h. (B)A er 22 hours of catheter-directed t-PA infusion, the patient had a good phlebographic and clinical response. Astenosis of the le iliac
vein was identi ed. (C) e stenosis was treated with balloon angioplasty, and a 16-mm Wallstent was deployed and dilated. (D)Final phlebogram
showing unobstructed venous drainage into the venacava.
We believe that the results available to date support a
strategy of catheter-directed thrombolysis for acute iliofemoral DVT in patients who have no contraindication
to thrombolytic therapy. If a contraindication to lytic
therapy exists, a contemporary venous thrombectomy
(Chapter45) followed by long-term anticoagulation should
be considered.
the majority of patients with DVT and therefore warrant
a search for an underlying etiology. Asymptomatic pulmonary emboli are present in at least 50%. It is important
that the PE be recognized early, since up to 25% will subsequently become symptomatic, manifesting as pleuritic
chest discomfort once the in ammatory pulmonary process
reaches the pleural surface. If the PE is not recognized, the
clinician o en mistakenly assumes that the pleuritic symptoms are due to a new PE and failure of treatment. Aspiral
PATIENT EVALUATION AND
TECHNIQUE OF CATHETERDIRECTED
THROMBOLYSIS
CT scan of the chest with contrast evaluates the pulmonary vasculature for PE and other thoracic pathology (see
Figure46.3A). e CT is extended to the abdomen and pelvis to identify the proximal extent of thrombus and to eval-
P A T I E N T E V A L U A T I O N
It is intuitive and clinically apparent that patients with iliofemoral DVT have a greater stimulus to thrombosis than
uate for abdominal or pelvic pathology (see Figure46.3B).
is has been an important addition to the evaluation of
these patients, as we have found serious unsuspected pathology with surprising frequency. Renal cell carcinoma, adrenal
THROMBOLYTIC THERAPY FOR ACUTE VENOUS THROMBOSIS • 391
A
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ere also has been an evolution in the dose and volume of plasminogen activator. Since the activation of
brin-bound plasminogen is not dose dependent, exposure
to the plasminogen activator is all that is required. e volume of the lytic solution has increased with a decrease in the
concentration (dose) of plasminogen activator. It is now our
preference to increase the volume of lytic infusion to 80 to
100 ml per hour. e larger volume is intended to saturate
the thrombus, exposing more brin-bound plasminogen
to the plasminogen activator. Phlebograms are obtained at
12-h intervals and are used to monitor the success of lysis
B
and reposition catheters if necessary. Vena caval lters are
not routinely used but are recommended for patients with
free- oating thrombus in the vena cava. Aretrievable lter
can be used in the patient in whom only temporary protection is needed.
Following successful thrombolysis, the venous system
is examined with completion phlebography. If a stenosis
Ao
VC
exists, which is frequently observed in the le common iliac
vein where it is compressed by the right common iliac artery,
the vein is dilated and stented if necessary. e addition of
intravascular ultrasonography has improved the evaluation
of iliac compression and the precision of stent deployment
when these lesions are corrected. Residual areas of stenosis must be corrected for long-term success; otherwise, the
patient faces a high risk of rethrombosis. If a stent is used,
it should be sized appropriate to the normal diameter of the
common iliacvein.
Figure46.3 Initial CT scan of the chest, abdomen, and pelvis of a
65-year-old male with chronic low back pain who presented with le
lower extremity phlegmasia cerulea dolens. e chest CT (A)shows
an asymptomatic pulmonary embolus (arrow). e abdominal CT
(B)shows extensive retroperitoneal and pelvic lymphadenopathy
(arrows) compressing the distal vena cava and the le iliac system. All
patients presenting with iliofemoral DVT by duplex ultrasound receive
chest, abdominal, and pelvic CT scans as part of the initial workup.
tumors, retroperitoneal lymphoma, hepatic metastases, iliac
vein aneurysms, and vena caval atresia all have been identi ed. A full hematologic evaluation for an underlying
thrombophilia is also performed.
TECHNIQUE
ere has been an evolution of catheter-directed thrombolytic techniques since around 2000. e preferred approach
is through an ultrasound-guided popliteal vein puncture
with antegrade passage of the infusion catheter. rough
this approach physicians can incorporate adjunctive
mechanical thrombectomy techniques.
If the popliteal vein is thrombosed, an additional catheter is placed through an ultrasound-guided tibial vein
puncture. Using catheters that achieve long segments of
thrombus infusion is advised.
ADJUNCTIVE TECHNIQUES TO
CATHETERDIRECTED THROMBOLYSIS
Percutaneous mechanical thrombectomy techniques are
discussed in detail in Chapter46. ere appears to be a
higher incidence of embolic complications with mechanical
thrombectomy. In a prospective evaluation of pulse-spray
pharmacomechanical thrombolysis of clotted hemodialysis
27
gra s,
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 =0.04). Since clotted hemodialysis gra s are in
direct communication with the venous circulation, they can
be considered similar to proximal veins with acute DVT.
Observations would likely be magni ed when treating
larger venous thromboses.
In an experimental model, Greenberg and associates
28
evaluated mechanical, pharmacomechanical, and pharmacologic thrombolysis. eir ndings are consistent with
anecdotal clinical observations as well as the results reported
27
by Kinney and associates.
Greenberg etal. demonstrated
that pulse-spray mechanical thrombectomy was associated
with the largest number and greatest size of distal emboli.
When urokinase was added to the solution, the embolic
392 • VENOUS THROMBOEMBOLISM
particles diminished in number and in size and increased
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the speed of lysis with reperfusion. Catheter-directed
thrombolysis alone was associated with the slowest reperfusion but the fewest distal emboli. In general, mechanical
thrombectomy alone most o en is inadequate. Hemolytic
complications of rheolytic mechanical thrombectomy are
common and occasionally can result in anemia and renal
dysfunction.
A new device recently released for segmental and controlled pharmacomechanical thrombolysis is the reengineered Trellis catheter (Bacchus Vascular, Santa Clara, CA),
which is a hybrid catheter that isolates the thrombosed vein
segment between two occluding balloons (see Figure46.4).
A lytic agent is infused into the thrombus between the
occluding balloons. e intervening catheter sha assumes a
sine wave or spiral con guration and, when activated, spins
at 15,000 rpm. A er 10 to 15 min, the liqui ed thrombus
and remaining fragments are aspirated. Phlebographic evaluation of the result is performed before moving on to treat
additional thrombosed vein segments (see Figure49.4). e
advantages of such a device are its ability to incorporate
mechanical and pharmacologic therapies, even in patients
with a contraindication to thrombolytic therapy since the
infusate is aspirated, and the rapidity with which treatment
A B
D E F
C
Figure46.4 (A–C) Phlebogram of a patient 2 d a er exploratory laparotomy shows le iliofemoral (A), femoropopliteal (B), and posterior tibial
(C)DVT. e treatment goal was to lyse the extensive thrombus rapidly with minimal systemic exposure to the plasminogen activator. (D) is was
accomplished using segmental pharmacomechanical thrombolysis with the hybrid Trellis peripheral infusion system (Bacchus Vascular, Santa Clara,
CA) and ultrasound-accelerated thrombolysis of popliteal and tibial thrombus with the EKOS LysUS® System (EKOS Corp, Bothell, WA). e
Trellis system achieves isolated thrombolysis between two occluding balloons by lytic infusion and mechanical drug dispersion with the intervening
catheter rotating at 15,000 rpm. is mechanism of thrombolysis enables focused treatment of thrombus within the target vessel. (E, F) Phlebogram
30 min a er using the Trellis system shows resolution of the thrombus in the iliac and femoralveins.
THROMBOLYTIC THERAPY FOR ACUTE VENOUS THROMBOSIS • 393
can be achieved. e rationales behind the design of this
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catheterare:
indicating that an infusion catheter with ultrasound transducers built into the infusion end of the catheter can be
used to accelerate thrombolysis.
1 . Rapidly resolve thrombus during a short course of
treatment.
2. Limit or avoid exposure to thrombolytic therapy by
aspirating liqui ed thrombus and infused lyticagent.
3 . Prevent PE by proximal balloon occlusion.
demonstrated that ultrasound enhances the brinolytic
activity of tissue plasminogen activator (t-PA).
potential mechanism for augmented clot lysis has been
extrapolated from in vitro studies showing that ultrasound
produces clot fragmentation in the presence of t-PA, and
consequently, more t-PA binds to brin-binding sites due
to the larger available surface area.
A clinical trial designed to evaluate the success and complication rate of this technique is underway.
An interesting new adjunct to catheter-directed thrombolysis is the addition of the emission of ultrasound waves
from the infusion catheter while delivering the plasminogen
activator (see Figure46.5). Several reports have emerged
A B C D
transducer-tipped catheter that delivers a brinolytic drug
in combination with high frequency, low-intensity ultrasound has been well described. In vivo models
40
are now under way to assess the potential value of
trials
ultrasound enhancement of thrombolysis for the management of acuteDVT.
29–32
In vitro studies have
33–35
36–38
e concept of a
39
and clinical
e
FE
Figure 46 .5 (A) e EKOS LysUS System (EKOS Corp, Bothell, WA) is an ultrasonic infusion system designed for controlled and selective infusion of
thrombolytics into the thrombosed veins. Ultrasound waves accelerate thrombolysis, reducing treatment time. e catheter was advanced proximally
from an ultrasound-guided posterior tibial vein puncture. (B)Phlebogram showing popliteal vein thrombus. (C–E) Post ultrasound lysis,
dissolution of thrombus in the distal femoral vein (C), popliteal vein (D), and posterior tibial vein (E). (F)Angioplasty and stenting were performed
on the le iliac vein, establishing normal venous drainage into the inferior venacava.
394 • VENOUS THROMBOEMBOLISM
e patient with phlegmasia cerulea dolens, sum-
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marized in Figure46.4, illustrates the advantage of using
segmental, pharmacomechanical thrombolysis and
ultrasound-enhanced catheter-directed thrombolysis to
shorten treatment duration and limit exposure to the
thrombolytic agent, maximizing the chance of a successful
outcome.
rombolysis is e ective and has become safer with the
direct intrathrombus infusion and adjunctive mechanical
techniques. As technology continues to improve, lytic infusion times will shorten, more patients will be o ered a treatment strategy that includes thrombus removal, and many
patients will be spared their otherwise certain postthrombotic morbidity.
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2. Akesson H , Brudin L , Dahlstrom JA , Eklof B , Ohlin P , Plate G .
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rombolysis for experimental deep venous thrombosis main-
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13. Goldhaber SZ , Buring JE , Lipnick RJ , Hennekens CH . Pooled
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14. Plate G , Einarsson E , Ohlin P , Jensen R , Qvarfordt P , Eklof B .
rombectomy with temporary arteriovenous stula: e treatment
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. 1992 . 5 : 76–84 .
of choice in acute iliofemoral venous thrombosis , J Vasc Surg . 1984 .
1 : 867–876 .
15. Plate G , Akesson H , Einarsson E , Ohlin P , Eklof B . Long-term results
of venous thrombectomy combined with a temporary arterio-venous
stula , Eur J Vasc Surg . 1990 . 4 : 483–489 .
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396 • VENOUS THROMBOEMBOLISM
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PERCUTANEOUS MECHANICAL THROMBECTOMY IN
THE TREATMENTOFDVT
Colleen M . Johnson , Pritham P . Reddy , and Robert B . Mcla e r t y
INTRODUCTION
Deep venous thrombosis (DVT) is associated with signi cant morbidity and mortality. Symptomatic DVT a ects
250,000 to 300,000 people per year in the United States
and is responsible for approximately 300,000 hospital
admissions per year.
attributable to pulmonary embolism (PE) from DVT.
costs for treatment of DVT are estimated between $1.2 and
$2.4 billion peryear.
Once the diagnosis of DVT is established, the goals
of therapy are: (1)prevention of PE, (2) prevention of
thrombus propagation, (3)preservation of valvular function, and (4) prevention of postthrombotic syndrome
(PTS). Traditionally, treatment involves unfractionated
heparin (UH) or low molecular weight heparin (LMWH)
as a bridge to oral anticoagulation. In addition to the
prevention of PE and PTS, therapeutic anticoagulation
aids in the prevention of clot propagation. Asbeutah
etal. reported 5-year follow-up of y-one patients with
y-four DVTs for PTS. Twenty-six limbs were noted to
have proximal involvement. When treated with anticoagulation alone, 34% had thrombus resolution at 1month.
Sixty- ve percent of limbs went on to develop re ux, and
54% progressed to chronic venous insu ciency within
1year of diagnosis.
Surgical thrombectomy is an open procedure whereby
thrombus is manually extracted from a venotomy most
commonly created in the femoral vein. rombus proximal to the inguinal ligament is removed using a balloon
catheter and thrombus below is removed by compression
of the limb with an esmarch wrap (Spectrum Laboratories,
Rancho Dominguez, CA). Problems with this technique
include denuding endothelium, damage to the valves, and
incomplete thrombus removal. Although thrombectomy is
advocated by some as the preferred method of treatment for
DVT, the vast majority of patients continue to be treated
with anticoagulation.
1–4
Nearly 50,000 deaths each year are
5
6
3
e
With the advent of thrombolytic drugs, some institu-
tions have treated DVTs with intravenous administration.
7–9
Although thrombolysis theoretically satis es all therapeutic
goals, complete thrombus resolution occurs in only about
50% of patients with nonobstructive thrombus and 10% of
10,11
those with obstructive thrombi.
Serious bleeding complications such as retroperitoneal hematoma and intracranial hemorrhage are markedly elevated in patients receiving
systemic therapy when compared with patients treated with
12–15
anticoagulation alone.
Regional or catheter-directed thrombolysis (CDT) has
been used with some success. Potential advantages include
administration of the pharmacologic agent directly into
the thrombus and less systemic side e ects. AbuRahma
et al. reported complete resolution of symptoms in 83%
of patients undergoing CDT compared with 3% in the
16
group receiving anticoagulation alone.
CDT also has
proven advantageous in the prevention of recurrent DVT
17
in a large majority of patients.
Unfortunately, bleeding
complications continue to plague 4 to 6% of patients, and
intracranial hemorrhage still occurs in a small minority of
18,19
patients.
CDT usually requires 1 to 3 d of continuous
therapy and represents a major disadvantage to prompt and
safe treatment. Comerota etal. reported a 21% incidence of
severe PTS in patients treated for DVT with heparin alone,
20
compared to 5% in those treated with streptokinase.
CDT
in the management of DVT also has been proven superior
to anticoagulation alone when evaluating health-related
21
quality of life.
Percutaneous mechanical thrombectomy (PMT) refers
to the technique whereby a catheter utilizing mechanical
means can be used independently or coupled with pharmacologic thrombolysis in the treatment of DVT. Preliminary
data show that treatment with PMT may provide quicker
21,22
thrombus resolution than CDT alone.
With an increasing emphasis on minimal invasiveness, recent years have
witnessed an endovascular revolution that has ushered in
many di erent types of PMT catheters. Herein we provide
397
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