Acute Proximal Deep Venous Thrombosis Research Articles

Venous anomalies: an underrecognized but important cause of venous thromboembolism

AbstractAnatomical variants, such as May-Thurner syndrome (MTS) and inferior vena cava (IVC) variants, are underrecognized causes of deep venous thrombosis (DVT), despite affecting management. We aimed to identify the proportion of anatomical variants in proximal lower limb DVT. A retrospective cohort study was performed with cases of acute proximal DVT from 2014 to 2021 identified from ICD-10 codes. We identified 4731 DVTs and included 1268 proximal DVTs. Thirty-six (2.84%) had an anatomical variant (25 MTS and 11 IVC variants), with a rate of 14.39% in females <50 years old. Compared with nonvariant DVTs, they were more likely to be unprovoked (81% vs 23%), younger (median age, 37 vs 63 years), female (67% vs 37%), and have postthrombotic syndrome (22% vs 9%). Variants frequently received thrombolysis (58% vs 1%) or angioplasty (47% vs 0%) and indefinite anticoagulation (83% vs 40%). Further investigation for variants should be considered for high-risk patients, as variants affect management.

Catheter-Directed Thrombolysis for Postpartum Deep Venous Thrombosis.

Venous thromboembolism is a major concern during pregnancy as well as in the postpartum period. In acute proximal deep venous thrombosis, endovascular recanalization with locally administered thrombolytic agents has evolved as therapeutic alternative to anticoagulation alone. However, data on the bleeding risk of thrombolysis in the postpartum period is limited. We addressed the key clinical question of safety outcomes of catheter-directed thrombolysis (CDT) in the peri- and postpartum period. Therefore, we performed a non-exhaustive literature review and illustrated the delicate management of a patient with postpartum acute iliofemoral thrombosis treated with CDT and endovascular revascularization with thrombectomy, balloon angioplasty and stenting.

The Use of Point-of-Care Ultrasound (POCUS) in the Diagnosis of Deep Vein Thrombosis.

Acute lower extremity proximal deep venous thrombosis (DVT) requires accurate diagnosis and treatment in order to prevent embolization and other complications. Point-of-care ultrasound (POCUS), a clinician performed, and clinician interpreted bedside ultrasound examination has been increasingly used for DVT evaluation mainly in the urgent and critical care setting, but also in the ambulatory clinics and the medical wards. Studies have demonstrated that POCUS has excellent diagnostic accuracy for acute proximal DVT when performed by well-trained users. However, there is significant heterogeneity among studies on the necessary extent of training and universally acceptable standardized education protocols are needed. In this review, we summarize the evidence that supports the use of POCUS to diagnose acute proximal DVT and focus on methodology and current technology, sensitivity and specificity, pre-test probability and the role of D-dimer, time and resources, education, limitations, and future directions.

Where There's Smoke, There's Fire: A Case Report of Turbulent Blood Flow in Lower Extremity Point-of-care Ultrasound in COVID-19.

IntroductionCoronavirus disease 2019 (COVID-19) may predispose patients to increased risk of venous thromboembolism (VTE) due to various pathophysiological mechanisms, including but not limited to endothelial injury, inflammation, cytokine-mediated microvascular damage, and reactive thrombocytosis. A high risk of vessel thrombosis correlates with disease severity, making early identification and treatment of prime consideration.Although identification of a deep venous thrombosis (DVT) or pulmonary embolism warrants immediate treatment with anticoagulation, trying to predict which COVID-19 patients may be at increased risk for developing these pathologies is challenging.Case ReportsWe present two cases of patients with COVID-19 who had ultrasonographic findings of turbulent blood flow within the deep venous system, without clear evidence of acute proximal DVT, who were subsequently found to have significant VTE.ConclusionPoint-of-care lower extremity ultrasound has become one of the core applications used by emergency physicians. Typically we perform compression ultrasound for DVT evaluation. This novel finding of turbulent blood flow, or “smoke,” within the deep venous system, may serve as a marker of increased risk of clot development and could be an indication to consider early anticoagulation.

Midterm outcome of pharmacomechanical catheter-directed thrombolysis combined with stenting for treatment of iliac vein compression syndrome with acute iliofemoral deep venous thrombosis

ObjectiveThis study assessed the effectiveness and safety of percutaneous mechanical thrombectomy and catheter-directed thrombolysis combined with stent placement in the management of iliac vein compression syndrome with acute iliofemoral deep venous thrombosis (DVT). MethodsFrom December 2014 to April 2016, there were 46 patients with DVT who underwent percutaneous mechanical thrombectomy and catheter-directed thrombolysis and stenting for acute proximal DVT with computed tomography-verified iliofemoral stenosis. The Venous Registry Index was used for evaluating the degree of patency after pharmacomechanical thrombolysis; the prevalence of post-thrombotic syndrome (PTS) in the follow-up was assessed according to the Villalta scale. For up to 24 months, conditions of the patients were assessed using periodic duplex ultrasound scans. ResultsFor all patients, the technical success rate was 100%; no major bleeding or 30-day mortality was observed. Overall, the 6-, 12-, and 24-month primary patency rates were 97.8%, 95.7%, and 91.1%, respectively. There was a significant reduction in Venous Registry Index (9.82 ± 1.74 to 1.15 ± 1.02; P < .05) after the procedure. According to the Villalta score, only one patient developed mild PTS and none developed severe PTS. Symptomatic pulmonary embolism was not observed during the hospitalization. The mean hospital stay was 6.5 ± 1.7 days. ConclusionsThis technique provides a safe and effective treatment option for patients with acute proximal DVT caused by vein compression syndrome.

Evaluation of a Device Combining an Inferior Vena Cava Filter and a Central Venous Catheter for Preventing Pulmonary Embolism Among Critically Ill Trauma Patients

PurposeTo evaluate efficacy and safety of a novel device that combines an inferior vena cava (IVC) filter and central venous catheter (CVC) for prevention of pulmonary embolism (PE) in critically ill patients. Materials and MethodsIn a multicenter, prospective, single-arm clinical trial, the device was inserted at the bedside without fluoroscopy and subsequently retrieved before transfer from the intensive care unit (ICU). The primary efficacy endpoint was freedom from clinically significant PE or fatal PE 72 hours after device removal or discharge, whichever occurred first. Secondary endpoints were incidence of acute proximal deep venous thrombosis (DVT), catheter-related thrombosis, catheter-related bloodstream infections, major bleeding events, and clinically significant thrombus (occupying > 25% of volume of filter) detected by cavography before retrieval. ResultsThe device was placed in 163 critically ill patients with contraindications to anticoagulation; 151 (93%) were critically ill trauma patients, 129 (85%) had head or spine trauma, and 102 (79%) had intracranial bleeding. The primary efficacy endpoint was achieved for all 163 (100%) patients (95% confidence interval [CI], 97.8%–100%, P < .01). Diagnosis of new or worsening acute proximal DVT was time dependent with 11 (7%) occurring during the first 7 days. There were no (0%) catheter-related bloodstream infections. There were 5 (3.1%) major bleeding events. Significant thrombus in the IVC filter occurred in 14 (8.6%) patients. Prophylactic anticoagulation was not initiated for a mean of 5.5 days ± 4.3 after ICU admission. ConclusionsThis novel device prevented clinically significant and fatal PE among critically ill trauma patients with low risk of complications.

Clinical value of neutrophil to lymphocyte ratio in the region of lower extremity deep venous thrombosis

Objectives. M any studies have demonstrated a significant association between cardiovascular disease and neutrophil to lymphocyte ratio (NLR). To our knowledge, no study has been reported in patients with deep venous thrombosis (DVT) which affecting proximal or distal leg. In this study we analyzed proximal and distal DVT according to the NLR. Methods. This retrospective study was obtained from patients’ records of a tertiary university hospital between May 2011 to January 2014. A total of 57 patients with the diagnosis of acute primary DVT and 30 patients as control group included in the study. All of them were confirmed with lower extremity venous duplex examinations. Of these, 37 examinations with the diagnosis of proximal DVT were compared to 20 examinations with distal DVT. The groups compared regarding to complete blood counter values. Results. Mean eosinophil level was higher in the distal DVT group (0.28±0.24 vs. 0.12±0.01, p =0.001), whereas median NLR were higher in the proximal DVT group than the distal DVT group (3.5 [0.5-4.3] vs. 2.3 [1.2-9.7], respectively; p =0.002). In addition, median NLR, leukocyte and neutrophil counts were statistically lower in the control group than the others ( p =0.014, p =0.027 and p =0.004, respectively). Conclusion. NLR, an inexpensive and easily measurable laboratory variable, was independently and significantly associated with the presence and severity of DVT, especially acute proximal DVT.

Incidence and Outcomes of Inferior Vena Cava Filter Thrombus during Catheter-directed Thrombolysis for Proximal Deep Venous Thrombosis

The aim of the study was to retrospectively evaluate the incidence and outcomes of inferior vena cava (IVC) filter thrombus during catheter-directed thrombolysis (CDT) for acute proximal deep venous thrombosis (DVT). From October 2006 to June 2015, patients diagnosed with acute proximal DVT and received CDT after a retrievable IVC filter was placed were included. The incidence, treatment, and outcomes of IVC filter thrombus during CDT were recorded and analyzed. A total of 189 patients (91 women, 98 men; mean age, 57.6±9.8years; range, 24-85years) were included in this study. Among the 189 cases, the DVTs involved popliteal iliofemoral veins in 54 patients, iliofemoral veins in 113 patients, and iliac veins in 22 patients, of which 18 patients had thrombus extended into the IVC. Of the 189 patients, a total of 8 (4.2%, 8 of 189) patients were identified with IVC filter thrombus during CDT. The IVC filter thrombus was detected on a median of 2days (range, 2-4days) of CDT therapy, including small-size (n=6) and large-size (n=2) filter thrombus. Of the 8 patients, CDTs were performed with a mean 7.6±1.1days (range, 6-11days) after the presence of symptoms for the treatment of proximal DVT, and all the IVC filter thrombi were lysed during CDT for the proximal DVT. All the IVC filters were removed successfully with a mean of 12.8±0.93days from placement. There were no procedure- or thrombolysis-related major complications, and no symptomatic pulmonary embolism breakthrough was seen in any of the patients after the filter placement. IVC filter thrombus during CDT for the acute proximal DVT is uncommon, and all of them did not need any additional treatment.

Pharmacomechanical thrombolysis with a rotator thrombolysis device in iliofemoral deep venous thrombosis.

Deep venous thrombosis (DVT) is a life-threatening and morbid pathology. This study aimed to investigate the efficacy of an early thrombolysis procedure using a rotator thrombolysis device. Sixty-seven patients with acute proximal DVT were enrolled in the study. Patients' data were recorded retrospectively. Initially, an infrarenal retrievable vena cava filter was placed through the femoral vein. Then, a rotator thrombolysis device and a thrombolytic agent injection were applied to the occluded segments of the deep veins by puncturing the popliteal vein. The identified reasons were trauma (43.3%), pregnancy (20.9%), undiagnosed (11.9%), major surgical operation (10.5%), immobilization (7.5%), and malignancy (5.9%). Immediate total recanalization was conducted in all patients, and the leg diameters returned to normal ranges in the early postoperative period. Hospital mortality or severe complications were not detected. New thrombolytic devices seem to reduce in-hospital mortality risks and may potentially decrease post-thrombotic morbidity.

Trajectories of Inflammation Markers after Acute DVT and Their Association with the Postthrombotic Syndrome

IntroductionThe postthrombotic syndrome (PTS) is the most common chronic complication of deep venous thrombosis (DVT). Inflammation markers can predict PTS when measured at discrete time points after DVT; however, this approach does not recognize patterns of change over time. ObjectiveTo describe change of inflammation marker levels after acute proximal DVT and assess the association of individual biomarker trajectories with risk of PTS. MethodsThe BioSOX is a substudy of the SOX Trial. Patients with first, symptomatic, proximal DVT were followed for 24 months. The study end point, PTS, was diagnosed starting from 6 months post DVT using the Villalta scale. During the SOX trial we collected blood samples from participants at baseline, 1 and 6 months, and measured concentrations of C-reactive protein (CRP), interleukin (IL)-6, IL-10 and intercellular adhesion molecule (ICAM)-1 using validated established methods.We used group-based trajectory modeling (GBTM) to identify biomarker level trajectories from the time of acute DVT up to six months post DVT and assign patients to trajectory groups. Chi-square and ANOVA tests were used to investigate the association of clinical and demographic characteristics and trajectory group assignment. Modified Poisson regression models were used to estimate risk ratios (RR) for PTS according to trajectory group. Models were adjusted for predefined covariates (age, sex, body mass index (BMI) and extent of DVT) and data driven confounders found to be significantly associated with trajectory group. ResultsOf 703 patients, 327 developed PTS. Figure 1 depicts the best trajectory models for each of the 4 biomarkers. For both ICAM-1 and IL-10, the best model was a 3-group model with high, intermediate and low biomarker level trajectories. For both IL-6 and CRP, the best model was comprised of 4 groups, which consisted of the highest group (group 3) having a rapidly declining profile to an intermediate level by the first month after DVT, and a second high group (group 4) having levels that remained high for the entire sampling time. Clinical and demographic variables most closely associated with trajectory group assignment were age, BMI, infectious or inflammatory conditions in the month prior to DVT, smoking, cancer related DVT and anatomical extent of DVT.For ICAM-1 there was a significant association of trajectory group assignment and risk of PTS (Table 1). Adjusted RR for trajectory group 2 vs. group 3 was 0.79 (95% confidence interval 0.67 – 0.93). There were no associations of the other biomarker trajectory groups with PTS risk. ConclusionTo our knowledge, this is the first study to use trajectory analyses to describe temporal patterns of change in inflammation marker levels after acute DVT and relate these to risk of PTS. Results suggest that patients demonstrate distinct patterns of change in biomarker levels over the first six months after acute DVT. Persistently high ICAM-1 levels in the first six months after DVT were associated with an increased risk of PTS. Verification of these results is needed by other studies. [Display omitted] Table 1:Association between biomarker trajectory group and PTSTrajectory group*Crude RR (95% CI)Adjusted† RR (95%CI)ICAM-11 vs. 30.60 (0.33-1.10)0.67 (0.36-1.24)2 vs. 30.74 (0.63-0.87)0.79 (0.67-0.93)IL-101 vs. 31.01 (0.60-2.02)1.19 (0.66-2.16)2 vs. 31.08 (0.79-1.46)1.13 (0.83-1.53)CRP1 vs. 40.80 (0.60-1.04)0.95 (0.70-1.28)2 vs. 40.91 (0.73-1.13)1.00 (0.80-1.25)3 vs. 40.79 (0.61-1.01)0.89 (0.68-1.16)IL-61 vs. 40.84 (0.62-1.15)1.01 (0.73-1.40)2 vs. 41.01 (0.76-1.35)1.02 (0.76-1.36)3 vs. 40.90 (0.62-1.32)0.96 (0.65-1.41)ICAM-1, intercellular adhesion molecule1; IL-10, Interleukin 10; CRP, C-reactiveprotein; IL-6, Interleukin 6; RR, risk ratio.*See Figure 1 for graphical depiction of trajectory group patterns over time†Adjustment variables:ICAM-1: age, sex, BMI, extent of DVT, smoking status and type of DVTIL-6 and IL-10: age, sex, BMI, extent of DVT, infection or inflammatory condition in the month prior to DVT, smoking status and type of DVT CRPage, sex, BMI, extent of DVT, infection or inflammatory condition in the month prior to DVT and type of DVT. DisclosuresNo relevant conflicts of interest to declare.

Value of platelet indices in identifying complete resolution of thrombus in deep venous thrombosis patients.

We aimed to evaluate whether mean platelet volume (MPV) and platelet distribution width (PDW) are helpful to identify complete thrombus resolution (CTR) after acute deep venous thrombosis (DVT). Patients who had first-time episode of acute proximal DVT were included in this retrospective study. 100 patients with DVT were divided into two groups according to absence (group 1; n=68) or presence (group 2; n=32) of CTR on doppler ultrasonography at month 6. There were no significant difference in admission MPV and PDW levels between group 1 and group 2. MPV (p=0.03) and PDW (p<0.001) levels at month 6 were significantly higher in group 1 than in group 2. CTR showed a moderate negative correlation with PDW at month 6 (ρ=-0.47) and a weak negative correlation with MPV at month 6 (ρ=-0.26). Logistic regression analysis showed that PDW (OR, 2.2; p=0.004) at month 6 was an independent risk factor for the presence of residual venous thrombosis in DVT patients. Receiver operating characteristics analysis revealed that a 8.4% decrease in admission MPV at month 6 provided 62% sensitivity and 62% specificity (AUC: 0.64) and a 15.4% decrease in admission PDW at month 6 provided 87% sensitivity and 94% specificity (AUC: 0.89) for prediction of CTR in DVT patients. Percent change in admission MPV and PDW levels at month 6 may be used to identify the patients with CTR after a first episode of acute proximal DVT.

Graduated compression stockings to treat acute leg pain associated with proximal DVT. A randomised controlled trial.

Acute deep venous thrombosis (DVT) causes leg pain. Elastic compression stockings (ECS) have potential to relieve DVT-related leg pain by diminishing the diameter of distended veins and increasing venous blood flow. It was our objective to determine whether ECS reduce leg pain in patients with acute DVT. We performed a secondary analysis of the SOX Trial, a multicentre randomised placebo controlled trial of active ECS versus placebo ECS to prevent the post-thrombotic syndrome.The study was performed in 24 hospital centres in Canada and the U.S. and included 803 patients with a first episode of acute proximal DVT. Patients were randomised to receive active ECS (knee length, 30-40 mm Hg graduated pressure) or placebo ECS (manufactured to look identical to active ECS, but lacking therapeutic compression). Study outcome was leg pain severity assessed on an 11-point numerical pain rating scale (0, no pain; 10, worst possible pain) at baseline, 14, 30 and 60 days after randomisation. Mean age was 55 years and 60% were male. In active ECS patients (n=409), mean (SD) pain severity at baseline and at 60 days were 5.18 (3.29) and 1.39 (2.19), respectively, and in placebo ECS patients (n=394) were 5.38 (3.29) and 1.13 (1.86), respectively. There were no significant differences in pain scores between groups at any assessment point, and no evidence for subgroup interaction by age, sex or anatomical extent of DVT. Results were similar in an analysis restricted to patients who reported wearing stockings every day. In conclusion, ECS do not reduce leg pain in patients with acute proximal DVT.

The Effectiveness Of 30-40 Mm Hg Compression Stockings To Treat Acute Leg Pain Associated With Proximal Deep Vein Thrombosis: Results From The Sox Randomized Controlled Trial

▪ BackgroundAcute deep venous thrombosis (DVT) is associated with leg pain and discomfort. Elastic compression stockings (ECS) have the potential to improve DVT-related leg pain by reducing the diameter of distended veins, increasing venous blood flow and reducing venous hypertension. To date, however, the effect of ECS on DVT-related leg pain has not been studied. In the SOX Trial, a randomized trial of active ECS vs. placebo ECS to prevent the post-thrombotic syndrome, we measured leg pain intensity at baseline and at several time-points during follow-up. ObjectiveIn a secondary, non-prespecified analysis of the SOX Trial, to determine whether active ECS, compared with placebo (sham) stockings, are effective to reduce leg pain associated with acute proximal DVT. MethodsWe did a multicenter (24 centres in Canada and U.S.) randomized placebo controlled trial of active ECS vs. placebo ECS after a first, symptomatic proximal DVT. Active ECS were knee length, 30-40 mm Hg (Class II) graduated ECS. Placebo ECS were manufactured to appear identical to active ECS but lacked therapeutic compression. Study stockings were worn on the DVT-affected leg daily and continued for up to 2 years. Exclusion criteria were >10 days since DVT diagnosis, not planned to be treated with anticoagulants, known peripheral arterial disease or limb phlegmasia, anticipated lifespan < 6 months, inability of patient or caregiver to apply ECS, thrombolysis to treat DVT, geographically inaccessible for follow-up visits or unable to give informed consent. Leg pain intensity was assessed on a 10-point Visual Analog Scale (0, no pain; 10, worst possible pain) via patient self-report at baseline, 14 days, 1 month and 60 days after randomization. We compared mean pain scores at each time point in the active ECS vs. placebo ECS groups using t-tests. We repeated this analysis, restricted to patients who reported daily stockings use at the 1 month visit (the first visit at which frequency of stocking use was assessed). We conducted pre-specified subgroup analyses by age, sex, and extent of DVT. Results are presented as mean difference (95% confidence interval [CI]) in pain intensity score between groups. All statistical tests were 2-sided and significance was set at P<0.05. Results410 patients were randomized to active ECS and 396 to placebo ECS. One and 2 patients, respectively, were found to be ineligible soon after randomization and excluded from the analysis. Mean time from DVT diagnosis to randomization was 4.7 days. Baseline characteristics were similar in the 2 groups (60% male, mean age 55.1 years, highest proximal extent of DVT was iliac or femoral vein in 70% and popliteal vein in 30%, 87% were out-patients). Pain scores diminished over time in both groups. There were no differences between groups in pain scores at any time-point (Table), and no evidence for subgroup interaction by age category, sex or anatomical extent of DVT (not shown). ConclusionsIn a large randomized placebo-controlled trial in patients with symptomatic proximal DVT, leg pain improved at each follow-up visit to a similar degree in patients randomized to active ECS and placebo ECS, and we did not find evidence for benefit of active ECS to reduce pain associated with acute proximal DVT. As our first follow-up assessment was 14 days after DVT, we were unable to evaluate if active ECS had a beneficial or detrimental effect on pain scores during the first 2 weeks after DVT. Disclosures:No relevant conflicts of interest to declare.

Endovascular treatment of acute proximal deep venous thrombosis secondary to iliac vein compression syndrome: a novel technique for thrombus removal

Endovascular treatment of acute proximal deep venous thrombosis secondary to iliac vein compression syndrome: a novel technique for thrombus removal

Role of IVC Filters in Endovenous Therapy for Deep Venous Thrombosis: The FILTER-PEVI (Filter Implantation to Lower Thromboembolic Risk in Percutaneous Endovenous Intervention) Trial

The purpose of this study was to evaluate the necessity of and recommend indications for inferior vena cava (IVC) filter implantation during percutaneous endovenous intervention (PEVI) for deep venous thrombosis (DVT). PEVI has emerged as a powerful tool in the management of acute proximal DVT. Instrumentation of extensive fresh thrombus is potentially associated with iatrogenic pulmonary embolism (PE). The true frequency of this complication has not been studied in a randomized fashion. We evaluated IVC filter implantation during PEVI for DVT. A total of 141 patients with symptomatic proximal DVT undergoing PEVI for symptomatic DVT were randomized to receive an IVC filter (70 patients) or no filter (71 patients; control group). The anticoagulation and PEVI regimen were similar between the two groups. Patients with development of symptoms suggestive of PE underwent objective testing for PE. PE developed in 1 of the 14 symptomatic patients in the filter group and 8 of the 22 patients in the control group (P=0.048). There was no mortality in any group. Three patients (4.2%) in the control group had transient hemodynamic instability necessitating resuscitory efforts. Predictors of iatrogenic PE were found to be PE at admission; involvement of two or more adjacent venous segments with acute thrombus; inflammatory form of DVT (severe erythema, edema, pain, and induration); and vein diameter of≥7mm with preserved architecture. IVC filter implantation during PEVI reduces the risk of iatrogenic PE by eightfold without a mortality benefit. A selective approach may be exercised in filter implantation during PEVI.

Thrombose veineuse profonde aiguë: Place de la thrombolyse

Acute Deep Venous Thrombosis (DVT) therapies have been judged primarily on their ability to prevent symptomatic pulmonary embolism, early thrombus progression, and recurrent VTE. The cornerstones of current management of DVT, supported by the 2008 American College of Chest Physicians (ACCP) guidelines, are the routine use of anticoagulant therapy, graduated elastic compression stockings, and early ambulation. For selected appropriate patients with extensive acute proximal DVT, while the French recommendations (Afssaps 2009) still consider thrombolysis not indicated, ACCP guidelines now suggest in-situ thrombolysis in addition to anticoagulation to reduce the risk of subsequent postthrombotic syndrome (PTS) and recurrent DVT (Grade 2 B recommendation). Contemporary invasive endovascular treatments, called pharmacomechanical treatment, mitigate the drawbacks (major bleeding) historically associated with systemic thrombolytic approaches, by means of intra-thrombus delivery of drugs, followed by mechanical dispersion to accelerate lysis and then aspiration of remaining drug and clot debris. The proof of concept for the "open vein" hypothesis - that a strategy of early thrombus removal can reduce the incidence of PTS long term - comes incrementally and randomized trials (ATTRACT trial with a 2016 target completion date) are currently under way and might lead to a shift of the paradigms of the management of acute DVT focused on active thrombus removal.

Inferior Vena Cava Filter Migration to the Right Ventricle

Inferior vena cava (IVC) filter placement is recommended for acute proximal deep venous thrombosis if anticoagulation is contraindicated. A 52-year-old man presented with weakness, dyspnea, syncope, and renal failure 8 months after IVC filter placement. Imaging revealed migration of the IVC filter to the right ventricle. Endovascular retrieval was not feasible, thus surgical extraction and tricuspid valve repair was performed. IVC filter migration to the heart is a rare, but a potentially life-threatening complication. Retrieval can be accomplished using endovascular or open surgical technique.

Determination of the appropriate transcatheter endovenous tissue plasminogen activator dose for the treatment of extensive acute proximal DVT

Background: Transcatheter delivery of thrombolytic therapy is an effective tool in the treatment of acute deep venous thrombosis (DVT). We sought to determine an effective and safe thrombolytic regimen with tPA in the treatment of severe DVT when used in conjunction with percutaneous endovenous intervention (PEVI). Methods: Eighty consecutive patients with acute symptomatic DVT were randomized to receive four different doses of tPA. They had all undergone PEVI from 0.5 to 18 h following presentation to the hospital. PEVI consisted of any or a combination of the following: Trellis, Angiojet, or manual suction thrombectomy, balloon venoplasty, or stenting. Following initial PEVI, if N50% thrombus remained, tPA was given via an infusion catheter for 16–20 h. Patients were randomized to receive tPA at 0.5, 1, 2, or 4 mg/h and were assigned to Groups I–IV, respectively, with 20 in each group. Warfarin was continued, and during tPA administration heparin dose was reduced to 12 U/kg per hour. The end points evaluated were venous patency post-tPA (b5% residual thrombus), bleeding, and length of hospital stay. Results: The results are demonstrated in the Table 1. Venous patency rate was similar in Groups II–IV. Bleeding was seen more in Group IV, lengthening hospital stay. Venous patency was low in Group I. Conclusions: We conclude that transcatheter endovenous administration of tPA following suboptimal PEVI at 1 mg/h for 16–20 h is highly safe and effective in the treatment of DVT allowing for high patency rate, no complications, and early discharge.

Endovenous therapy for deep venous thrombosis: The TORPEDO trial

We compared the efficacy and safety of percutaneous endovenous intervention (PEVI) plus anticoagulation with anticoagulation alone in the reduction of venous thromboembolism (VTE) and post-thrombotic syndrome (PTS) in acute proximal deep venous thrombosis (DVT). Recurrent VTE and PTS are common complications of DVT. There are no randomized trials investigating the efficacy of PEVI in the reduction of the above complications. Patients with symptomatic proximal DVT were randomized to receive PEVI plus anticoagulation or anticoagulation alone. Anticoagulation consisted of intravenous unfractionated heparin or subcutaneous low-molecular weight heparin plus warfarin. PEVI consisted of one or more of a combination of thrombectomy, balloon venoplasty, stenting, or local low-dose thrombolytic therapy. At 6 months follow-up, recurrent VTE developed in 2 of 88 patients of the PEVI plus anticoagulation group versus 12 of 81of the anticoagulation-alone group (2.3% vs. 14.8%, P = 0.003). PTS developed in 3 of 88 patients of the PEVI plus anticoagulation Group and 22 of 81 of the anticoagulation-alone group (3.4% vs. 27.2%, P < 0.001). In patients with symptomatic proximal DVT, PEVI plus anticoagulation may be superior to anticoagulation-alone in the reduction of VTE and PTS at 6 months.

Indications for Catheter-Directed Thrombolysis in the Management of Acute Proximal Deep Venous Thrombosis

Deep vein thromboses (DVTs) cause significant morbidity and mortality in the general population. Oral anticoagulation therapy may reduce thrombus propagation but does not cause clot lysis and therefore does not prevent postthrombotic syndrome (PTS). Catheter-directed thrombolysis (CDT) can be used to treat DVTs as an adjunct to medical therapy, but there is no consensus defining exact indications. Current evidence suggests that CDT can reduce clot burden and DVT recurrence and consequently prevents the formation of PTS compared with systemic anticoagulation. Appropriate indications include younger individuals with acute proximal thromboses, a long life expectancy, and relatively few comorbidities. Limb-threatening thromboses may also be treated with CDT, although the subsequent mortality remains high. A number of randomized controlled trials are currently under way comparing the longer-term outcomes of CDT compared with anticoagulation alone. Initial reports suggest that venous patency and valvular function are better maintained after CDT. The effectiveness of combined pharmacomechanical thrombectomy and the role of vena cava filters need to be investigated further before strong recommendations can be made. The reported short-term outcomes following catheter-based intervention for DVT are encouraging in selected patients. Further evidence is required to establish long-term benefits and cost-effectiveness.