Intrathrombus Thrombolysis Research Articles

Design and rationale of the ATTRACTIVE trial: a randomised trial of intrAThrombus Thrombolysis versus aspiRAtion thrombeCTomy during prImary percutaneous coronary interVEntion in ST-segment elevation myocardial infarction patients with high thrombus burden

IntroductionST-segment elevation myocardial infarction (STEMI) with high thrombus burden is associated with a poor prognosis. Manual aspiration thrombectomy reduces coronary vessel distal embolisation, improves microvascular perfusion and reduces cardiovascular deaths,...

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

Tratamiento recanalizador de las trombosis venosas del sector iliofemoral

Patients with DVT affecting the iliac veins develop a more severe post-thrombotic syndrome. This has been traditionally treated with anticoagulation alone, based on outdated experiences.Contemporary venous thrombectomy, intrathrombus thrombolysis, and pharmaco-mechanical thrombolysis can be offered with increasing safety.Thrombus removal offers better long-term outcomes than anticoagulation alone.In the literature, including our own experience, venous stenting techniques have zero mortality and low complication rates. In stenosis or thrombotic stent occlusions it is almost zero. Patency is almost 100% in non-post thrombotic lesions, 74-89% in post-thrombotic non-occlusive lesions, and 66-90% in chronic occlusions.In patients with iliofemoral DVT without contraindication, thrombus removal should be attempted.Surgical thrombectomy should be considered when lytic therapy is contraindicated, and in phlegmasia.Thrombolytic therapy, mechanical thrombectomy, and angioplasty and stenting are the treatments of choice of iliac vein DVT. They are safe and can be performed with high long-term patency rates, especially if used in the acute phase.

Short-term results of catheter-directed intrathrombus thrombolysis versus anticoagulation in acute proximal deep vein thrombosis

BackgroundDeep vein thrombosis (DVT) is a potentially progressive disease with complex clinical sequelae. The clinical practice guidelines of the American College of Chest Physicians (ACCP) recommend various treatments for all patients with objectively proven DVT. This study retrospectively compares enoxaparin with CDT on treatment efficacy and safety and the evolution of acute proximal DVT in the lower limbs. MethodsThis study comprised 53 patients with acute proximal DVT, who received either CDT followed by intravenous unfractionated heparin (UFH) or adjusted subcutaneous low-molecular-weight heparin (LMWH) (enoxaparin) for 7–14 days. Warfarin was administered to all patients for at least 6 months. The study endpoints included the evolution of DVT and treatment efficacy and safety, which were assessed with frequent duplex ultrasounds, plethysmography, and venography. The mean duration of the follow-up was 15.2 months. ResultsIn the CDT group, patency of the iliofemoral vein segment was observed in 42.3% of the patients after 1 week (p < 0.001) and in 69.2% after 6 months. In the control group, patency was present in 15.4% of the patients after 3 months and in 38.5% after 6 months (p = 0.05). Femoral venous obstruction was found in 30.8% of CDT patients and in 61.5% of the control group (p = 0.05). Furthermore, femoral venous insufficiency was present in 46.2% of the CDT group and 53.9% of the control group after 6 months (p = 0.587). After 12 months, post-thrombotic syndrome (PTS) was found in 19.2% of the CDT patients compared to 50% of the LMWH group (p = 0.04). ConclusionDuplex ultrasound analysis of thrombus progression is useful for assessing the treatment of a patient with acute proximal DVT. In this study, patients undergoing CDT experienced higher thrombus resolution and early recanalization of their veins, which may preserve venous function and further prevent development of post-thrombotic syndrome.

Natriuretic peptide type-B can be a marker of reperfusion in patients with pulmonary thromboembolism subjected to invasive treatment

This study was intended to investigate changes in cardiac biomarkers and pulmonary hemodynamic effects of invasive treatment in patients with intermediate-risk (hemodynamic stability with evidence of right ventricle dysfunction and/or myocardial injury) pulmonary embolism. Also, to also evaluate if natriuretic peptide type-B (NT-proBNP) plasma levels are associated with right ventricle function and pulmonary arterial pressures. Interventional study: Fourteen normotensive adult patients with acute and radiologically massive pulmonary embolism plus positive biomarkers and evidences of right ventricle dysfunction underwent invasive pulmonary angiography for invasive treatment consisting on mechanical thrombus fragmentation and catheter-directed intrathrombus thrombolysis. Angiography was repeated after 12-24 h to reevaluate perfusion status. Plasma biomarkers were monitored before and 8-h after intervention. Biomarkers were initially elevated in all patients. Eleven patients (78.6%) exhibited significant angiographic reperfusion. NT-proBNP and mean pulmonary arterial pressure decreased significantly in all of them [3693 (1803, 8862) to 1951 (1309, 7918) pg/ml; P = 0.008) and 40.0 (24.0, 46.0) to 22.0 (14.0, 27.0) mmHg; P = 0.003, respectively]. No significant variation was observed in troponin-T levels. In patients with high-risk pulmonary embolism, NT-proBNP plasma levels experience rapid and significant reduction after successful invasive treatment. In pulmonary embolism, serial measurements of NT-proBNP could be useful as a tracking tool to assess the success or failure of the thrombolytic treatment.

Recanalization of an Occluded Intrahepatic Portosystemic Covered Stent via the Percutaneous Transhepatic Approach

A 41-year-old woman with liver cirrhosis had recurrent portal hypertension and bleeding from esophageal varices due to complete occlusion of a previously inserted transjugular intrahepatic portosystemic shunt stent. Because recanalization of the stent by the transjugular approach was unsuccessful, ultrasound-guided entry to the splenic vein and portal vein was used. After catheter-directed intrathrombus thrombolysis, successful opening of the stent was achieved and a stent was placed. We herein report a rare case in which thrombolysis and recanalization of a TIPS stent were performed via a percutaneous transhepatic approach.

Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal

Suresh Vedantham, MD, Akhilesh K. Sista, MD, Seth J. Klein, MD, Lina Nayak, MD, Mahmood K. Razavi, MD, Sanjeeva P. Kalva, MD, Wael E. Saad, MD, Sean R. Dariushnia, MD, Drew M. Caplin, MD, Christine P. Chao, MD, Suvranu Ganguli, MD, T. Gregory Walker, MD, and Boris Nikolic, MD, MBA, for the Society of Interventional Radiology and Cardiovascular and Interventional Radiological Society of Europe Standards of Practice Committees

Society of Interventional Radiology Position Statement: Treatment of Acute Iliofemoral Deep Vein Thrombosis with Use of Adjunctive Catheter-directed Intrathrombus Thrombolysis

THE Society of Interventional Radiology (SIR) considers the use of catheterdirected intrathrombus thrombolysis (CDT) as an adjunct to anticoagulant therapy to represent an acceptable initial treatment strategy for carefully selected patients with acute iliofemoral deep vein thrombosis (DVT). The SIR defines acute iliofemoral DVT as complete or partial thrombosis of any part of the iliac vein and/or the common femoral vein with or without associated femoropopliteal DVT, in which symptoms have been present for 14 days or less or for which imaging studies indicate that venous thrombosis has occurred within the past 14 days (1).

Development of catheter-directed intrathrombus thrombolysis with plasmin for the treatment of acute lower extremity arterial occlusion

Catheter-directed thrombolysis is an important treatment option for many patients with acute lower extremity ischemia due to arterial and/or graft thrombosis. A growing body of evidence demonstrates that thrombolytic therapy for acute limb ischemia reduces the need for amputation; however, bleeding complications are more likely with lytic therapy. New direct-acting fibrinolytic compounds are being developed that facilitate thrombolysis while reducing the risk of bleeding. Plasmin, the active enzyme produced by all plasminogen activators, works directly upon thrombus and is neutralized instantly in the systemic circulation. This report reviews the principles for effective catheter directed thrombolysis for acute arterial occlusions and describes the development and evaluation of the new thrombolytic, plasmin.

Manual Aspiration Thrombectomy with Stent Placement: Rapid and Effective Treatment for Phlegmasia Cerulea Dolens with Impending Venous Gangrene

Phlegmasia cerulea dolens is an uncommon but potentially life-threatening complication of acute deep vein thrombosis. It is an emergency and delay in treatment may cause death or loss of the patient's limb. Surgical thrombectomy is the recommended treatment in venous gangrene. Catheter-directed intrathrombus thrombolysis has been reported as successful, but it may require a lengthy infusion. Manual aspiration thrombectomy may clear the entire thrombus with no need for thrombolytic administration and provide rapid and effective treatment for patients with phlegmasia cerulea dolens with impending venous gangrene.

Symptomatic Intracranial Stenosis: Cerebrovascular Complications from Elective Stent Placement

To retrospectively evaluate the cerebrovascular complications from elective stent placement for symptomatic intracranial stenosis and to explore preliminarily which factors are associated with complications. Institutional ethics committee approval was obtained, with waiver of informed consent. Records were reviewed of 181 consecutive elective stent placement procedures in 169 patients (mean age, 51.8 years; 142 male and 27 female patients) with symptomatic intracranial stenosis of more than 50% diameter reduction. Complications were evaluated. Fisher exact or chi(2) tests were used to assess statistical differences between rates for discrete variables. Stratification analysis was used to assess the significant relationship (P < .05) between a potential risk factor and a complication. Complications occurred in 20 patients (11.8%) of 169 patients: Ten patients (5.9%) had stroke (four patients had symptomatic intracranial hemorrhages [ICHs], and two of these patients died; six patients had ischemic strokes). Six patients had target-lesion thrombosis for which intrathrombus thrombolysis resulted in early complete patency without sequelae, two had asymptomatic ICHs, one had transient ischemic attack, and one had asymptomatic dissection. Perioperative noncompliance with antiplatelet therapy was found to be significantly associated with target-lesion thrombosis (two of eight patients [noncompliance] vs four of 161 patients [compliance], P = .027). Stratification analysis revealed a significant correlation between the use of double stents for a lesion and ICH (P = .005). Cerebrovascular complications from elective stent placement for intracranial stenosis are diverse. The use of double stents for a lesion is an independent risk factor for ICH. Perioperative noncompliance with antiplatelet therapy is associated with a higher frequency of target-lesion thrombosis.

Society of Interventional Radiology Position Statement: Treatment of Acute Iliofemoral Deep Vein Thrombosis with Use of Adjunctive Catheter-directed Intrathrombus Thrombolysis

THE Society of Interventional Radiology (SIR) considers the use of catheterdirected intrathrombus thrombolysis (CDT) as an adjunct to anticoagulant therapy to represent an acceptable initial treatment strategy for carefully selected patients with acute iliofemoral deep vein thrombosis (DVT). The SIR defines acute iliofemoral DVT as complete or partial thrombosis of any part of the iliac vein and/or the common femoral vein with or without associated femoropopliteal DVT, in which symptoms have been present for 14 days or less or for which imaging studies indicate that venous thrombosis has occurred within the past 14 days (1).

Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal

Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal

Safety and Efficacy of Reteplase for the Treatment of Acute Arterial Occlusion: Complexity of Underlying Lesion Predicts Outcome

We evaluated both the safety and efficacy of reteplase for treatment of acute arterial occlusion as well as outcomes based on treatment of the underlying lesion. From November 2000 to February 2004, reteplase was used to treat arterial occlusions in 81 patients. Catheter-directed intrathrombus thrombolysis was performed with reteplase (0.5 units/hr) continuous infusion. Percutaneous mechanical thrombectomy (Angiojet) was performed in 61% (n = 50) of patients prior to thrombolysis. Unmasking of significant lesions resulted in endovascular intervention (39.5%), open surgical repair (24.6%), or both endovascular and surgical repair (9.8%) of the lesion. No lesion was found in 25.9% of patients. Major and minor complication rates as well as restoration of patency, limb salvage, and amputation-free survival were evaluated. Eighty-one patients received reteplase therapy (median = 10.3 +/- 5.3 units, 19.5 +/- 7.4 hr) followed by next-day arteriogram to assess thrombus removal. Technical success was achieved in 96.2% (n = 78) of cases. Kaplan-Meier life table analysis revealed overall primary patency rates of 76.3%, 60.1%, and 51.6%, at 1, 6, and 12 months, respectively. Overall amputation-free survival rates were 86.4%, 76.4%, and 69.7% at 1, 6, and 12 months, respectively. When subdivided into postlysis intervention, the lysis-only group achieved increased patency (p = 0.0143) and increased limb salvage (p = 0.0219) at 1 year compared to the lysis and endovascular intervention and the lysis and surgical groups. The 30-day complication rate was 17.3% (n = 14), with a major complication rate of 4.9% (n = 4) and a minor complication rate of 12.3% (n = 10). There were no intracranial hemorrhagic complications. Intra-arterial catheter-directed infusion of reteplase for acute lower extremity ischemia is safe and efficacious, as shown by the low risk of bleeding complications, high limb salvage rates, and low mortality rates in this study. The complexity of the lesion that is unmasked through thrombolytic therapy is a predictor of patency and limb salvage.

Contemporary Treatment of Iliofemoral Deep Vein Thrombosis

The standard treatment for acute iliofemoral venous thrombosis has been hospital admission with bedrest, leg elevation, and anticoagulation using unfractionated heparin IV and warfarin. With the recent release from the FDA of low molecular weight heparin we can anticipate a rapid embrace of this drug for ambulatory treatment. Based on level I studies from mainly Canada and Europe, low molecular weight heparin has been proven to be highly effective in the initial treatment of established deep vein thrombosis. We will argue that the long term sequels of low molecular weight heparin treatment is not known. Early and quick removal of the thrombus is indicated to avoid the late postthrombotic syndrome. We suggest that catheter-directed intrathrombus thrombolysis with or without adjunct procedures such as angioplasty and stenting should be the first line of treatment. When there are contraindications or failure of thrombolysis, thrombectomy with a temporary arteriovenous fistula is a valid alternative, with bot...

Homozygous hereditary resistance to activated protein C presenting as cerebral venous thrombosis

The factor V Leiden mutation is a specific point mutation in the gene coding for factor V. It renders activated factor V resistant to degradation by activated protein C (APC). This hereditary resistance to APC (HRAPC) is a known risk factor for systemic venous thrombosis. We present a case of homozygous HRAPC presenting as cerebral venous thrombosis (CVT). A 24-year-old woman presented with a dense left hemiplegia and papiledema. A computed tomography scan showed a high ritht parieto-occipital infarct with hemorrhagic conversion. Angiography confirmed the diagnosis of extensive CVT. Treatment included heparin and direct intrathrombus thrombolysis initially as a bolus and then as an infusion for 21 hours. Repeat angiography showed partial recanalization. After 9 days, the patient was discharged on warfarin with minimal residual left weakness but persistent papilledema. Homozygous HRAPC appears to be a risk factor for CVT and should be considered in the evaluation of CVT.

Dural sinus thrombosis treated by intrathrombus thrombolysis: J. Maurice Hourihane, Wayne M. Clark, Gary M. Nesbit, Stanley L. Barnwell (Oregon Stroke Center, OHSU, Portland, OR)

Dural sinus thrombosis treated by intrathrombus thrombolysis: J. Maurice Hourihane, Wayne M. Clark, Gary M. Nesbit, Stanley L. Barnwell (Oregon Stroke Center, OHSU, Portland, OR)