Catheter-directed Thrombolytic Therapy Research Articles

4:12 PM Abstract No. 229 The thromboaspiration with INDIGO system reduces the time and dose of fibrinolysis and improves the results in massive pulmonary embolism in comparison with catheter fragmentation (previous cohort study)

Determine if thromboaspiration with indigo system improves short- and medium-term outcomes compared with interventional treatment of choice for pulmonary embolism (PE) (mechanical thrombolysis + catheter-directed thrombolytic therapy). From Apr-2016 to Aug-2017, 43 patients diagnosed massive PE and a comparative with previous study of 111 patients with massive PE. In the first cohort all patients were treated with thromboaspiration + catheter-directed thrombolytic therapy (TAs) and the other cohort were treated with conventionally according to our protocol: thrombolysis + catheter fragmentation (MFT). There were no significant differences in age, sex and the angiographic pulmonary index (Miller index). Pulmonary pressures after fibrinolysis and one month later were compared. The total dose and the total time of fibrinolysis were also compared in both groups. Postoperative mean pulmonary arterial pressure (PAPm) was 34.06 ± 5.81 mm Hg TAs and 39.46 ± 6.39 mm Hg MFT, without showing significant differences in both groups regarding the 24hours and after 1- month angiographic control. There were significant differences in the total dose administered of urokinase (UK) (1.38 ± 0.25 IU of UK TAs MFT vs 2.82 ± 0.89 million IU of UK MFT) and the total time of UK perfusion (13.05 ± 1.70 hours TAs vs. 21.69 ± 11.92 hours MFT). four patients (9.3%) died in the follow-up in the cohort TAs with only 1 (2.3%) related to PE vs. 7 patients (6.3%) with only 4 (3.6%) related to PE or complications of endovascular treatment MFT. Thromboaspiration improves the results of conventional mechanical fragmentation and catheter-directed thrombolytic therapy, decreasing the time and total dosage of fibrinolysis and also decreasing PAP more rapidly.

Abstract No. 657 Impact of venous collaterals on clinical outcomes in Paget-Schroetter syndrome

Effort thrombosis, Paget-Schroetter syndrome (PSS), is an axillo-subclavian venous thrombosis often following repetitive and vigorous use of the upper extremities. The development of collateral venous circulation is known to occur around the region of first rib impingement, but the effect these collaterals have on thrombolysis and surgical outcomes is unknown. The object of this study was to characterize the effect of venous collaterals on the success of thrombolysis and the rate of reinterventions after surgery in patients with PSS. Single-center retrospective study of all patients presenting with the clinical diagnosis of PSS receiving catheter-directed thrombolytic therapy (CDT) from 2007 through 2017. Patients receiving prior surgical intervention were excluded. Three readers analyzed venograms at presentation, post-lysis, and at each reintervention for severity of venous stenosis, thrombus burden, and collateralization. Subjects were divided into groupings of high and low-grade collateral flow based on venographic appearance. CDT was performed in 35 extremities (34 patients) with a success rate of 100%. Pre-procedure venogram showed 27 extremities with low-grade collaterals and 8 with high-grade collaterals. The reintervention rate within 12 months for extremities with high-grade collaterals was 88% (7 of 8), significantly higher than those with low-grade collaterals, 41% (11 of 27, p = 0.021). There was a significant decrease in the severity of collateralization post thrombolysis (p = .048) and within 30 days postoperatively (p = .038). The severity of venous collateralization on presenting venogram in patients with PSS does not appear to affect success rates of initial CDT, but may be predictive of long-term patency of the affected extremities. CDT seems to be effective in reducing collateral burden; however, patients with severe collateralization on presentation are more likely to need reintervention.

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Echocardiographic assessment with right ventricular function improvement following ultrasound-accelerated catheter-directed thrombolytic therapy in submassive pulmonary embolism

Introduction The objective of this study was to evaluate the efficacy of ultrasound-accelerated catheter-directed thrombolytic therapy in patients with submassive pulmonary embolism. Methods Clinical records of 46 patients with submassive pulmonary embolism who underwent ultrasound-accelerated catheter-directed pulmonary thrombolysis using tissue plasminogen activator, from 2007 to 2017, were analyzed. All patients experienced clinical symptoms with computed tomography evidence of pulmonary thrombus burden. Right ventricular dysfunction was present in all patients by echocardiographic finding of right ventricle-to-left ventricle ratio > 0.9. Treatment outcome, procedural complications, right ventricular pressures, and thrombus clearance were evaluated. Follow-up evaluation included echocardiographic assessment of right ventricle-to-left ventricle ratio at one month, six months, and one year. Results Technical success was achieved in all patients ( n = 46, 100%). Our patients received an average of 18.4 ± 4.7 mg of tissue plasminogen activator using ultrasound-accelerated thrombolytic catheter with an average infusion time of 16.5± 5.4 h. Clinical success was achieved in all patients (100%). Significant reduction of mean pulmonary artery pressure occurred following the treatment, which decreased from 36 ± 8 to 21 ± 5 mmHg ( p < 0.001). There were no major bleeding complications. All-cause mortality at 30 days was 0%. No patient developed recurrent pulmonary embolism during follow-up. During the follow-up period, 43 patients (93%) showed improvement of right ventricular dysfunction based on echocardiographic assessment. The right ventricle-to-left ventricle ratio decreased from 1.32 ± 0.18 to 0.91 ± 0.13 at the time of hospital discharge ( p < 0.01). The right ventricular function remained improved at 6 months and 12 months of follow-up, as right ventricle-to-left ventricle ratio were 0.92 ± 0.14 ( p < 0.01) and 0.91 ± 0.15 ( p < 0.01), respectively. Conclusion Ultrasound-accelerated catheter-directed thrombolysis is a safe and efficacious treatment for submassive pulmonary embolism. It reduces pulmonary hypertension and improves right ventricular function in patients with submassive pulmonary embolism.

Catheter directed thrombolytic therapy and percutaneous thrombectomy

Abstract 40% of DVTs occur in the femoral and iliac veins and have a high risk of pulmonary thromboembolism and Post Thrombotic Syndrome (PTS), which can be avoided by timely interventional management. Catheter Directed Thrombolytic Therapy (CDTT) and Pharmacomechanical Catheter-Directed Thrombolysis (PCDT), (combination of CDTT with percutaneous mechanical thrombectomy) techniques enhance the efficiency and rate of thrombus removal. It also uncovers the May Thurner syndrome in many cases. Massive Pulmonary Embolism (PE) is associated with high morbidity and mortality due to thrombotic occlusion of main pulmonary artery and/or both major pulmonary arteries leading to severe hypoxemia, pulmonary artery hypertension and cardiogenic shock. Till now, open surgical pulmonary endarterectomy was the only option for prompt restoration of flow in major pulmonary arteries but carried a high mortality in hemodynamically unstable patients. Catheter based pulmonary thromboaspiration and intrapulmonary thrombolysis can be used. We present our experience in 45 consecutive patients of massive PE presenting with cardiogenic shock.

Frostbite, Injury, and Trauma in the Extremities

The objective of the study is to review the current methods of evaluating and managing both frostbite injury and non-thermal extremity vascular trauma, with an emphasis on endovascular techniques. The traditional management of frostbite has a well-established role for the rapid rewarming of injured tissues. This literature review highlights the evolution of the various management techniques with a specific focus on the more recent role of intra-vascular catheter-directed thrombolytic therapy. Non-thermal extremity trauma with resulting vascular injury requires prompt diagnosis that relies heavily on both the physical examination and the appropriate imaging. Frostbite injury manifests as a progressive insult with distinct pathophysiologic phases during which imaging can guide appropriate care. Traditional medical management, in combination with intra-vascular catheter-directed thrombolytic regimens, can restore blood flow to poorly or non-perfused digits, thereby ultimately reducing the risk of delayed amputation. Non-thermal trauma to the extremities can result in a variety of vascular injuries. Interventional radiology plays a key role in diagnosis and an expanding role using transcatheter therapies in order to provide efficacious and optimal management of patients with vascular injury.

A Dual-Snare Percutaneous Retrieval of Venous Stent Embolization to the Right Heart

A 57-year-old man with past medical history of asthma was transferred from an outside hospital for evaluation of cardiac mass where he was treated for extensive right lower extremity iliofemoral deep venous thrombosis with catheter-directed thrombolytic therapy and thrombectomy. Due to concern of

VESS06. Clinical Outcome of Ultrasound-Accelerated Catheter-Directed Thrombolytic Therapy for the Treatment of Submassive Pulmonary Embolism

VESS06. Clinical Outcome of Ultrasound-Accelerated Catheter-Directed Thrombolytic Therapy for the Treatment of Submassive Pulmonary Embolism

Transesophageal Echocardiography-Guided Thrombus Extraction and Catheter-Directed Thrombolytic Therapy During Orthotropic Liver Transplantation

Transesophageal Echocardiography-Guided Thrombus Extraction and Catheter-Directed Thrombolytic Therapy During Orthotropic Liver Transplantation

TCT-781 Safety and Outcomes of Catheter-directed Thrombolytic Therapy in High-risk Pulmonary Embolism

TCT-781 Safety and Outcomes of Catheter-directed Thrombolytic Therapy in High-risk Pulmonary Embolism

Quantitation of Venous Clot Lysis With D-Dimer Assay During Catheter-Directed Thrombolysis for Lower Extremity Deep Venous Thrombosis

This study evaluated whether D-dimer (DD) concentration analysis is a useful approach for noninvasive monitoring of clot lysis during catheter-directed thrombolysis (CDT) for deep vein thrombosis (DVT). DD levels have been found to be elevated during fibrinolytic therapy for DVT. Therefore, measuring the level of DD is a potential alternative method to assess the effect of fibrinolytic therapy. From January 2013 to March 2014, 32 patients with symptomatic acute DVT involving the iliac or femoral veins were treated using CDT. Urokinase was the thrombolytic agent. Demographics, procedural details, DD concentration, and thrombus score were recorded before and after the thrombolytic therapy. The peak DD concentration was 35.35 ± 11.18 μg/mL during CDT therapy, and the time-integrated DD concentration was 157.95 ± 69.46 μg·d/mL. The peak DD concentrations were higher in patients with substantial lysis compared with those in patients with minimal or no lysis (40 ± 0 versus 30.7 ± 14.57 μg/mL; P = 0.016). The time-integrated DD concentrations were also higher in patients with substantial lysis compared with those in patients with minimal or no lysis (194.14 ± 37.57 units versus 121.75 ± 75.93 units, P = 0.002). There was a moderate correlation (r = 0.57) between the peak DD level and the lysed clot volume. There was also a correlation between the time-integrated DD and clot lysis (r = 0.65). DD concentration analysis offers an alternative approach to noninvasive monitoring of venous clot lysis during CDT for 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.

Catheter-directed thrombolytic therapy and endovascular interventions for acute massive pulmonary embolism

Catheter-directed thrombolytic therapy and endovascular interventions for acute massive pulmonary embolism

Efficacy of Retrievable Inferior Vena Cava Filter Placement in the Prevention of Pulmonary Embolism during Catheter-Directed Thrombectomy for Proximal Lower-Extremity Deep Vein Thrombosis

Inferior vena cava (IVC) filter placement is not indicated for thrombolytic interventional treatment for deep vein thrombosis (DVT). We analyzed the efficacy and feasibility of retrievable IVC filter placement for the preventive management of embolic shedding during catheter-directed thrombectomy (CDT) for DVT of lower extremity. Seventy patients (35 males and 35 females) who underwent retrievable IVC filter placement to prevent thrombus dislodgement during CDT in all symptomatic DVT with thrombus age suspected within 4weeks of the lower extremity between March 2008 and January 2014 were included in this study. All patients underwent laboratory blood study, duplex ultrasound and/or computed tomography for diagnosis, treatment, and follow-up in accordance with treatment policy of our Uijeongbu St. Mary's hospital. Two types of retrievable IVC filters (OptEase Filter, Cordis, Roden, The Netherlands; Gunther Tulip Filter, Cook, Bloomington, IN) were usedto prevent thromboembolic events during CDT. After filter placement, subcutaneous low-molecular-weight heparin and overlapped to warfarin or new oral anticoagulant tried to achieve a target international normalized ratio (INR) of 2.0-3.0 in warfarin patients. The thrombus was dislodged through the IVC filter during catheter-directed thrombolytic therapy in 22 patients (31.4%). In 22 cases, the thromboses were trapped by the retrievable IVC filter, and follow-up images showed thrombus capture. Thirty-four patients (48.6%) received percutaneous transluminal angioplasty (PTA). Additional stents were inserted in 23 patients (32.8%). Pulmonary embolism (PE) was not observed in patients implanted with retrievable IVC filters. Our study findings suggest that retrieval IVC filter placement during interventional treatments of DVT of lower extremity such as thrombectomy of vein thrombus with or without stent insertion at compressed deep vein is favorable and effective for protecting against PE or lethal complications. We recommend carefully that before the management of DVT thrombus of lower extremity, retrieval IVC filter placement should be considered for preventing morbidity related with the PE.

GW26-e2507 The Effect of Catheter-directed Thrombolysis with Low-dose Urokinase on Acute Lower Extremity limb Ischemia

To evaluate the safety and effectiveness of catheter-directed thrombolysis therapy with low-dose urokinase for acute lower extremity ischemia limb. Retrospective analysis of clinical data of 50 cases, including 27 males and 23 females, aged 27-81 years old, the onset time of 10 hours to 14 days,

Comparative Outcomes of Catheter-Directed Thrombolysis Plus Anticoagulation Versus Anticoagulation Alone in the Treatment of Inferior Vena Caval Thrombosis

While there has been a steady increase in the use of catheter-directed thrombolytic therapy in treatment of patients with inferior vena cava (IVC) thrombosis, there has been no significant difference in mortality between CDT vs anticoagulation alone, but bleeding events and resource utilization are higher in the CDT group.

Long-Term Results of Catheter-Directed Thrombolysis Combined with Iliac Vein Stenting for Iliofemoral Deep Vein Thrombosis.

Purpose:We were going to access the effect of catheter-directed thrombolytic therapy (CDT) on post-thrombotic syndrome (PTS) and the long term effects of iliac vein stenting in acute iliofemoral deep vein thrombosis (IFDVT).Materials and Methods:Fifty-six limbs in fifty-one patients (46 unilateral, 5 bilateral) were included from November 2001 through December 2007. Patients were classified based on the method of treatment: with stent implantation (n=37) and without stent implantation (n=19). The Villalta scale was chosen to assess for severity of PTS. The validated outcome measures were compared between the treatment groups. Statistical analysis was estimated according to the Kaplan-Meier test and Pearson chi-square test.Results:Mean age was 57±13 years (range, 27–76 years). Mean follow up duration was 56±12 months (range, 24–144 months). Overall 5-year primary patency rate was 66.1% (77.8% in the stenting group and 42.1% in the non-stenting group) and showed statistically significant difference between the two groups (P=0.02). The recurrence rate of deep vein thrombosis was 10/37 (27.1%) in the stenting group and 11/19 (57.9%) in the non-stenting group, respectively, which showed statistically significant difference between the two groups (P=0.024). Overall incidence of mild PTS was 8/30 (26.7%): 4/13 (30.8%) in the stenting group and 4/17 (23.5%) in the non-stenting group. None of the other factors showed statistically significant difference between the groups.Conclusion:Long term results of CDT in IFDVT were acceptable, and stent implantation to the iliac segment seems to have a good effect on the long term results. Therefore CDT with simultaneous stenting is recommended to improve long term results of IFDVT, if indicated.

Catheter-directed thrombolysis plus anticoagulation versus anticoagulation alone in the treatment of proximal deep vein thrombosis - a meta-analysis.

The aim of this meta-analysis was to compare the clinical outcomes of catheter-directed thrombolysis (CDT) plus anticoagulation with anticoagulation alone in patients with lower-extremity proximal deep vein thrombosis (DVT). We systematically searched Pubmed, Embase, and the Cochrane Library from inception to October, 2014. All randomized controlled trials (RCTs) and non-randomized studies comparing the clinical outcomes between additional CDT and anticoagulation alone were included. The primary outcomes were postthrombotic syndrome and major bleeding complications. The secondary outcomes included the iliofemoral patency rate, deep venous function, mortality, pulmonary embolism, and recurrent DVT. Three RCTs and 3 non-randomized studies were included. Compared with standard anticoagulation treatment, additional CDT was associated with a significantly higher rate of complete lysis within 30 days (OR = 91; 95 % CI 19.28 to 429.46), a higher rate of 6-month patency (OR = 5.77; 95 % CI 1.99 to 16.73), a lower rate of postthrombotic syndrome (OR = 0.4; 95 % CI 0.19 to 0.96), and a lower rate of venous obstruction (OR = 0.20; 95 % CI 0.09 to 0.44). More major bleeding episodes occurred in the CDT group (Peto OR 2.0; 95 % CI 1.62 to 2.62). CDT was not found to reduce mortality, pulmonary embolism, or recurrent DVT. Additional CDT therapy appeared to be more effective than standard anticoagulation treatment in improving the venous patency and preventing venous obstruction and postthrombotic syndrome. Caution should be taken when performing CDT given the increased risk of major bleeding. However, no evidence supported benefits of CDT in reducing mortality, recurrent DVT, or pulmonary embolism.

Dimerized plasmin fragment D as a potential biomarker to predict successful catheter-directed thrombolysis therapy in acute deep vein thrombosis.

The value of dimerized plasmin fragment D in the clinical monitoring during the catheter-directed thrombolysis in patients with acute deep vein thrombosis is not known. Dimerized plasmin fragment D levels in 24 patients with acute deep vein thrombosis undergoing catheter-directed thrombolysis were prospectively evaluated. The plasma dimerized plasmin fragment D level was measured serially before and at every 12 h during catheter-directed thrombolysis for 24 h. Technical success was defined as restoration of patency and flow with less than 50% residual thrombus by surveillance rotational venography. Technical success was achieved in 79.2% (19 of 24) of the treated limbs after catheter-directed thrombolysis. In univariate analysis, there was significant elevation of the dimerized plasmin fragment D at 12th h after starting the catheter-directed thrombolysis (P < 0.05) in patients with less than 50% residual thrombus stenosis. The optimal cut-off value of dimerized plasmin fragment D to predict successful catheter-directed thrombolysis was determined as 18.4 µg/ml at the 12th h after starting the catheter-directed thrombolysis with sensitivity 0.8 and specificity 0.8 (P = 0.03). It was further validated in multivariate logistic regression analysis (odds ratio: 14.38; 95% CI: 1.22-169.20; P = 0.03). Catheter-directed thrombolysis is safe and effective for restoration of blood flow in patients with acute deep vein thrombosis. Dimerized plasmin fragment D value greater than 18.4 µg/ml at the 12th h after starting catheter-directed thrombolysis had a high predictive rate of greater than 50% lysis at the end of catheter-directed thrombolysis.

Acute superior mesenteric venous thrombosis: transcatheter thrombolysis and aspiration thrombectomy therapy by combined route of superior mesenteric vein and artery in eight patients.

To assess the feasibility, effectiveness, and safety of catheter-directed thrombolysis and aspiration thrombectomy therapy by combined route of superior mesenteric vein and artery (SMV+SMA) for acute superior mesenteric venous thrombosis (ASMVT). This retrospective study reviewed eight ASMVT patients with transcatheter direct thrombolysis and aspiration thrombectomy therapy via SMV and indirect thrombolysis via SMA during a period of 14 months. The demographics, etiology, risk factors, therapeutic effect, complications, mortality, and follow-up of the study population were assessed. Anatomic and imaging classification of location and extent of thrombus at diagnosis and degree of thrombus lysis were described. Technical success was achieved with substantial improvement in symptoms and thrombus resolution after thrombolytic therapy in all patients. The local urokinase infusion by SMA and SMV was performed for 5-7 (6.13 ± 0.83) and 7-15 (12 ± 2.51) days. Anticoagulation was performed catheter-directed and then orally throughout hospitalization and after discharge. Four patients required delayed localized bowel resection after thrombolytic therapy with no death. Thrombolytic therapy was not interrupted despite minor bleeding at the puncture site in two patients and sepsis in another two postoperatively. Nearly complete removal of thrombus was demonstrated by contrast-enhanced CT scan and portography before discharge. Patients were discharged in 10-27 (19.25 ± 4.89) days after admission. No recurrence developed during the follow-up of 10-13 (12.13 ± 0.99) months. Catheter-directed thrombolytic and aspiration therapy via SMV+SMA is beneficial for ASMVT in avoiding patient death, efficient resolving thrombus, rapid improving symptoms, reversing extensive intestinal ischemia, averting bowel resection, or localizing infarcted bowel segment and preventing short bowel syndrome.