Catheter-directed Therapy Research Articles

Open vs. endovascular repair of isolated iliac artery aneurysms: A 12-year experience

To examine contemporary operative techniques and outcomes for repair of isolated iliac artery aneurysms. We retrospectively reviewed the charts of all patients who underwent repair of an isolated iliac artery aneurysm from February 1995 to June 2007. Mycotic aneurysms and patients with concurrent infrarenal abdominal aortic aneurysms greater than 3.5 cm in diameter were excluded from analysis. Patients with prior abdominal aortic aneurysm repair were not excluded. Fifty-six patients (96% male; mean age, 72 +/- 10 years) had either open (n = 24) or endovascular (n = 32) repair with median follow-up of 36 months. Seven patients were treated for rupture, six with open repair, and one with an endograft. Average aneurysm size for patients in the open and endovascular repair cohorts was 4.5 +/- 2.4 cm and 4.0 +/- 1.1 cm, respectively (P = .35). One episode of endograft limb thrombosis at five months was treated with catheter-directed thrombolytic therapy and stent placement. Thirty-day mortality for patients undergoing elective and emergent open repair was 1/18 (6%) and 1/6 (17%), respectively. There was no 30-day mortality for the endovascular group. Median length of stay was 10.5 days in the open group and one day in the endovascular elective group (P < .01). There was no mid-term aneurysm-related mortality in either group. Primary patency rates were similar between the open and endovascular groups at five years (100% vs. 96%, P = .07). Aneurysm sac diameter decreased in 67% (21/28) of patients that underwent endovascular repair. One patient with a Type III endoleak required relining of the endograft with a second endograft at 72 months. These data demonstrate that in appropriately selected patients, endovascular repair of isolated iliac artery aneurysms is a safe, effective alternative to open repair with mid-term follow-up. Endovascular repair is associated with a significantly reduced hospital length of stay and may be associated with decreased need for transfusion and mortality when compared with open repair.

Atherosclerotic Peripheral Vascular Disease Symposium II

Percutaneous intervention for peripheral artery disease has evolved from balloon angioplasty for simple focal lesions to multimodality techniques that enable treatment of severe arterial insufficiency. This technological expansion comes without a standard approach or algorithm, which makes the decision-making process more subjective than objective. Nevertheless, clinical tools are available that can have a favorable effect on patient care, and these promote usage. So, when are standard endovascular techniques (such as balloon and stents) good enough, and when are the latest advances (eg, atherectomy, drug-eluting stents) more appropriate? This section will address these questions for acute limb ischemia (ALI) and chronic critical limb ischemia (CLI). It will also delineate the problem of restenosis, particularly of the superficial femoral artery (SFA), and describe treatment alternatives. The discussion will review the role of drug-eluting stents, atherectomy devices, reentry catheters, and brachytherapy, as well as their potential complications and appropriate remedies. Treatment algorithms for aortoiliac and infrainguinal disease are provided in Figures 1 through 3⇓⇓. Figure 1. Treatment algorithm for acute lower-limb ischemia. *Short infusion of thrombolytic therapy proximal to occlusion can be used to facilitate wire traversal. Figure 2. Simplified treatment algorithm for symptomatic aortoiliac disease in patients deemed candidates for revascularization. In patients with multilevel disease, the aortoiliac segment should be addressed first. TASC indicates TransAtlantic Inter-Society Consensus; AI, aortoiliac; PTA, percutaneous transluminal angioplasty; PE, physical examination; ABI, ankle-brachial index; and U/S, ultrasound. Figure 3. Simplified treatment algorithm for symptomatic infrainguinal peripheral arterial disease, assuming concomitant aortoiliac disease has been treated and the patient is an acceptable candidate for revascularization. *Alternative therapies to PTA include cryotherapy, atherectomy (directional, rotational, ablative), and cutting balloon. †Alternative stent options include stent (graft, balloon expanding, and self expanding) and drug-eluting stent. PTA indicates percutaneous transluminal angioplasty; TASC, TransAtlantic Inter-Society Consensus; PE, physical examination; …

What Will It Take to Initiate a Move Toward a More Aggressive Therapeutic Approach to Venous Thromboembolism?

Recent decades have engendered significant advances in the treatment of venous thromboembolism (VTE). However, patients with deep vein thrombosis (DVT) continue to experience complications, highlighting the need for more effective approaches. A systematic approach involving prophylaxis, early detection, triage, risk assessment, and aggressive anticoagulation or lytic therapy can be of great clinical benefit. Articles in the current published literature report caval interruption, anticoagulant therapy, and catheter-directed lytic therapies (CDT) as being effective in clot resolution. More recently, more aggressive new treatment approaches have been considered for acute VTE. Patients who present with symptomatic pulmonary embolism (PE) appear more likely to die of recurrent PE and are nearly 4 times as likely (1.5% vs. 0.4%) to die of PE within the next year, compared with patients who present with acute DVT. Although heparins possess anti-inflammatory properties, they do not guarantee the prevention of damage to venous valves. Advances in caval filter technology have made them easier to insert, position accurately, and remove based on clinical reports. Thrombolysis has proved to hasten clot resolution, and is usually safe when there are no contraindications. However, only 54% of pulmonologists surveyed have ever used this therapy for PE and only 28% have used it for DVT. Clinical reports show considerable potential for this therapy to prevent clinical sequelae of DVT such as PE, postthrombotic syndrome and chronic thromboembolic pulmonary hypertension. Yet the adoption for this treatment has been slow and appears to be only in its early stages. The current standard of care does not promote direct lysis of thrombi, and anticoagulation therapy alone may not always be sufficient. Clinical evidence strongly suggests that CDT offers significant potential in promoting effective clot dissolution and removal. A new paradigm, including the identification and involvement of stakeholders and key players appears to be a crucial step. Evidence from rigorous clinical studies and randomized control trials should be reviewed by potential stakeholders, individual physician specialists, and organizational experts to develop a new treatment paradigm. Ideally, this would be a standardized protocol for thromboembolism that outlines a step-by-step comprehensive plan that ensures early detection and, when appropriate, careful consideration of aggressive clot resolution.

Videoassistierte thorakoskopische Chirurgie (VATS) zur Behandlung des parapneumonischen Pleuraempyem

Parapneumonic pleural empyema has been classified by international societies and by pleural diseases experts into different stages and classes. While the American Thoracic Society (ATS) classification is based on the natural course of the disease, Light has classified pleural empyema according to radiological, physical and biochemical characteristics, and the American College of Chest Physicians (ACCP) has categorised patients with pleural empyema according to the risk of a poor outcome. According to these classifications, the management of the pleural empyema is based on the stage of the disease. The recommended treatment options in (ATS) stage I disease (Light classes I-III, ACCP categories I and II) are therapeutic thoracentesis or tube thoracostomy and antibiotics when necessary. In (ATS) stage II disease (Light classes IV-VI, ACCP category III), thoracoscopy (VATS) is the treatment of choice because it has a higher efficacy than treatment strategies that utilise tube thoracostomy or catheter-directed fibrinolytic therapy alone, whereas in (ATS) stage III disease (Light class VII, ACCP category IV), decortication via thoracoscopy or thoracotomy is the treatment of choice.

Massage-induced Delayed Venous Stent Migration

Catheter-directed therapies in chronic deep vein thromboses can help improve leg function by mechanically addressing residual obstruction in lower extremity or pelvic veins, although the reported use of stents in leg veins is relatively unusual. The author reports a case of this type with long-term patency and clinical success, culminating in asymptomatic delayed venous migration of a stent to the right atrium after 3 years. Open heart surgery was required to remove the embedded stent fragments. The attributed mechanism was deep tissue massage of the thigh.

Abstract No. 10: Catheter-Directed Therapy for Massive Pulmonary Embolism: Systematic Review &amp; Meta-Analysis of the Modern Technique

The use of systemic thrombolysis carries a 5% risk of major hemorrhage including a 0.5-1% risk of hemorrhagic stroke. We used evidence-based methods to evaluate the safety and efficacy of modern catheter-directed therapy (CDT), as a potential alternative treatment to systemic thrombolysis, in patients with massive PE.

Abstract No. 35: Yttrium 90 Radioembolization for Liver Metastases: Prognostic Factors Associated with Survival

To identify the prognostic clinical and imaging variables in patients undergoing catheter-directed Yittrium-90 therapy for various liver metastases. We performed a prospective statistical analyses encompassing 137 patients (M = 66, F = 71, median age 61) who underwent 225 administrations of Y-90 via direct intra-arterial infusion for treatment of liver metastases. Primary sites included colon, neuroendocrine, and others (e.g. breast, biliary, pancreatic). Baseline functional status, laboratory values and diagnostic imaging of each patient were obtained prior to therapy. Subsequently, the patients were followed for survival from time of the first Y-90 intra-arterial treatment. A total of 332 lesions were evaluated on follow-up tumor imaging. Multivariate analysis was performed using the Cox Method for proportional hazard regression to determine the prognostic value of each variable analyzed. The table below reflects the overall hazard ratios for each prognostic variable analyzed in 137 patients who underwent Y-90 therapy.Tabled 1Hazard Ratio (95% CI)P-valueAge (> 65 y/o)1.45 (0.87, 2.43)0.1552ECOG group (<>0)10.0 (5.47, 18.5)<0.0001Bilobar involvement1.87 (0.92, 3.80)0.0860Tumor burden51-75%4.50 (1.91, 10.6)0.000626-50%1.35 (0.70, 2.59)0.36800-25%ReferenceExtrahepatic metastases2.30 (1.38, 3.83)0.0015Elevated bilirubin (> 1.3 mg/dl)2.91 (1.51, 5.61)0.0014Dose utilization < 104 Gy1.10 (0.65, 1.86)0.7286Positive tumor response to treatment0.30 (0.17, 0.55)0.0001 Open table in a new tab As expected, poor ECOG status, elevated bilirubin level, tumor burden > 50% and extrahepatic disease were negative prognostic factors for patients undergoing Y-90 intra-arterial therapy. Unexpectantly, tumor response to therapy was associated with significant increased survival benefit, a finding not previously recognized in the metastatic patient. These parameters should be used in the decision making process when selecting patients for Y-90 therapy.

Arterivenous Fistula Complicated by Popliteal Venous Access for Endovascular Thrombolytic Therapy of Deep Vein Thrombosis

We report a case of an iatrogenic arteriovenous fistula complicated by catheter-directed thrombolytic therapy in a patient with acute deep vein thrombosis of a lower extremity. To the best of our knowledge, this is the first report of an arteriovenous fistula between the sural artery and popliteal vein in that situation. As the vessels have a close anatomical relationship, the arteriovenous fistula seems to be a potential complication after endovascular thrombolytic therapy of acute deep vein thrombosis.

Catheter‐directed therapy for DVT after pancreas transplantation

Iliac vein deep venous thrombosis (DVT) ipsilateral to the pancreas transplant can lead to severe leg edema and compromise graft function. Treatment modalities for iliac vein DVT in the pancreas transplant recipient are limited. Medical records of patients receiving pancreas transplants at a single center from November 1989 to July 2003 were reviewed retrospectively, identifying patients with iliac vein DVT. There were 287 pancreas transplants performed during this time. Pancreas transplantation in all recipients was performed in the right iliac fossa with the arterial supply consisting of a donor iliac artery Y interposition graft. Systemic venous drainage was to the iliac vein. Exocrine drainage was enteric or to the bladder. Four (1.4%) cases of iliac DVT were identified. All patients manifested lower extremity edema ipsilateral to the pancreas transplant. DVT was detected by ultrasound on days 4, 5, 13, and 60 post-transplant. In all cases, the iliac vein caudad to the pancreatic venous anastomosis was noted to be stenotic. Management involved balloon dilatation and endovascular stent placement in one patient, thrombolysis with tissue plasma antigen (t-PA) followed by stent placement in one patient, and percutaneous mechanical thrombectomy in two patients. All patients had improvement in leg edema and two patients continue to have good pancreatic allograft function. Iliac DVT is a rare complication of pancreas transplantation that usually develops in an area of stenosis caudad to the pancreatic venous anastomosis. Catheter-based treatment modalities with use of endovascular stents for treatment of underlying stenoses can serve as an adjunct in treating these complications.

Successful catheter-directed venous thrombolysis in phlegmasia cerulea dolens

Background Phlegmasia cerulea dolens is an extremely rare condition caused by complete venous occlusion and often results in tissue necrosis, limb amputation, or death. Treatment options include systemic anticoagulation, systemic thrombolytic therapy, fasciotomy, or surgical thrombectomy. Rare case reports have described the use of catheter-directed thrombolysis in the treatment of this condition. Prompt diagnosis and treatment initiation are important to prevent gangrene, amputation, and ultimately death. Case We report two unusual cases of phlegmasia cerulea dolens that presented in patients with aggressive gynecologic malignancies and who were successfully treated with catheter-directed thrombolytic therapy. Conclusion To maximize the opportunity for limb salvage, catheter-directed venous thrombolytic therapy should be considered in the treatment of phlegmasia cerulea dolens that presents in the gynecologic oncology patient.

Catheter‐directed thrombolysis (intrathrombus injection) in treatment of deep venous thrombosis: A systematic review

Methods of delivery of thrombolytic agents for massive or limb threatening deep venous thrombosis (DVT) include a systemic infusion, local-regional administration, and catheter-directed therapy (tip of catheter placed inside the thrombus). We evaluated the effectiveness of catheter-directed therapy and compared the results with randomized clinical trials of systemic and local-regional thrombolytic therapy. Many who used catheter-directed thrombolysis used balloon angioplasty, stents, or thrombectomy in addition. Pooled data showed higher rates of complete early opening of occluded veins with catheter-directed thrombolysis alone, 90%, or with catheter-directed thrombolysis often followed by adjunct therapy, 76%, than with a systemic infusion, 28%, or local-regional administration, 20%. The prevalence of postthrombotic syndrome was lower with catheter-directed combined with adjunct therapy, 26%, compared with 56% and 69%, respectively. Rates of any bleeding were higher with catheter-directed thrombolytic therapy, but bleeding was usually minor. In conclusion, the data suggest that catheter-directed thrombolytic therapy may be more beneficial than systemic or local regional administration. An advantage is that it lends itself to adjunct treatment following the administration of thrombolytic agents if the thrombolysis is inadequate.

Is initial success of thrombolytic therapy with rt-PA in patients with lower limb ischemia durable? A long-term follow-up series

Catheter-directed intraarterial thrombolytic therapy with rt-PA has been established as an alternative to surgery in selected patients with lower limb ischemia. The purpose of this study is to evaluate its long-term results and to try to identify patient variables influencing outcome. The results of thrombolytic treatment for acute or subacute lower limb ischemia in 82 patients (51 male, 31 female) were retrospectively analysed. Clinical data (time of symptoms onset, clinical stage, type of affected vessel, anatomical localisation) as well as comorbidities were recorded. The success rate of thrombolysis as well as the incidence of adverse events was evaluated. Patients with initial success were followed up after a median of 52,5 months. Thrombolytic therapy was successful in 67 cases (82%). An additional endovascular or surgical procedure was necessary in 39 of these patients (48%). The overall bleeding rate was 18% and the mortality and major amputation rate was 1%. 42 patients with early clinical success were available for follow-up. 34 of them (81%) were free of ischemic symptoms and the overall limb salvage rate was 96%. We could not identify factors significantly influencing early or long-term results, although there was a trend towards better results in patients with acute ischemia and in patients with occluded native arteries. Intraarterial local thrombolytic therapy has a relatively high initial success rate in selected patients with lower limb ischemia, but is associated with a significant number of bleeding complications. Furthermore, additional procedures are required in almost half the patients. Initial success is durable at the long-term in the majority of cases. Better selection of patients and refinements of the thrombolytic therapy might help to further improve results and lower the bleeding complications.

Superior vena cava syndrome: an increasingly frequent complication of cardiac procedures

A 29-year-old woman presented with chest pressure, progressive dyspnea, fatigue, and swelling of her face, neck and upper extremities. Four days earlier, she had undergone a procedure for treatment of inappropriate sinus tachycardia, during which atrioventricular node ablation and implantation of a single-lead VVI pacemaker had been performed following an unsuccessful attempt at sinus node modification. Physical examination, contrast-enhanced CT of the chest, Doppler ultrasonography of the upper extremities, venography, coagulation studies, echocardiography. Superior vena cava syndrome due to thrombotic obstruction-a complication of a cardiac procedure. Anticoagulation, catheter-directed thrombolytic therapy, mechanical thrombectomy, pericardiocentesis.

Catheter-Directed Therapies for Deep Venous Thrombosis

Contemporary Diagnostic Radiology: March 31, 2007 - Volume 30 - Issue 7 - p 6 doi: 10.1097/01.CDR.0000266532.94811.8c

Catheter-Directed Therapies for Deep Venous Thrombosis

Dr. Cura is Assistant Professor, and Dr. Orsi is Radiology Resident, Department of Radiology, University of Texas Health Science Center, Mail Code 7800, 7703 Floyd Curl Drive, San Antonio, TX 78229; E-mail: [email protected]. The authors have disclosed that they have no significant relationships with or financial interests in any commercial organizations pertaining to this educational activity. Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity.

Superior vena cava syndrome with central venous catheter for chemotherapy treated successfully with fibrinolysis

Recently, there has been an increase in the number of cases of superior vena cava (SVC) syndrome associated with chronic indwelling central venous catheters. Fibrinolytic therapy and endovascular treatment are currently achieving good results. We present a case history of a patient with SVC with a catheter used for chemotherapy, which was successfully treated with catheter-directed (intraclot) infusion thrombolytic therapy with urokinase.

Aggressive Surveillance and Early Catheter-Directed Therapy in the Management of Intra-Abdominal Hypertension

Trauma patients represent a heterogeneous group at risk for the development of both primary and secondary abdominal compartment syndrome (ACS). Our study aims at identifying these individuals early in their course and placing an intra-abdominal catheter to reduce intra-abdominal pressure before the serious hemodynamic consequences of ACS occur. During a 10-month period, 12 patients were identified who developed intra-abdominal hypertension. Patients who received 12 L or more of intravenous fluids in the first 24 hours of their resuscitation or received 500 mL/hr of intravenous fluids for more than 4 consecutive hours were considered at risk and had intra-abdominal pressure readings via bladder catheters every 4 hours. After resuscitation, patients were given a physical examination and intra-abdominal pressures were taken every 4 hours or when clinically necessary. When abdominal compartment pressures (ACPs) exceeded 20 mm Hg or the abdominal perfusion pressure (APP = mean arterial pressure-ACP) fell below 50 mm Hg, a diagnostic peritoneal lavage catheter was placed. Fluid volume and type drained, abdominal pressures, heart rate, mean arterial pressure, and pulmonary compliance were recorded. If adequate control of abdominal compartment pressures was not achieved, the patients were managed with a traditional decompressive laparotomy. Readings taken 30 minutes after placement of the peritoneal catheter showed an average decrease in ACP of 8.0 mm Hg (p = 0.01); an increase in APP of 13.8 mm Hg (p = 0.14); an increase in static pulmonary compliance of 8.1 mL/cmH2O (p = 0.16); and an increase in mean arterial pressure of 5.8 mm Hg (p = 0.52). Ten of the twelve patients were managed nonoperatively. Four patients failed to have their APP improve to >50 mm Hg with the catheter. Two of these patients underwent laparotomy, with one survivor and one mortality secondary to infarcted small bowel. Two did not undergo laparotomy, with one dying of cerebral herniation and the other having care withdrawn. Eight of the twelve patients required intra-abdominal catheters early in their admission (in the first 32 hours), with 7 of 8 surviving. Four patients received intra-abdominal catheters later than day 4 in their admission. All of those four patients died, three within 24 hours. Overall, 5 of the 12 patients died. Intra-abdominal catheter placement is a reasonable first step in the early management of ACS. It may prevent a portion of patients from progressing to hemodynamically significant ACS and prevent the complications of managing an open abdominal wound. Also, the late intra-abdominal hypertension may be a prognostic indicator of an impending rapid clinical deterioration. Further prospective investigation is warranted to determine whether this method reduces overall morbidity and mortality in critically ill patients.

A Unified Approach to Axillosubclavian Venous Thrombosis in a Single Hospital Admission

Spontaneous or effort-related thrombosis of the axillosubclavian vein, termed Paget-Schroetter syndrome, is thought to be related to repetitive upper extremity physical activity, most commonly afflicting young, otherwise healthy, individuals. For the past 25 years, the mainstay of treatment for acute axillosubclavian venous thrombosis has consisted of early local catheter-directed thrombolytic therapy, an interval period of anticoagulation (3 months), and late surgical decompression of the thoracic outlet, with either a transaxillary or supraclavicular first rib resection. Immediate thrombolytic therapy followed by early surgical decompression has also been suggested previously, but has only recently been shown to be safe and efficacious, while significantly decreasing the duration of disability suffered by patients with this form of thoracic outlet syndrome. Therefore, a unified approach to acute axillosubclavian venous thrombosis in a single hospital admission should be considered an alternative standard of care for treatment of Paget-Schroetter syndrome.

Endovascular management of acute deep vein thrombosis

The goals of successful management of deep vein thrombosis (DVT) include relief of acute symptoms with restoration of venous patency, prevention of clot propagation and subsequent pulmonary embolism, and maintenance of venous valvular function. Valvular incompetence is the leading cause of postthrombotic syndrome (PTS), which is characterized by chronic leg heaviness and aching, lower extremity edema, and impaired viability of subcutaneous tissues, which may lead to chronic trophic skin changes and venous ulceration. Anticoagulation with unfractionated or low-molecular-weight heparin followed by warfarin is recognized as the standard therapy for acute DVT. Although this approach may effectively prevent recurrent thrombosis, it often fails to meet the other treatment goals. Recent studies have demonstrated that early clot lysis through the use of catheter-directed thrombolytic therapy and other adjunctive endovascular techniques rapidly restores venous patency, more effectively preserves valvular function, and improves quality of life. When used in conjunction with anticoagulation, these minimally invasive endovascular techniques have the potential to lead to improved long-term outcomes in patients with DVT.

Catheter-Directed Thrombolysis for the Management of Postpartum Deep Venous Thrombosis

Women are at their highest risk of developing venous thromboembolism, still the most important cause of maternal mortality in developed countries, during the postpartum period. Acute deep venous thrombosis (DVT) causes significant morbidity, chiefly as a result of postthrombotic syndrome. Heparin anticoagulation can prevent pulmonary embolism but leads to thrombolysis in fewer than 15% of patients with DVT and does not protect against postthrombotic syndrome. Catheter-directed thrombolysis, combined with angioplasty and stent placement when indicated, removes thrombus and restores venous patency. This treatment has, however, been avoided during and after pregnancy because of an increased risk of placental abruption and bleeding complications as well as fetal exposure to radiation. The investigators performed this procedure in 5 women having acute postpartum DVT within 6 weeks of delivery and for less than 3 weeks. The diagnosis was confirmed by color Doppler ultrasound and/or venography. Patients received low-molecular-weight heparin when diagnosed as having DVT. With the patient prone on an angiography table, the ipsilateral popliteal vein was entered with a 6-F microaccess set under ultrasound guidance using a 21-G needle and a guidewire 0.46 mm in diameter. Ascending venography was performed and, using a sidearm sheath and 5-F angled endhole catheter, a 0.89-mm hydrophilic guidewire was passed into the inferior vena cava. The endhole catheter than was replaced with a 5-F multisideholed catheter that was embedded in the thrombus. A recombinant human tissue plasminogen activator, alteplase, was infused for up to 24 hours. Unfractionated heparin also was infused. Doses were adjusted to maintain a fibrinogen level above 1 g/L and cephotest of 50s to 70s. Venography was repeated after 20–24 hours of thrombolytic treatment. If stenosis was found, angioplasty was carried out with or without a stent. Lysis was considered complete if the remaining luminal-area narrowing was less than 5%. Catheter-directed thrombolysis was carried out in 4 women with iliofemoral DVT and 1 with renal and ovarian vein thrombus. Two women had a positive thrombophilia screen for protein S deficiency, but none had recognized risk factors during or after pregnancy. One woman received low-molecular-weight heparin postoperatively after cesarean delivery. Two patients had a stent placed. Thrombolysis succeeded in all 4 patients with iliofemoral DVT. Partial lysis was achieved in the patient with renal and ovarian vein thrombosis, but kidney function was absent a month later. Symptoms resolved completely in all 5 patients. In women with acute postpartum DVT, early endovascular catheter-directed thrombolytic therapy—combined with thrombectomy, angioplasty, and/or stenting when indicated—may preserve function of the venous vales and prevent later venous occlusive disease. Evidence of safety remains insufficient. The authors recommend the use of graded compression stockings after thrombolysis to lessen the risk of postthrombotic syndrome.