Inflow thrombosis does not adversely affect thrombolysis outcomes of symptomatic iliofemoral deep vein thrombosis

Abstract

The presence of popliteal or tibial vein clot is thought to adversely affect thrombolysis for iliofemoral deep vein thrombosis (DVT). We examined the effect of inflow thrombosis on functional and anatomic outcomes. Data for 44 patients treated for symptomatic iliofemoral DVT between 2006 and 2009 were retrospectively reviewed. All patients were treated by pharmacomechanical thrombectomy with local lytic therapy. Catheter-directed lysis and vena cava filters were used sparingly. Univariate and multivariate logistic regression analyses were used. The independent variable used in the logistic regression model was symptom relief. Forty-four patients (mean age, 52.1 ± 15.8 years) presented with symptoms averaging 13.4 ± 9.9 days in duration. Twenty (45.4%) had symptoms for >14 days. Seventeen patients were treated in one session, but 27 patients required lytic infusion for residual thrombus. Iliac stenting was required in 49% of limbs. Successful lysis (>50%) was achieved in 91% of patients, and symptom resolution or improvement in 91%. All patients became ambulatory, with no or minimal limitation. No major systemic bleeding complications occurred. Freedom from DVT recurrence and reintervention was 84% at 24 months by life-table analysis. Preoperative ultrasound imaging showed 89% had popliteal and tibial clots. A thrombosed popliteal vein was accessed for treatment and was corroborated by venographic findings. One patient required simultaneous tibial lysis. At a mean follow up of 8.7 ± 6.3 months, 41 patients (93%) had no symptom recurrence, 82% had preserved valve function and no reflux on duplex imaging, with a mean CEAP class of 1.4 and Villalta score of 3.3. Inflow thrombus had no adverse effect on symptom relief, treatment duration, patency, CEAP class, or valve reflux. Interestingly, 90% of patients with initial popliteal thrombus had a patent popliteal vein on postlysis ultrasound imaging, and the presence of tibial thrombus on presentation was predictive of symptom relief with thrombolysis (odds ratio, 13.03; 95% confidence interval, 1.02-165.58; P = .048). Inflow thrombosis is common and does not preclude successful thrombolysis of iliofemoral DVT. Valve function is preserved on midterm follow-up, with maintained CEAP class and symptom relief.