Pharmacomechanical Thrombolysis Research Articles

Short-term outcomes of endovascular management of acute limb ischemia using aspiration mechanical thrombectomy.

Management of acute limb ischemia (ALI) has seen greater utilization of catheter-based interventions over the last two decades. Data on their efficacy is largely based on comparisons of catheter-directed thrombolysis (CDT) and open thrombectomy. During this time, many adjuncts to CDT have emerged with different mechanisms of action, including pharmacomechanical thrombolysis (PMT) and aspiration mechanical thrombectomy (AMT). However, the safety and efficacy of newer adjuncts like AMT have not been well established. This study is a retrospective analysis of the contemporary management of ALI comparing patients treated with aspiration mechanical thrombectomy to patients treated with the more established CDT adjunct, pharmacomechanical thrombolysis. Patients undergoing peripheral endovascular intervention for ALI using an adjunctive device were identified through query of the Vascular Quality Initiative (VQI) Peripheral Vascular Intervention (PVI) module from 2014 to 2019. Patients with a nonviable extremity (Rutherford ALI Stage 3), prior history of ipsilateral major amputation, popliteal aneurysm, procedures that were deemed elective (>72h from admission), procedures that did not utilize an endovascular adjunctive device, and patients without short-term follow-up were all excluded from analysis. The primary outcome was a composite outcome of freedom from major amputation and/or death in the perioperative time period. We identified 528 patients with Rutherford ALI Stage 1 or 2 who were treated with an endovascular adjunct. 433 patients did not undergo aspiration mechanical thrombectomy (no AMT group) and 95 patients did undergo aspiration mechanical thrombectomy (AMT group). The amputation-free survival across all patients was 93.4%. There were significant differences in demographic, comorbidity, and treatment variables between groups (e.g., gender, prior percutaneous coronary intervention (PCI), history of prior peripheral artery disease intervention, and history of prior infra-inguinal PVI), so a propensity score matched analysis was included to account for these group differences. In the propensity score matched analysis, there was no significant difference in major amputation (AMT 7.4% vs no AMT 3.2%, p = 0.13) or death (AMT 95.8% survival vs no AMT 98.4% survival, p = 0.23) with the use of aspiration mechanical thrombectomy. However, there was significantly worse amputation-free survival with the use of aspiration mechanical thrombectomy (AMT 88.4% vs no AMT 95.3%, p = 0.03). On multivariate analysis, prior supra-inguinal bypass (OR 4.85, 1.70-13.84, p = 0.003), Rutherford ALI Stage 2B (OR 3.13, 1.47-6.67, p = 0.003), and aspiration mechanical thrombectomy (OR 2.71, 1.03-7.17, p = 0.05) were associated with the composite outcome. Short-term amputation-free survival rates of endovascular management of acute limb ischemia are adequate across all modalities. However, aspiration mechanical thrombectomy was associated with significantly worse amputation-free survival compared to other endovascular adjuncts alone (i.e., pharmacomechanical thrombolysis). Severe limb ischemia (Rutherford ALI Stage 2B) and prior supra-inguinal bypass were associated with worse amputation-free survival regardless of the choice of endovascular intervention.

Rescue From Permanent Kidney Injury in Acute Thrombosis of Both Renal Veins, the Inferior Vena Cava, and Both Iliofemoral Veins by Catheter-Based Thrombectomy.

A 33-year-old man with previously diagnosed lupus membranous nephropathy presented with painful swelling in both legs. Laboratory tests revealed acute kidney injury, and imaging studies by duplex ultrasound and computed tomography scan showed acute thrombosis of both renal veins, the infrahepatic inferior vena cava, and both iliofemoral venous segments. Initially, pharmacomechanical thrombolysis led to an insufficient morphological result. The therapeutic breakthrough was achieved by catheter-based mechanical thrombectomy of the infrarenal vena cava and both renal veins, which successfully cleared all affected venous segments from thrombus, paralleled by improvement of the patient's condition. However, after 1 week, the patient experienced recurrent thrombosis of the right renal vein with hemorrhagic infarction of the right kidney. After further optimization of immunomodulatory and antithrombotic therapy, a repeated catheter-based mechanical thrombectomy resulted in sustained clinical improvement and preservation of renal venous drainage and kidney function. Extensive acute thrombosis of both renal veins, the inferior vena cava, and both iliofemoral venous segments is a rare emergency potentially threatening kidney function. Immediate effective thrombus removal is essential to preserve kidney function and can be achieved by catheter-based mechanical thrombectomy embedded in a comprehensive immunomodulatory and antithrombotic therapeutic concept. This case demonstrated the efficacy of a catheter-based therapeutic approach in patients with extensive thrombosis of the venous system. A catheter-based approach must be embedded in a comprehensive medical therapeutic concept, which is essential to achieve a sustainable result.

Diagnosis, Management and Outcomes in Children with Paget Schroetter Syndrome: A Retrospective Cohort Study

Introduction Venous thoracic outlet syndrome occurs secondary to the extrinsic compression and impingement of the subclavian vein as it passes through the thoracic outlet, eventually resulting in upper extremity effort thrombosis, or Paget-Schroetter syndrome (PSS). This rare condition typically affects the dominant arm of athletic young adults with a history of repeated overhead activities. At Boston Children's Hospital (BCH), a multidisciplinary team of hematologists, interventional radiologists, and vascular surgeons manage these patients according to a standardized protocol including anticoagulation, pharmaco-mechanical thrombolysis, venoplasty, and decompressive rib-resection surgery. Herein we report the clinical and radiological outcomes of a cohort of patients with PSS managed at BCH. Objective The principle objective of this retrospective cohort study was to review the diagnosis, pharmacological, interventional radiology and surgical management, complications, and long-term outcomes of sequential pediatric patients (≤21 years) treated for PSS at BCH over a 3.5-year period of time (January 1, 2020 to July 31, 2023). Methods This study was performed as a part of an ongoing quality improvement initiative and was deemed exempt by the Institutional Review Board. Eligible patients were defined as children (≤21 years) with PSS per criteria established by the Society for Vascular Surgery. Clinical and demographic data, including post-thrombotic syndrome (PTS) scores of eligible patients were abstracted from their medical records. PTS evaluation at BCH is typically performed 6-12 months after DVT diagnosis using both the modified Villalta and Manco-Johnson instruments. Major bleeding, and recurrent/progressive thromboses were defined per published guidelines by the International Society on Thrombosis and Haemostasis. Standard statistical methods were used - median (range) for continuous variables and frequency with 95% CI for categorical data. Results The study cohort consisted of 20 patients (9 female). PSS was confirmed based on dynamic imaging with provocative maneuvers for all patients. Median (range) age at DVT diagnosis was 17 (15-21) years. Thirteen patients were diagnosed at an outside hospital and referred to BCH for further management. Fourteen patients received upfront anticoagulation with low molecular weight heparin of whom 13 patients were transitioned to a DOAC. Six patients were started on DOACs upfront. Fifteen subjects (75%) received upfront endovascular intervention at diagnosis. Median interval between DVT diagnoses to endovascular intervention was 5 (1-118) days. All patients underwent decompressive rib-resection surgery. Median interval between DVT diagnosis and surgery was 12 (7-39) weeks. Three patients (15%) developed major bleeding and 3 (15%) patients developed recurrent/progressive thrombosis after surgery. Two of the 3 patients who developed major bleeding were anticoagulated with a DOAC pre-operatively, which had been held for 48 hours before surgery. All subjects had a planned post-operative venogram, 14 (70%) of whom underwent completion venoplasty. Anticoagulation was discontinued in 18/20 (90%) patients with a median duration of therapy of 19.5 (14-60) weeks. Four patients (20%) were noted to have an underlying thrombophilia (Factor 5 R506Q [2]; Factor 2 G20210A [1]; Protein S deficiency [1]). End-of-therapy imaging was obtained for all patients - 17 (85%) had complete thrombus resolution, while two (10%) had partial thrombus resolution. Seventeen (85%) patients have undergone evaluation for PTS, of whom 12 (71%) were noted to have mild PTS and 2 (12%) have moderate-severe PTS as defined by the modified Villata instrument. Discussion Greater than 90% of pediatric patients with PSS who were treated per our institutional multi-disciplinary protocol had complete or partial thrombus resolution. Additionally, only 12% of patients reported moderate to severe PTS on follow-up and were prescribed sequential compression sleeves. Lastly, DOACs appear to be safe and efficacious in this cohort, though based on our internal data, we now interrupt DOACs for 72 hours before decompressive surgery.

Effect of Pharmacomechanical Catheter-Directed Thrombolysis on Segmental Artery Occlusions: Insights From the RESCUE Trial

BackgroundReduction in distal vascular volume in acute pulmonary embolism (PE) is a significant predictor of 30- and 90-day mortality. The likely cause of this is pulmonary arterial obstruction. The effect of pharmacomechanical catheter-directed thrombolysis (PM-CDT) on the occlusions of these pulmonary artery (PA) branches is not known. ObjectivesThe RESCUE study evaluated PM-CDT with the Bashir endovascular catheter in patients with acute intermediate-risk PE. This analysis assessed PA occlusions using core laboratory data before and after PM-CDT therapy. MethodsThe baseline and 48-hour post-treatment contrast-enhanced chest computed tomography angiography of PE patients with right ventricular dilatation enrolled in the RESCUE trial were used. The primary analysis was the change in the number of segmental and proximal PA branches with total or subtotal (>65%) occlusions after 48 hours compared to baseline using McNemar’s test. ResultsA total of 107 patients enrolled across 18 United States sites comprised this analysis. At 48 hours post-PM-CDT, the number of segmental PA branches with total or subtotal occlusions decreased from 40.5% to 11.7% (P < 0.0001). Proximal PA branch total or subtotal occlusions decreased from 28.7% to 11.0% (P < 0.0001). The reduction in segmental artery occlusions correlated significantly with the magnitude of reduction in right ventricular/left ventricular ratio (correlation coefficient of 0.287 [95% CI: 0.102-0.452]; P = 0.0026), whereas that in the proximal PA arteries did not (correlation coefficient of 0.132 [95% CI: 0.059-0.314] P = 0.173). ConclusionsPM-CDT with the Bashir catheter was associated with a significant reduction in total and subtotal occlusion of segmental and proximal PAs.

TCT-395 Pharmacomechanical Thrombolysis and Deep Venous Thrombosis Outcomes: Systematic Review and Meta-analysis

TCT-395 Pharmacomechanical Thrombolysis and Deep Venous Thrombosis Outcomes: Systematic Review and Meta-analysis

Comparative outcomes of catheter-directed thrombolysis versus AngioJet pharmacomechanical catheter-directed thrombolysis for treatment of acute iliofemoral deep vein thrombosis

ObjectiveThe objective of this study was to compare the outcomes of pharmacomechanical thrombolysis and thrombectomy (PCDT) plus catheter-directed thrombolysis (CDT) vs CDT alone for the treatment of acute iliofemoral deep vein thrombosis (DVT) and summarize the clinical experience, safety outcomes, and short- and long-term efficacy. MethodsWe performed a 4-year retrospective, case-control study. A total of 95 consecutive patients with acute symptomatic iliofemoral deep vein thrombosis (DVT) with a symptom duration of ≤7 days involving the iliac and/or common femoral veins underwent endovascular interventions. The patients were divided into two groups according to their clinical indications: PCDT plus CDT vs CDT alone. Statistical analyses were used to compare the clinical characteristics and outcomes between the two groups. Additionally, the patients were followed up for 3 to 36 months after treatment, and the proportions of post-thrombotic syndrome (PTS) and moderate to severe PTS were analyzed using the Kaplan-Meier survival method. ResultsA total of 95 consecutive patients were analyzed in this retrospective study, of whom, 51 underwent CDT alone and 44 underwent PCDT plus CDT. Between the two groups, in terms of immediate-term efficacy and safety, significant differences were found in the catheter retention time (60.64 ± 12.04 hours vs 19.42 ± 4.04 hours; P < .001), dosages of urokinase required (5.82 ± 0.81 million units vs 1.80 ± 0.64 million units; P < .001), the detumescence rate at 24 hours postoperatively (48.46% ± 8.62% vs 76.79% ± 7.98%; P = .026), the descent velocity of D-dimer per day (2266.28 ± 1358.26 μg/L/D vs 3842.34 ± 2048.02 μg/L/D; P = .018), total hospitalization stay (6.2 ± 1.40 days vs 3.8 ± 0.70 days; P = .024), number of postoperative angiograms (2.4 ± 0.80 vs 1.2 ± 0.30; P = .042), and grade III venous patency (>95% lysis: 54.5% vs 68.6%; P = .047). Furthermore, during the follow-up period, significant differences were found in the incidence of PTS (Villalta scale ≥5 or a venous ulcer: 47.0% vs 27.7%; P = .037), and the incidence proportion of moderate to severe PTS at 12 months (15.7% vs 4.5%; P = .024) and 24 months (35.3% vs 11.4%; P = .016). ConclusionsCompared with CDT alone, in the iliofemoral DVT subgroup with a symptom duration of ≤7 days, PCDT plus CDT could significantly relieve early leg symptoms, shorten the hospitalization stay, reduce bleeding complications, promote long-term venous patency, and decrease the occurrence of PTS and the incidence proportion of moderate to severe PTS. Thus, the short- and long-term outcomes both support the superiority of PCDT plus CDT vs CDT in this subgroup.

Endovascular Thrombectomy for Acute Iliofemoral Deep Venous Thrombosis Through a Jugular Approach with a Rotational Device.

To report the effectiveness of pharmacomechanical catheter-directed thrombolysis (PCDT) in the management of acute iliofemoral deep venous thrombosis (DVT) via the jugular vein using a slow rotation and large-tip device (SRD) in a large cohort of patients. From 2011 to 2021, 277 patients (mean age 45years, 59.2% women) were treated in 6 centres with PCDT for ilio-fémoral DVT. PCDT was performed via the jugular vein and consisted of one session of fragmentation-fibrinolysis, aspiration and, if needed, angioplasty with stenting. The aim of PCDT was to achieve complete clearance of the venous thrombosis and to restore iliofemoral patency. Residual thrombotic load was assessed by angiography, venous patency by duplex ultrasound and clinical effectiveness by the rate of post-thrombotic syndrome (Villalta score > 4). All patients were treated via the jugular vein using an SRD, and all but one were treated with fibrinolysis. Angioplasty with stenting was performed in 84.1% of patients. After the procedure, the residual thrombotic load at the ilio-fémoral region was < 10% in 96.1% of patients. The rate of major complications was 1.8% (n = 5), the rate of minor complications was 4% (n = 11), and one patient died from pulmonary embolism (0.4%) At a median follow-up of 24months, primary and secondary iliofemoral patency was 89.6% and 95.8%, respectively. The rate of PTS was 13.8% at 12months. PCDT via the jugular vein using an SRD is an efficient treatment for acute iliofemoral DVT and results in high long-term venous patency and low PTS rates. Level of evidence Level 4, Case series.

Interventional therapies in acute pulmonary embolus-current trends and future directions.

Venous thromboembolic disease presenting with acute pulmonary embolus (PE) can be treated in a variety of ways from anticoagulation as an outpatient to surgical embolectomy with many new interventional therapies being developed. Mortality in these patients can be as high as 50% and many of these treatments are also considered to be high risk. Early involvement of a multidisciplinary team and patient risk stratification can aid management decisions in these complex patients who can suddenly deteriorate.In this review, we summarise the evidence behind new and developing interventional therapies in the treatment of high and intermediate-high risk PE including catheter-directed thrombolysis, pharmacomechanical thrombolysis, thromboaspiration and the growing role of extracorporeal membrane oxygenation in the stabilisation and management of this cohort of patients.

Effects of Deep Venous Thrombosis Treatments on Early and Long-term Quality of Life: Medical Therapy vs. Systemic Thrombolysis vs. Pharmacomechanical Thrombolysis.

The present study aimed to compare the effects of medical therapy (MT), systemic thrombolysis (ST), and pharmacomechanical thrombolysis (PMT) methods used in our clinic for the treatment of deep venous thrombosis (DVT) on symptom reduction, the incidence of post-thrombotic syndrome (PTS) development, and quality of life. Data from160 patients diagnosed with acute DVT between January 2012 and May 2021 and treated and followed up in our clinic were retrospectively analyzed. The patients were divided into three groups according to treatment method. The patients who received MT treatment were defined as Group 1, anticoagulant treatment after ST as Group 2, and anticoagulant treatment after PMT as Group 3. The patients were called to the outpatient clinic, informed consent was obtained, EuroQol-5D-3L (EQ-5D-3L) scoring and Villalta scoring were performed, and anamnesis was taken. A total of 160 patients were included, with 71 (44.4%) patients in Group 1, 45 (28.1%) in Group 2, and 44 (27.5%) in Group 3. The mean age was 48.9 ± 14.9years for Group 1, 42.2 ± 10.8 for Group 2, and 29.0 ± 7.2 for Group 3. When the time to return to normal life and the EQ-5D-3L score index were compared, the differences between Groups 1 and 2 and between Groups 1 and 3 were statistically significant (P = .000 and P = .000, respectively). However, the differences between Groups 2 and 3 were statistically insignificant (P = .213 andp = .074, respectively). When Villalta scores and EQ Visual Analogue Scale (EQ-VAS) scores were compared between groups, the difference between all groups was statistically significant (P = .000). The medical treatment alone was observed to be insufficient in terms of symptomatic improvement, development of PTS, quality of life, and long-term complications. When the ST and PMT groups were compared, it was determined that PMT treatment was more advantageous in terms of EQ-VAS score and PTS development, although there was no statistical difference regarding complications, such as return to normal life and long-term quality of life, the incidence of recurrent DVT development, and pulmonary thromboembolism incidence.

Strain-gauge venous occlusion plethysmography: An objective and non-invasive approach to the evaluation of venous hemodynamics in patients with acute deep-vein thrombosis undergoing post-pharmacomechanical thrombolysis.

Strain-gauge venous occlusion plethysmography (SGVOP) is a means of acquiring hemodynamic data non-invasively, unlike other methods used routinely for the diagnosis and follow-up of venous diseases. The present study compares the plethysmographic data with early- and mid-term routine data of patients with acute deep-vein thrombosis (DVT) who underwent pharmacomechanical thrombolysis. Included in this retrospective study were 118 patients with acute DVT, who underwent pharmacomechanical thrombolysis between February 2018 and July 2019. Pre- and post-procedure follow-up data including CIVIQ-20 (quality of life), VCSS (Venous Clinical Severity Score), D-Dimer, Doppler USG results, venous capacity (VC), and venous outflow (VO) obtained by SGVOP were recorded and compared. In all 118 (100%) patients who underwent the procedure, early- and mid-term patency was seen to have been provided on Doppler USG follow-up, and various degrees of venous insufficiency were identified. A statistically significant improvement was observed in VCSS, CIVIQ-20, D-Dimer, VO, and VC measurements, although when the discrepancies between CIVIQ-20 and plethysmographic measurements were examined individually during the 6-month follow-up, nine (13.1%) patients were identified with comorbidities. Pharmacomechanical thrombolysis is an effective treatment approach for patients with acute DVT. Providing non-invasive objective data supporting the diagnosis and follow-up of venous diseases, the SGVOP approach offers significant benefits and should be considered more frequently as a viable therapy.

TCTAP A-055 A Comparison of Pharmaco-Mechanical Thrombolysis and Catheter-Directed Thrombosis for Treatment of Thromboembolic Occlusion of Lower Limb – An Observational Case-Control Study.

TCTAP A-055 A Comparison of Pharmaco-Mechanical Thrombolysis and Catheter-Directed Thrombosis for Treatment of Thromboembolic Occlusion of Lower Limb – An Observational Case-Control Study.

The effects of pharmacomechanical thrombolysis treatment administered to patients with iliofemoral deep vein thrombus

Aim: In this study, the mid-term results of the pharmacomechanical thrombolysis treatment administered in patients with iliofemoral acute-subacute (patients with symptoms less than 21 days old whose DVT was diagnosed with physical examination and duplex ultrasonography) deep vein thrombus (DVT) were investigated. The cases were evaluated in terms of disease-related quality of life, and the presence of post-thrombotic syndrome (PTS) which occurred in patients after previous DVT and treatment, and if present, its severity was determined. Material and Methods: Disease-related status of 40 patients (24 males, 16 females; mean age 44; age interval 20-80 years) treated due to iliofemoral acute-subacute DVT with interventional method between July 2013 and January 2017 were retrospectively analyzed two years after the interventional treatment. These patients were considered as mid-term patients. The patients were evaluated with VEINES-QOL/Sym quality of life scale and the Villalta scale. The occurrence and severity of PTS, the presence of venous ulcer, and the diameter difference between legs were evaluated. Results: No venous ulcer was present in our cases. In the evaluation made with Villalta scale, PTS was not observed in 20 out of 40 cases, mild PTS was found in 15, moderate PTS in 4, and severe PTS was observed in 1 case. Conclusion: We have concluded that pharmacomechanical thrombolysis treatment administered in well-selected patients reduced the severity of PTS and increased the quality of life associated with disease in DVT treatment.

Short-Term Complications and Outcomes in Pharmaco-Mechanical Thrombolysis First and Catheter-Directed Thrombolysis First in Patients with Acute Lower Limb Ischemia

Pharmaco-mechanical thrombolysis (PMT) has emerged as a treatment option in patients with acute lower limb ischemia (ALI), especially Rutherford IIb (motor deficit) for rapid revascularization, but supportive data is scarce. The aim of the present study was to compare the effects of thrombolysis, complications, and outcomes of PMT first versus catheter-directed thrombolysis (CDT) first in a large cohort of patients with ALI. All endovascular thrombolytic/thrombectomy events in patients with ALI performed between January 1st, 2009, and December 31st, 2018 (n=347) were included. Successful thrombolysis/thrombectomy was defined as complete or partial lysis. Reasons for using PMT were described. Complications such as major bleeding, distal embolization, and new onset of renal impairment, and major amputation and mortality at 30days were compared between PMT (AngioJet) first and CDT first groups in a multivariable logistic regression model with adjustment for age, gender, atrial fibrillation, and Rutherford IIb. The most common reason for initial use of PMT was the need for rapid revascularization, and the most common reason for use of PMT after CDT was the insufficient effect of CDT. Presentation of Rutherford IIb ALI was more common in the PMT first group (36.2% vs. 22.5%, respectively, P=0.027). Among the 58 patients receiving PMT first, 36 (62.1%) were terminated within a single session of therapy without need of CDT. The median duration of thrombolysis was shorter (P<0.001) for the PMT first group (n=58) compared to the CDT first group (n=289) (4.0hr vs. 23.0hr, respectively). There was no significant difference in amount of tissue plasminogen activator given, successful thrombolysis/thrombectomy (86.2% and 84.8%), major bleeding (15.5% and 18.7%), distal embolization (25.9% and 16.6%), major amputation or mortality at 30-days (13.8% and 7.7%) in the PMT first compared to the CDT first group, respectively. The proportion of new onset of renal impairment was higher in the PMT first compared to the CDT first group (10.3% vs. 3.8%, respectively), and the increased odds (odds ratio 3.57, 95% confidence interval 1.22-10.41) were maintained in the adjusted model. In Rutherford IIb ALI, no difference in rate of successful thrombolysis/thrombectomy (76.2% and 73.8%), complications or 30-day outcomes was found between PMT first (n=21) and CDT (n=65) first group. PMT first appears to be a good treatment alternative to CDT in patients with ALI, including Rutherford IIb. The found renal function deterioration in the PMT first group needs to be evaluated in a prospective, preferably randomized trial.

Direct Percutaneous Thrombolysis (DPT): A novel method of salvaging Thrombosed Native Arteriovenous Fistula.

Thrombosed arteriovenous fistulas (AVFs) are either treated by thrombectomy or pharmaco-mechanical thrombolysis with or without percutaneous balloon angioplasty. In this study, we have described an effective and economical technique of salvaging these fistulae using a 20-22-gauge spinal needle and urokinase and have named it direct percutaneous thrombolysis (DPT). This prospective study comprised of 148 patients out of which 120 patients presented with AVF thrombosis and were divided into two groups; those with no obvious stenosis on ultrasound (n = 38) and second with venous stenosis (n = 82). Remaining 28 patients developed thrombosis post angioplasty for venous stenosis. Percutaneous injection of urokinase into the thrombus was done under ultrasound guidance, followed by balloon angioplasty if there was associated stenosis. In 38 patients who didn't have any stenosis, 32 AVFs were successfully thrombolysed by DPT, with technical success of 84.2%. Remaining six patients required angioplasty because of chronic nature of clot. In 82 patients who had venous stenosis, 80 cases were treated successfully by DPT followed by angioplasty with technical success of 97.5%. In third group (n = 28), who developed thrombosis post angioplasty, 100% success rate was noted. The mean length of thrombus was 31.4 ± 4.6 mm and mean diameter of thrombosed vein was 10.5 ± 1.2 mm. There were no major complications encountered during the procedure. Minor complications were seen in 19 patients which included prolonged oozing from puncture site and local hematoma formation. Ultrasound guided DPT with urokinase is a safe and economical option for salvaging thrombosed AVF without vascular stenosis that does not need angioplasty.

Angiojet pharmacomechanical thrombectomy versus anticoagulant therapy alone in massive cancer-associated thrombosis: a single centre retrospective cohort study.

The therapeutic regimen option for the cancer-associated thrombosis (CAT) patients is still a major clinical challenge. The present study aimed to investigate the safety and efficacy of pharmacomechanical catheter-directed thrombolysis (PCDT) with AngioJet treatment compared with the conventional anticoagulation alone therapy in the patients with CAT. We retrospectively reviewed the patients who underwent PCDT and/or anticoagulation for the treatment of CAT between August 1, 2016 and March 1, 2022. Each patient was divided into the PCDT group or the anticoagulation alone group. The baseline demographics, comorbidities, clinical characteristics, treatment details, course data were reviewed. A total of 51 eligible patients were included, of whom 21 were in PCDT group (mean age, 60.1 ± 13.0years; 52.4% male) and 30 in anticoagulation alone group (mean age, 66.6 ± 11.1years; 50.0% male). No significant differences regarding age, sex, onset time, limb characteristics, cancer conditions or risk factors were detected (p > .05). After PCDT, grade III lysis was achieved in 8 and grade II lysis in 11 patients. Clinical success was achieved in 90.5% (19/21) patients. The symptoms of leg pain and swelling were significantly improved in both groups. Except for transient macroscopic hemoglobinuria occurring in PCDT group, none of all patients suffered from procedure-related and major complications. Minor complications such as bleeding events occurred in 23.8% (5/21) of patients in PCDT group compared with 10.0% (3/30) in anticoagulation alone group (p > .05). At the 6-month follow-up, iliofemoral patency was found an absolute risk reduction of 37.9% (70.0 vs. 32.1%) (95% CI: 1.183-4.008%; P = 0.010). The incidence of mild PTS was 5.0% (1/20) in PCDT group compared with 10.7% (3/28) in anticoagulation alone group (p > .05). The PCDT is a safe and effective modality in managing patients with CAT, leading to improved clinical outcomes with alowcomplication. The PCDT was more effective than anticoagulation alone in massive symptom relief and venous patency.

Endovascular Thrombus Removal for Treating Post-Partum Iliofemoral Deep Vein Thrombosis: A Single-Centre Retrospective Cohort Study.

To evaluate the safety and efficacy of percutaneous thrombectomy for treating postpartum iliofemoral vein thrombosis. A retrospective analysis was performed on patients with continuous postpartum acute symptomatic iliofemoral deep vein thrombosis who were treated in our center, including all patients who underwent pharmacomechanical thrombolysis (PMT) or only catheter-directed thrombolysis (CDT) (study group), and patients that received simple anticoagulation treatment (control group). We evaluated the incidence of lower extremity postthrombotic syndrome, recanalization rate of lower extremity veins, and complications in the study and control groups. Overall, 72 postpartum women were included in this study, including the PMT combined with CDT group (14 cases, 15 limbs), CDT alone group (26 cases, 27 limbs), and anticoagulant therapy alone group (32 cases, 34 limbs). The thrombectomy group completed the treatment with a technical success rate of 100%, and no serious bleeding complications occurred. The patency rate of lower limb veins in the thrombectomy group was 85.09 ± 16.51% after treatment and 82.60 ± 21.45% after 1 year. At the 1-year follow-up, the Villalta score in the study group was lower (1.90 ± 2.45 vs 8.50 ± 5.33, P < .001), and the incidence of postthrombotic syndrome was significantly different between the groups (17.50% in the study group vs 68.75% in the anticoagulant group, P < .001). Lower extremity venous thrombectomy is a safe and effective treatment for postpartum iliofemoral venous thrombosis. It can improve the patency rate of lower extremity veins and reduce the incidence of postthrombotic syndrome compared with anticoagulation alone.

Exploring the Villalta scale to capture postthrombotic syndrome using alternative approaches: A subanalysis of the ATTRACT trial

BackgroundClinical trials that evaluated interventions to prevent postthrombotic syndrome (PTS) used the Villalta scale (VS) to define PTS, but there is a lack of consistency in its use. ObjectivesThis study aimed to improve the ability to identify patients with clinically meaningful PTS after DVT in participants of the ATTRACT trial. MethodsWe conducted a post hoc exploratory analysis of 691 patients from the ATTRACT study, a randomized trial evaluating the effectiveness of pharmacomechanical thrombolysis to prevent PTS in proximal deep vein thrombosis. We compared 8 VS approaches to classify patients with or without PTS in terms of their ability to discriminate between those with poorer vs better venous disease-specific quality of life (Venous Insufficiency Epidemiological and Economic Study Quality of Life [VEINES-QOL]) between 6- and 24-months follow-up. The difference in the average area under the fitted curve of VEINES-QOL scores between PTS and no PTS (ΔAUC¯) were compared among approaches. ResultsFor any PTS (a single VS score ≥5), approaches 1 to 3 had similar ΔAUC¯ (−21.2, −23.7, −22.0, respectively). Adjusting the VS for contralateral chronic venous insufficiency (CVI) or restricting to patients without baseline CVI (approaches 7 and 8) did not improve ΔAUC¯ (−13.6, −19.9, respectively; P >.01). For moderate-to-severe PTS (a single VS score ≥10), approaches 5 and 6 requiring 2 positive assessments had greater but not statistically significant ΔAUC¯ than approach 4, using one single positive assessment (−31.7, −31.0, −25.5, respectively; P >.01). ConclusionA single VS score of ≥ 5 reliably distinguishes patients with clinically meaningful PTS as assessed by impact on QOL and is preferred because of greater convenience (only one assessment needed). Alternative methods to define PTS (ie, adjusting for CVI) do not improve the scale’s ability to identify clinically meaningful PTS.

Controversies in the management of proximal deep vein thrombosis.

Controversies in the management of proximal deep vein thrombosis.

The Importance of Early Thrombus Removal

Historically, anticoagulation has been the primary treatment for acute lower extremity deep venous thrombosis (DVT) with or without thrombolysis. Despite large amounts of clinical research data supporting an ‘open vein hypothesis’, which favours early thrombus removal, clinicians have been hesitant to take this option due to a historically high risk of major bleeding and a few notable studies that failed to show any meaningful benefit. The ATTRACT trial failed to show the benefit of using pharmacomechanical catheter-directed thrombolysis (PCDT) for iliofemoral and femoropopliteal DVT but did result in more bleeding. However, the CaVent study before it revealed a significant reduction in post-thrombotic syndrome (PTS) for patients with iliofemoral and femoral DVT after long-term follow-up past 24 months that grew over time. Since these trials, there have been significant advancements in magnetic resonance and CT venography, intravascular ultrasound (IVUS), venous stenting and thrombectomy catheters meaning there is little to no need for adjunct thrombolytics. Results from ongoing research such as CLEAR-DVT reflect the advances in modern technology.

INTRACEREBRAL HEMORRHAGE POSTPHARMACOMECHANICAL CATHETER-DIRECTED THROMBOLYSIS: CAN WE PREVENT IT?

INTRACEREBRAL HEMORRHAGE POSTPHARMACOMECHANICAL CATHETER-DIRECTED THROMBOLYSIS: CAN WE PREVENT IT?