Efficacy Of Catheter-directed Thrombolysis Research Articles

Catheter-Directed Thrombolysis in the Management of Thrombotic Peripheral Artery Occlusions-Acute and Mid-Term Clinical Outcomes.

Objectives: To evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) with the recombinant tissue plasminogen activator (rt-PA) in all patients with symptomatic peripheral artery disease in real world practice. Methods: Consecutive patients treated with CDT between January 2013 and December 2020 were included in this retrospective analysis. The primary endpoint was the rate of serious adverse events (SAEs) until discharge. Secondary endpoints included interventional success, predictors for SAEs, bleeding and reperfusion edema/compartment syndrome, limb salvage, and clinical outcomes including target lesion revascularization rate (TLR). Results: Overall, 1238 patients were treated with CDT. SAEs occurred in 511 (41.3%) of the patients, 314 (25.4%) being bleeding complications. There were 95 cases of reperfusion edema/compartment syndrome. Forty-two patients underwent amputation and 33 patients (2.7%) died. CDT was successful in 1177 cases (95.1%). Multivariate logistic regression analysis identified age, abciximab and alprostadil usage, and lysis duration as predictors for SAEs and the use of abciximab as a predictor of reperfusion edema/compartment syndrome. Predictors for bleeding were age, alprostadil usage, and lysis duration. At 12 and 24 months, the limb salvage rate was 91.6% and 88.8%, and TLR rate was 46% and 57.2%, respectively. Conclusions: CDT is an effective endovascular method for the treatment of thrombotic peripheral artery occlusions but is associated with a high complication rate. For SAEs in general and bleeding specifically, increasing age, alprostadil use, and lysis duration were independent risk factors.

Comparative Study of Two Different Access Points, One Tibial Vein and the Popliteal Vein, for Catheter-Directed Thrombolysis in the Treatment of Acute Mixed Lower Extremity Deep Vein Thrombosis

Although the popliteal vein approach is commonly used for catheter-directed thrombolysis (CDT) treatment in patients with acute lower extremity deep vein thrombosis (DVT), CDT via a new access route, the posterior tibial vein, is also used and has demonstrated good results. However, this tibial approach has not been tested in large samples. In this article, we compare the early efficacy of CDT using the tibial and popliteal vein approaches for the treatment of acute mixed lower extremity DVT. In this retrospective cohort study, 87 patients with acute mixed lower extremity DVT treated at the Department of Interventional Medicine of Zhuhai People's Hospital were enrolled; those with tibial vein access and popliteal vein access were included in the observation (n=55) and control (n=32) groups, respectively. The safety and efficacy of CDT via tibial vein access were investigated by collecting and comparing indicators such as venous patency, thrombus removal effect, thigh and calf circumference difference, swelling reduction rate of the affected limb, surgical complications, and postdischarge complication rate of the patients in the 2 groups. The postoperative thrombus clearance effect of the observation group was significantly better than that of the control group (P<0.05), and the postoperative venous patency rate of the observation group was 83.2±15.7%, which was higher than that of the control group (62.2±38.2%) (P=0.005). The swelling reduction rate of the lower extremity was 74.0±33.8% in the observation group and 51.4±30.0% in the control group, with a statistically significant difference (P=0.002). However, there was no statistically significant difference (P>0.05) in the rates of thigh swelling reduction, bleeding-related complications, or postoperative complications between the 2 groups of patients. CDT via the tibial vein approach is safe, effective, and may be a better approach for CDT access, offering superior thrombus clearance, venous patency, and lower extremity swelling reduction postoperatively.

Ultrasound Combined With Continuous Microbubble Injection to Enhance Catheter-Directed Thrombolysis in Vitro and in Vivo.

To investigate the influence of microbubble perfusion mode on catheter-directed thrombolysis (CDT), we evaluated the effect of two different types of microbubble perfusion modes (continuous injection versus bolus injection) on the thrombolytic efficacy of CDT in vitro and further assessed the effect of continuous microbubble injection on CDT in vivo. In an in vitro experimental setup, 50 fresh bovine whole blood clots were randomized into five groups: ultrasound and continuous microbubble injection-enhanced CDT (US + cMB + CDT), ultrasound and bolus microbubble injection-enhanced CDT (US + bMB + CDT), US + CDT, US + cMB, and CDT. In a porcine femoral vein thrombosis model, 16 completely obstructive thrombi were randomly assigned to the CDT group and the US + cMB + CDT group, respectively. Thrombolysis rate, vascular recanalization rate, hematoxylin-eosin, and immunofluorescence staining were used to evaluate the thrombolytic effect in vitro and in vivo. In vitro, US + cMB + CDT group resulted in a significantly higher thrombolysis rate compared with the other four groups (P < .05). Meanwhile, this group also demonstrated a looser clot structure and more disrupted fibrin structures. In vivo, US + cMB + CDT contributed to a significantly higher vascular recanalization rate compared with CDT (87.50% versus 25.00%, P < .05). US + cMB + CDT was more effective than US + bMB + CDT in thrombolysis, and ultrasound combined with continuous microbubble injection could enhance the thrombolytic efficacy of CDT.

Outcomes of catheter-directed thrombolysis versus systemic thrombolysis in the treatment of pulmonary embolism: a meta-analysis.

To evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) versus systemic thrombolysis (ST) in the treatment of pulmonary embolism (PE). The Cochrane Library, PubMed, and Embase databases were searched to collect the literature on the comparison of the results of CDT and ST in the treatment of PE from the beginning of their records to May 2020, and meta-analysis was performed by STATA software (version 15.1). Using standardized data-collection forms, the authors screened the studies and independently extracted data, and assessed the quality of the studies using the Newcastle-Ottawa Scale for cohort studies. Cohort studies that examined the following results were included in the current study: in-hospital mortality, all-cause bleeding rate, gastrointestinal bleeding rate, intracranial hemorrhage rate, the incidence of shock, and hospital length of stay. A total of eight articles, with 13,242 participants, involving 3962 participants in the CDT group and 9280 participants in the ST group were included. CDT compared with ST in the treatment of PE can significantly affect in-hospital mortality rate [odds ratio (OR) = 0.41, 95% CI: 0.30-0.56, P < 0.05], all-cause bleeding rate (OR = 1.20, 95% CI: 1.04-1.39, P = 0.012), gastrointestinal bleeding rate (OR = 1.43, 95% CI: 1.13-1.81, P = 0.003), the incidence of shock (OR = 0.46, 95% CI: 0.37-0.57, P < 0.05), and hospital length of stay [standard mean difference (SMD) = 0.16, 95% CI: 0.07-0.25, P < 0.05]. However, there was no significant effect on intracranial hemorrhage rate in patients with PE (OR = 0.70, 95% CI: 0.47-1.03, P = 0.070). CDT is a viable alternative to ST in the treatment of PE, as it can significantly reduce in-hospital mortality rate, all-cause bleeding rate, gastrointestinal bleeding rate, and incidence of shock. However, CDT may prolong hospital length of stay to a certain extent. Further research is needed to evaluate the safety and efficacy of CDT and ST in the treatment of acute PE and other clinical outcomes.

Abstract No. 274 Cost analysis of ultrasound-enhanced catheter use in the treatment of pulmonary embolism

Pulmonary embolism (PE) is a common form of venous thromboembolism, which causes around 300,000-600,000 deaths every year in the US. Currently, there are a variety of methods to treat pulmonary embolism, including pharmacological, procedural, and surgical interventions. With the emergence of novel technology, physicians are able to utilize techniques such as catheter-directed thrombolysis (CDT) and ultrasound-accelerated thrombolysis (USAT) to treat PE. While literature exists on the safety and efficacy of CDT and USAT, little research has been published on the cost-effectiveness of the two interventions.

Abstract 14165: Ultrasound-Accelerated Thrombolysis May Be the Preferred Catheter-Based Lytic Therapy for Pulmonary Embolism

Introduction: Pulmonary embolism (PE) is estimated to cause 100,000 deaths annually in the US. Systemic use of fibrinolytic drugs carries risks of significant bleeding. Catheter directed thrombolysis (CDT) delivers thrombolytic drugs directly to the site of the clot and in lower doses which may improve its safety profile. We aimed to investigate the safety and efficacy of CDT in intermediate risk PE and contemporary trends of follow-up cardiac testing in these patients. Methods: 75 patients who underwent CDT for intermediate risk PE at a single center from 2014-2021 were studied retrospectively. Outcomes included procedure related complications and mortality. Continuous variables are presented as mean±SD, categorical variables as percentages. Logistic regression and survival analysis was used. Data was analyzed in Stata/BE 17.0. Results: Demographics (Table 1), lab and imaging data (Table 2) were assessed for 75 patients. Troponin and BNP were elevated in 63.5% and 60% respectively. RV dilation was present in 86.7%. Ultrasound accelerated thrombolysis (EKOS) was performed in 80% and standard CDT in 20%. One procedural complication occurred, a patient undergoing standard CDT suffered a cardiac arrest and died. Major bleeding occurred in four patients but did not contribute to mortality. Mortality at 30 days and one year were 6.8% (5/73) and 13% (9/69) respectively. Only three deaths were attributed to cardiovascular causes. Those who underwent EKOS had 85.6% lower odds of death in 30 days (OR 0.14 (0.03-0.79), p=0.02) compared to CDT; however, our results are limited by a small sample size. Follow up imaging was assessed at 1 year (Table 3). Echo was most frequently performed in 45.3% of patients. Conclusions: EKOS for intermediate risk PE is a safe procedure with no procedural mortalities in our study. As follow up was poor, with less than 50% of the cohort receiving imaging, future directions should be aimed at ensuring these patients are monitored for long-term sequelae of PE.

Outcomes and Risk Factors Associated with Thrombosis Recurrence and Post-Thrombotic Syndrome in Children and Adolescents with May-Thurner Syndrome

Introduction : May-Thurner syndrome (MTS) is a condition in which the right iliac artery compresses the left iliac vein, predisposing affected individuals to venous outflow obstruction and deep vein thrombosis (DVT). Despite the frequency of this anatomic variant, found in 20-25% of adults, not everyone with this variant will develop a DVT. Adults with MTS are treated with catheter-directed thrombolysis (CDT), anticoagulation, and often iliac vein stent placement. There is no standard of care established for pediatric MTS patients. The aims of this study are to 1) describe risk factors, clinical factors, and outcomes (complications of CDT, recurrence rate, post-thrombotic syndrome) in a pediatric MTS cohort and 2) determine what factors are associated with thrombus resolution, recurrence, and development of post-thrombotic syndrome (PTS).Methods : A retrospective cohort of children (0-21 years) diagnosed with MTS and DVT were identified between January 1, 2012 and July 15, 2017. MTS was confirmed by CT venogram, MR venogram, intravascular ultrasound, and/or conventional endovascular venography. Patient demographic, clinical, and thrombophilic risk factors, clinical outcomes (resolution, recurrence, PTS using modified Villalta scale), and bleeding complications were abstracted from review of the electronic medical record. Bleeding complications were defined by ISTH definitions for pediatric trials. Student's t test, Wilcoxon rank sum test, Chi square test and logistic regression analysis were used for statistical analysis (SAS v9.4, Cary, NC, USA).Results : The cohort was comprised of 23 subjects, 65% of them female (n=15), with a median age at presentation of 16.1 years (9.9-19.7 years). The median follow-up time was 505 days. The most frequent risk factor was thrombophilia (n=10), which included Factor V Leiden mutation (n=6), antithrombin deficiency (n=3), protein S deficiency (n=3), lupus anticoagulant (n=3), prothrombin gene mutation (n=1), protein C deficiency (n=1), or more than one thrombophilia (n=3). Other risk factors included hormone therapy (n=8), obesity (n=7), family history of DVT (n=6), immobility (n=5), central line (n=2), lupus (n=1), pregnancy (n=1), trauma (n=1), surgery (n=1), nephrotic syndrome (n=1), and retroperitoneal fibrosis (n=1). One subject had no risk factor, while 14 (61%) had multiple risk factors. Among the subjects, 78% underwent CDT (n=18) and 83% had stent placement (n=19). The remaining subjects will have future stent placement. Following CDT, there were no major bleeding complications (1 minor and 1 clinically relevant non-major bleeding complication). Other complications included pain (n=8), hemolysis (n=7), hemoglobinuria (n=2), hypofibrinogenemia requiring cryoprecipitate infusion (n=2), and transient increase in creatinine (n=1). Primary patency, defined as >90% patency of vessel diameter in the first week after CDT, was achieved in 91% (n=21). Thrombosis resolution was seen in 91% (n=21) of the cohort. Anticoagulant treatment prescribed included enoxaparin (65%), rivaroxaban (30%) and warfarin (26%). In univariate analyses, the only factor associated with thrombus resolution was primary patency (p=0.0012). DVT recurred in 13% (n=3), with a median time of 32 days off anticoagulation. The only factor associated with recurrence was antithrombin deficiency (p=0.048). Ten subjects (43%) had no evidence of PTS and 13 had mild PTS (57%). There were no significant factors associated with the development of PTS.Conclusions : To our knowledge, this is the largest retrospective cohort of pediatric subjects with MTS and DVT. Underlying thrombophilia was the most common risk factor found, suggesting that patients diagnosed with MTS warrant thrombophilia evaluation. Bleeding complications associated with CDT were minimal and non-bleeding complications were transient, demonstrating that CDT is safe in the pediatric population. Efficacy of CDT in this population is supported by the finding that primary patency is an important factor for thrombosis resolution. Lastly, thrombosis recurrence was not uncommon (13%) and was likely to occur soon after stopping anticoagulation. These findings demonstrate that multicenter studies are needed in children with MTS to evaluate the efficacy of CDT to achieve thrombus resolution, and that evaluation of thrombophilic risk factors should be considered. DisclosuresNo relevant conflicts of interest to declare.

The plasma D-dimer trends and their value in acute lower limb ischemia patients treated by catheter directed thrombolysis

To investigate the change trends of plasma D-dimer during catheter-directed thrombolysis (CDT) in acute lower limb ischemia (ALI) patients and their clinical value. A retrospective review of patients with ALI who received CDT was carried out. The repeated measurements of plasma D-dimer were analyzed by generalized estimating equations (GEEs) and the change trends of D-dimer were analyzed by spline regression approach. A total of 150 patients were included. Among them, 3 days of CDT was ineffective in 41 cases, effective in 33 cases and markedly effective in 76 cases. The results of GEEs analysis showed that serum D-dimer changed significantly with time (time effect, P < 0.001). Serum D-dimer levels of patients with different treatment outcomes were different after treatment (group effect, P < 0.001), and serum D-dimer levels in these three groups showed different trends over time (group*time effect, P < 0.001). The different trends in serum D-dimer level with time after treatment in the three groups could be directly seen in the spline regression curve (P < 0.001). The plasma D-dimer changes regularly during CDT for ALI. We can predict the efficacy of CDT and guide adjustments of the therapeutic regimen according to the trend of D-dimer changes during thrombolysis.

Outcome of catheter directed thrombolysis for popliteal or infrapopliteal acute arterial occlusion.

Management of acute limb ischemia (ALI) due to occlusions in popliteal and infrapopliteal arteries remains a challenge. Open surgical methods and even the novel percutaneous mechanical thrombectomy devices have not shown satisfactory results in these small arteries. The aim of this prospective study was to assess the safety and efficacy of catheter-directed thrombolysis (CDT) in this type of ALI with distal occlusion. Between April 2017 and June 2019, 22 patients with ALI secondary to popliteal or infrapopliteal occlusion were enrolled in the study. Patients with thrombosis, embolism, and thrombosed bypass graft were included; all belong to category I or IIa of Rutherford's classification. Technical success, limb salvage, complications, and mortality were evaluated at short- and long-term follow-up. Technical success was achieved in 81.8%, while 36.4% of patients needed additional balloon angioplasty, major amputation in 13.6%, minor bleeding in 18.2%, andno major hemorrhage. Limb salvage at 30days and 1year was 86.4% and 72.7%, respectively. At 1year, primary patency was 63.6% and mortality was 9.1%. Catheter directed thrombolysis is a safe and highly effective treatment modality for popliteal or infrapopliteal acute limb ischemia unless contraindicated.

Evaluation of Percutaneous Mechanical Thrombectomy via the AngioJet System Combined with Catheter-Directed Thrombolysis for the Treatment of Symptomatic Lower Extremity Deep Venous Thrombosis

Current methods of treating lower extremity deep venous thrombosis (LEDVT), such as catheter-directed thrombolysis (CDT) alone, or percutaneous mechanical thrombectomy (PMT) alone, are accompanied by unacceptably high risks of complications. This preliminary retrospective study evaluated the efficacy of CDT combined with PMT (via the AngioJet system), relative to CDT alone, in treating LEDVT. Forty-two patients (43 limbs) with symptomatic deep venous thrombosis received either CDT alone (n=12) or PMT combined with CDT (PMT+CDT) from May 2012 to December 2016. The groups were compared for clinical outcomes and demographics, LEDVT risk factors, and dosages of urokinase. Thrombus removal, by venographic evidence, was classified as grades I (<50%), II (50 to 99%), or III (>99%). In the CDT (PMT+CDT) cohorts, grades I, II, and III thrombus removal was achieved by 8% (3%), 17% (10%), and 75% (87%) of patients, respectively. The urokinase dosage and hospitalization required by the CDT group (5.29±0.45 million IU, 20.4±4.6days) were significantly greater than those required by the PMT+CDT group (4.08±1.15 million IU, 16.0±6.0days; P=0.001, 0.039). The clinical outcomes of the 2 groups were similar. Combined PMT and CDT was effective and safe for LEDVT clinical therapy, and hospital stay, urokinase dosage, and complications were less compared with patients who received CDT only.

Catheter Directed Thrombolytic Therapy for Pediatric Cerebral Sinus Vein Thrombosis

Background: Cerebral sinus vein thrombosis (CSVT) involves the thrombosis of the dural sinus and/or cerebral veins and it is considered a form of stroke. The estimated incidence of CSVT in children is 0.6 per 100,000 children per year. Poor outcomes, including death, happen in 9 to 29% of patients affected by CSVT. In addition, neurologic deficits, affecting primarily cognition and behavior, are seen in 50% of affected children. No randomized clinical trials have been conducted on pediatric CSVT so current guidelines for treatment have been extrapolated primarily from adult studies. Published guidelines by the American College of Chest Physicians, American Heart Association and American Society of Hematology, support the use of anticoagulation with unfractionated heparin (UFH) or low molecular weight heparin (LMWH). These same guidelines also suggest that catheter directed thrombolysis (CDT) with tissue plasminogen activator (tPA) and mechanical thrombectomy (MT) could be used when there has been clinical deterioration or no improvement (clot progression) despite anticoagulation. In all cases, these are based on uncontrolled case series and expert opinion. There is very little data on the safety and efficacy of CDT and/or MT for pediatric CSVT. Method: Pediatric patients with CSVT seen at Cook Children's Medical Center from January 1, 2008 to December 31, 2018 were identified by searching EMR using ICD-9 and ICD-10 codes. From this group, patients treated with MT and CDT in addition to anticoagulation were selected and reviewed. Results: Five children (4 to 14 y/o) were treated with MT and CDT after failing anticoagulation with UFH or LMWH. Diagnosis was made by MRI/MRV and all had CSVT of multiple sinuses. Four patients had more than one underlying disorders/factors that increased their risk for thrombosis including: Ulcerative Colitis in 2, severe anemia in 2, Systemic Lupus Erythematosus (SLE) in 1, use of oral contraceptives together with obesity and bacterial sepsis in 1. Two patients did have a thrombophilia: Protein S deficiency in 1 and Protein S and C deficiency in another. One patient with SLE had a positive hexagonal phase neutralization test but rest of evaluation was negative. Three patients had systemic bleeding prior initiation of UFH and MT/CDT. All children were treated with UFH, and due to clinical neurologic deterioration and/or worsening of imaging findings (4 comatose and 1 with persistent increased ICP), all underwent thromboaspiration and catheter directed infusion of tPA for 17 to 48 hours at a dose of 1 to 2 mg/hr. All patients continued anticoagulation with UFH during catheter directed tPA infusion and after the catheter was removed. All cases had partial resolution of the sinus vein thrombosis, although 1 had quick reocclusion. Post procedure bleeding happened in 1 patient who had also had an external ventricular drainage placed and developed parenchymal and intraventricular hemorrhage that led to discontinuation of tPA infusion, and 2 patients developed petechial brain hemorrhages. Four patients had great neurologic recovery and minimal deficits, but 1 had significant neurologic deficits. One patient died from lupus complications. (Table) Conclusion: Endovascular therapy including MT and CDT with tPA in conjunction with systemic UFH, may have a role in pediatric patients with CSVT who have deterioration despite initial anticoagulation. In our series, after procedures, all patients had partial resolution of their CSVT (but 1 had quick reocclusion) and 4 out of 5 patients had good neurologic outcomes despite bad predictor signs (coma, extensive CSVT). Further studies are needed to identify which patients would benefit from early endovascular treatment. Table Disclosures No relevant conflicts of interest to declare.

Efficacy of Catheter-directed Thrombolysis on Post-burn Deep Venous Thrombosis of Lower Extremity.

To observe the clinical effect of catheter-directed thrombolysis on deep venous thrombosis (DVT) of lower extremity after burn. An observational study. Invasive Technology Department, Binzhou City Center Hospital, China, from January 2015 to November 2017. Eighty-two patients with lower extremity DVT after burn were selected as the study object. All patients received catheter-directed thrombolysis and the clinical efficacy was evaluated. The blood coagulation parameters including plasma prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), and fibrin original (FIB) and inflammatory response factors including interleukin (IL)-6, C-reactive protein (CRP) and D-dimer were compared before and after treatment. All interventional surgeries that the patients received were successful. The effective rate of catheter-directed thrombolysis was 98.78% (81 cases). After 6 days of treatment, compared with that before treatment, serum PT, APTT and TT were up-regulated (all p <0.001) and FIB was down-regulated (p <0.001). After 6 days of treatment, the levels of serum IL-6, CRP and D-dimer were lower than those before treatment (all p <0.001). No visceral hemorrhage occurred after 1 week of treatment. Catheter-directed thrombolysis of patients with lower extremity DVT after burn produces a good effect. It can improve the coagulation function and reduce the level of inflammatory response factors in patients with high safety.

Results of Catheter-Directed Thrombolysis for Acute Iliofemoral Deep Venous Thrombosis—A Retrospective Cohort Study

The efficacy of catheter-directed thrombolysis (CDT) in a small, retrospectively reviewed cohort of very young Danish patients demonstrated excellent results at 1-year follow-up, with a small percentage of patients developing post-thrombotic syndrome (PTS).

Catheter-Directed Thrombolysis for Portal Vein Thrombosis in Children: A Case Series

PurposeTo describe safety and efficacy of catheter-directed thrombolysis (CDT) for portal vein thrombosis (PVT) in children. Materials and MethodsRetrospective review was performed of 10 consecutive patients (7 girls, 3 boys; mean age 11.9 y; range, 3–17 y) with PVT undergoing CDT at a single tertiary children’s hospital between August 2005 and March 2016. PVT was categorized by etiology and extent (intrahepatic, extrahepatic, or both). CDT was performed with infusion catheters placed via percutaneous transhepatic (PTH) and/or transjugular intrahepatic (TJ) approaches, with or without the use of adjunctive maneuvers, including balloon maceration and suction and rheolytic thrombectomy. Degree of thrombolysis on portal venography, presence of portal vein thrombus on available follow-up imaging, and complication rates were recorded. ResultsIn 10 patients, 13 CDT procedures were performed for PVT, with 3 patients requiring repeat CDT. Portal access was achieved with PTH (n = 6), TJ (n = 2), or combined (n = 2) approaches. All cases were successful in re-establishing patency and hepatopetal flow on portal venography with complete thrombolysis achieved in 10 of 13 cases (77%). Two major complications (20%) occurred, both with PTH access. Mean follow-up time for 9 patients was 2.6 years (range, 51–1,902 d) with long-term patency achieved in 6 (67%). ConclusionsCDT can be safe and effective for PVT in children. Portal access considerations and early initiation of thrombolysis may further increase safety and efficacy.

A Blue Leg: An Interventional Approach to a Limb-Threatening Deep Vein Thrombosis

A Blue Leg: An Interventional Approach to a Limb-Threatening Deep Vein Thrombosis

Comparison of Low-Dose Catheter-Directed Thrombolysis with and without Pharmacomechanical Thrombectomy for Acute Lower Extremity Ischemia

Catheter-directed thrombolysis (CDT) and/or pharmacomechanical thrombectomy (PMT) can dissolve/remove thrombus; PMT alone, however, may require the adjunctive use of CDT. The aim of this study was to compare the use of CDT with and without PMT for the treatment of acute lower extremity ischemia (ALI). We retrospectively reviewed all patients with ALI who underwent CDT with or without PMT between January 2008 and April 2014 (n=99). Patients with incomplete medical charts were excluded (n=16). Remaining patients were divided into 2 cohorts: group 1 included patients who underwent PMT+CDT (n=54); group 2 included those who underwent CDT alone (n=29). Lesions were further characterized by anatomic location: iliac disease (n=14), femoropopliteal disease (n=53), tibial disease (n=2), and multilevel disease (n=14). Data collection included patient and limb characteristics, duration of treatment, complications, clinical outcomes, adjunctive interventions, and follow-up. No significant differences were seen between treatment groups in terms of patient characteristics, occlusion length and location, Rutherford class, median duration of ischemia time (P=0.22), or mean lysis time (P=0.58). Treatment groups were also similar with regard to outcomes, including periprocedure complications, patency, reintervention, limb salvage, and amputation-free survival. There was no different between PMT+CDT and CDT alone in terms of periprocedural complications or outcomes. In the quest to resolve ALI, initial thrombus extraction with PMT may not reduce the need, duration, or efficacy of CDT.

Safety of catheter-directed thrombolysis for massive and submassive pulmonary embolism: Results of a multicenter registry and meta-analysis.

To evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) in the treatment of acute pulmonary embolism (PE). The use of CDT for the treatment of acute submassive and massive PE is increasing in frequency. However, its safety and efficacy have not been well elucidated. This study is made of two parts: one is a two-center registry of acute PE patients treated with CDT. The safety outcome evaluated was any major complication including fatal, intracranial (ICH), intraocular, or retroperitoneal hemorrhage or any overt bleeding requiring transfusion or surgical repair. The efficacy outcome was acute change in invasive pulmonary artery systolic pressure (PASP). The second part is a meta-analysis of all contemporary studies that used CDT for PE. Reported outcomes are the same as in the registry, with the addition of right ventricular to left ventricular (RV/LV) ratio change. In the registry, 137 patients were included (age 59 ± 15, 50% male, 88% submassive PE). ICH occurred in two patients and major complications in 13 (9.4%). PASP decreased post procedure by 19 ± 15 mm Hg (95% CI 16-23). In the meta-analysis, 16 studies were included with 860 patients. Rate of ICH was 0.35% and the major complication rate was 4.65%, most requiring transfusion only. In-hospital mortality was 12.9% in the massive and 0.74% in the submassive group. All studies showed improvement in PASP and/or RV/LV ratio post CDT. CDT is associated with a low major complication rate. Randomized studies are needed to evaluate its efficacy relative to anticoagulation alone. © 2017 Wiley Periodicals, Inc.

Catheter-Directed Treatment of Pulmonary Embolism: A Systematic Review and Meta-Analysis of Modern Literature.

We summarize the evidence for the safety and efficacy of catheter-directed thrombolysis (CDT) with and without ultrasound-assisted therapy for treating submassive and massive pulmonary embolism (PE) in a systematic review. The primary efficacy outcome was mortality. Outcomes were pooled across studies with the random-effects model. Twenty-four studies enrolled 700 patients in total; 653 received mechanical thromboembolectomy treatments for PE (mortality rate, 9% [95% confidence interval (CI), 6%-13%], P = .12; rate of minor complications, 6% [95% CI, 2%-13%]). In the ultrasound-accelerated thrombolysis (USAT) studies, the mortality rate was 4% (95% CI, 1%-11%) and in the non-USAT studies, it was 9% (95% CI, 6%-13%). Secondary safety outcomes were all bleeding events, which occurred in 12% (95% CI, 7%-20%) of the USAT studies and in 10% (95% CI, 5%-20%) of the non-USAT studies. Current clinical evidence does not prove USAT is superior over CDT methods.

Эффективность катетер-направленного тромболизиса в лечении флеботромбозов

Эффективность катетер-направленного тромболизиса в лечении флеботромбозов

Safety and Efficacy of Catheter-directed Thrombolysis

To describe the background for--and mechanism of--catheter-directed thrombolysis (CDT) for iliofemoral deep venous thrombosis (DVT) accessed via the popliteal vein. Focus is on safety and efficacy. From the Copenhagen experience we have looked into the systematically registrated risk factors, peri- and postprocedure complications for patients consecutively treated from 1999 to 2006. The patients were treated in a clinical ward. The patients were followed yearly with ultrasonography for assessment of patency and valve function. Inclusion and exclusion criteria have been published earlier. A total of 89 patients with 91 extremities with iliofemoral DVT were included (70 women and 19 men, mean age 29 years [range 14-59]). Only 11% of the patients were without any risk factor for DVT. CDT was performed without mortality and pulmonary embolism. Major bleeding occurred in two patients and minor bleeding in 27 patients, mostly from the puncture site. Stenting was necessary in 54 limbs. Five stents revealed occlusion, three procedural (2 reopened) and two late. The median follow-up was 87 months (range 17-148). At six years, 86% had competent iliofemoral (and popliteal) vein segment. CDT of iliofemoral DVT is a safe procedure. The patients can stay in a clinical vascular ward. The long-term efficacy is still durable in producing competent veins as concluded in our earlier published results.