Regional Thrombolysis Research Articles

Regional catheter thrombolysis for late proximal deep vein thrombosis

To compare the efficacy of regional catheter thrombolysis with urokinase and alteplase for late proximal deep vein thrombosis. We analyzed safety and effectiveness of treatment of 38 patients with late proximal deep vein thrombosis divided into 2 statistically homogeneous groups by 19 people. In the first group, regional thrombolysis with urokinase was performed with injection of the drug into thrombosed popliteal, femoral and iliac veins. Alteplase was used in the second group. Patients received rivaroxaban in pre-, perioperative period and throughout 6 months after surgery. Complications of endovascular therapy were recorded. After 12 months, ultrasound and clinical examination were carried out to assess vein recanalization and venous outflow disorders. Vein recanalization was evaluated as follows: <50% - minimal, 50-99% - partial, 100% - complete. Minor hemorrhagic complications of endovascular treatment developed in 31.7 and 21% of patients, respectively. In the first group, complete vein recanalization occurred in 31.6%, partial - in 21%, minimal - in 47.4% of patients. In the second group, these values were 47.4%, 36.8% and 15.8%, respectively. In the first group, no signs of venous outflow disorders were observed in 31.6% of patients, mild disorders - in 15.8%, moderate disorders - in 31.6%, severe - in 21% of patients. In the second group, these values were 47.4%, 31.6%, 10.5% and 10.5%, respectively. Thrombolysis with alteplase is safer and more effective compared to urokinase.

Endovascular surgery for deep vein thrombosis

The authors reviewed national and world literature data on endovascular technologies for the treatment of deep vein thrombosis. Indications, technologies, complications and results of systemic and regional thrombolysis are described in detail. The authors consider percutaneous mechanical thrombectomy, pharmacomechanical thrombectomy, venous stenting and catheter thrombectomy. The role of combined endovascular approaches in delayed stages of disease is emphasized. The indications for implantation of cava filter are presented.

P262 ULTRASOUND–ASSISTED THROMBOLYSIS OF HIGH RISK AND INTERMEDIATE–HIGH RISK PULMONARY EMBOLISM: A MULTICENTRE REAL WORLD EXPERIENCE IN LOMBARDY REGION

Abstract Introduction Acute pulmonary embolism (PE) is associated with high morbidity and mortality rate. Catheter–directed treatments (CDTs) seem a therapeutical option in case of sistemic thrombolysis (ST) contraindication or failure. Ultrasound–assisted thrombolysis (USAT) allows low–dose thrombolytic loco–regional infusion facilitated by ultrasounds. Methods and Results A multicentre retrospective observational cohort study was conducted among 4 Cardiovascular Interventional Centres in Lombardy Region to evaluate safety and efficacy of USAT in high risk and intermediate–high risk PE patients presenting with contraindications to ST. Patients at high risk were included in case of USAT because of ST contraindications. Patients at intermediate–high risk were included in case of rescue USAT. Loco–regional thrombolysis was performed using rTPA. Procedural success was defined as successful catheters‘ deployment in pulmonary arteries and patient survival during the procedure. Bleeding were defined according to BARC criteria. Echocardiographic evaluation to determine the prevalence of right ventricular (RV) dysfunction and pulmonary hypertension was performed at presentation, discharge and follow–up. Between 2011 and 2021, 109 patients were included. 21.1% presented with high risk PE, the remaining 78.9% with intermediate–high risk. Procedural success was obtained in 99.1% of the cases; major bleedings occurred in 9.2%, minor bleedings in 11.9% and vascular complications in 7.3% of the patients. 91.7% of patients were alive at discharge. In–hospital all–cause mortality was higher in high risk patients (26.1% vs 3.5%; p = 0.003) that showed a steep decline in survival as compared to intermediate–high risk patients that constantly maintained a high survival rate throughout the observation period. At six–months follow–up 3 patients in intermediate–high risk group died so that the overall mortality remains higher in high risk patients (26.1% vs 7%; p = 0.018). No re–hospitalization for recurrent PE at six–months occurred. Prevalence of RV dysfunction and pulmonary hypertension significantly decreased from hospital admission to discharge and to six–months follow–up (p–value &amp;lt;0.0001 for all comparisons). Conclusions Our experience shows good short and mid–term outcomes in USAT in high risk and intermediate–high risk PE patients with contraindications to ST, suggesting that it might be considered in a neglected subset of patients with no alternative therapeutical options.

Case of effective endovascular treatment of venous gangrene

Presented in this article is a clinical case report regarding treatment of a patient with deep vein thrombosis complicated by venous gangrene having developed 10 days after the onset of the disease. Conservative therapy (infusion of colloids and crystalloids, anticoagulants, agents improving microcirculation, venotonics, nonsteroidal anti-inflammatory drugs, elevated position of the limb) made it possible to stabilize the patient's condition, but not improving haemodynamics of the affected limb. A decision was made to use endovascular techniques. Treatment was carried out in three stages. The first stage during 48 hours consisted in regional catheter thrombolysis with urokinase, exerting a minimal clinical effect. The second stage was percutaneous mechanical thrombectomy after which the diameter of thrombosed veins became free by half, with the beginning of disease regression. The third stage consisted in venous stenting of residual stenosis of the iliac vein, resulting in normalization of the venous outflow from the affected limb. A conclusion was drawn on feasibility of combined use of regional thrombolysis, percutaneous mechanical thrombectomy, and venous stenting in treatment of venous gangrene.

Endovascular Treatment (Stenting) of Total IVC Obstruction with Collaterals in Young Adult with Crohn’s Disease Maharishi Markandeshwar (Deemed to Be University)

We present a case of clinically extensive bilateral DVTs associated with chronic total inferior vena cava thrombosis with underlying crohn’s disease and who is on steroid therapy. Young patients presenting with symptoms of DVT should be investigated not only to establish any thrombophilic pre-disposition but to ascertain the proximal extent of thrombus which may itself influence treatment. Treatment options in the case of IVC thrombus without anatomical variance include anticoagulation, mechanical thrombectomy, systemic thrombolytic therapy, transcatheter regional thrombolysis, and angioplasty

Efficiency of regional catheter-guided thrombolysis in treatment of late total and subtotal deep vein thrombosis

The OBJECTIVE was to assess the effectiveness of the developed method for treating DVT with fibrinolytic agent injection via a catheter with multiple openings along the length of entire thrombus. METHODS AND MATERIALS. The analysis of treatment efficacy of 40 patients with late total and subtotal deep vein thrombosis was carried out. The patients were divided into two statistically valid groups. The first group of patients were treated using regional thrombolysis by injection of Urokinase into the popliteal vein. The second group had fibrinolytic agent injection via a catheter with multiple openings passed along the entire length of thrombosed venous segment. Patients were given Rivaroxaban before, during, and after the therapy continuously for 6 months. RESULTS. After 1 year in the second group, compared to the first group, the excellent and good results were higher by 10 % and 5 % respectively. Satisfactory and unsatisfactory results decreased by 10 and 5 % respectively. While using background Rivaroxaban, the thromboembolic complications were not registered. Hemorrhagic complications were found in 10 % of both group patients with equal rate. CONCLUSION. Injection of a fibrinolytic agent via a catheter with multiple openings along the length of entire thrombus is efficient and pathogenetically substantiated.

COMPARISON OF LONG-TERM RESULTS OF FEMORAL VEIN LIGATION AND TRANSCATHETER THROMBOLYSIS IN THROMBOSIS OF THE FEMORAL SEGMENT

INTRODUCTION. The problem of preventing massive pulmonary thromboembolism and post-thrombotic syndrome in deep vein thrombosis has been studied for a long period. The introduction of new treatments for deep vein thrombosis requires a detailed comparison of their effectiveness.The OBJECTIVE of this work was a comparative analysis of ligation of the superficial femoral vein and regional thrombolytic therapy.MATERIAL AND METHODS. A retrospective multicenter study involving 30 patients with femoproplite thrombosis, who had received catheter-directed thrombolysis or ligation of the superficial femoral vein, was performed. The investigated patients underwent inpatient treatment.RESULTS. The data on the effectiveness of both methods in preventing pulmonary thromboembolism were obtained. When comparing both groups, we revealed a statistically significant difference in the frequency of the development of PTS and the severity of its development in 1 year after treatment. With ligation vein, 73.3 and 6.7% in the thrombolysis group (p=0.0005).CONCLUSION. Regional thrombolysis was an effective treatment for deep vein thrombosis and prevention of PTS.The authors declare no conflict of interest.The authors confirm that they respect the rights of the people participated in the study, including obtaining informed consent when it is necessary, and the rules of treatment of animals when they are used in the study. Author Guidelines contains the detailed information.

Regional thrombolysis with massive thromboembolism of the pulmonary artery of women in the first first trimester of pregnancy

Regional thrombolysis with massive thromboembolism of the pulmonary artery of women in the first first trimester of pregnancy

Regional thrombolysis with massive thromboembolism of the pulmonary artery in a woman in the first trimester of pregnancy

Regional thrombolysis with massive thromboembolism of the pulmonary artery in a woman in the first trimester of pregnancy

Marked Regional Variation in Acute Stroke Treatment Among Medicare Beneficiaries.

Little is known about how regions vary in their use of thrombolysis (intravenous tissue-type plasminogen activator and intra-arterial treatment) for acute stroke. We sought to determine regional variation in thrombolysis treatment and investigate the extent to which regional variation is accounted for by patient demographics, regional factors, and elements of stroke systems of care. Retrospective cross-sectional study of all fee-for-service Medicare patients with ischemic stroke admitted via the Emergency Department from 2007 to 2010 who were assigned to 1 of 3436 hospital service areas. Multilevel logistic regression was used to estimate regional thrombolysis rates, determine the variation in thrombolysis treatment attributable to the region and estimate thrombolysis treatment rates and disability prevented under varied improvement scenarios. There were 844 241 ischemic stroke admissions of which 3.7% received intravenous tissue-type plasminogen activator and 0.5% received intra-arterial stroke treatment without or without intravenous tissue-type plasminogen activator over the 4-year period. The unadjusted proportion of patients with ischemic stroke who received thrombolysis varied from 9.3% in the highest treatment quintile compared with 0% in the lowest treatment quintile. Measured demographic and stroke system factors were weakly associated with treatment rates. Region accounted for 7% to 8% of the variation in receipt of thrombolysis treatment. If all regions performed at the level of 75th percentile region, ≈7000 additional patients with ischemic stroke would be treated with thrombolysis. There is substantial regional variation in thrombolysis treatment. Future studies to determine features of high-performing thrombolysis treatment regions may identify opportunities to improve thrombolysis rates.

The Role of Thrombectomy in the Management of Deep Vein Thrombosis

Introduction Surgical venous thrombectomy has recently gained increasing popularity in the literature for the management of a range of clinical presentations of extensive acute deep vein thrombosis including; young and active patients, during pregnancy, postpartum and in patients with traumatic or postoperative thrombosis. Report We report a case of unilateral iliofemoral deep vein thrombosis arising secondary to external compression of the left common iliac vein by large uterine fibroids, successfully managed with open venous thrombectomy. Discussion Where conventional anticoagulation or catheter directed regional thrombolysis may be contraindicated, surgical thrombectomy has provided an appropriate alternative with good results.

Manual High-Dose Regional Intraoperative Thrombolysis of Lower Extremity Emboli After Open Repair of a Ruptured Abdominal Aortic Aneurysm

We describe a case of high-dose regional intraoperative thrombolysis subsequent to mechanical thrombectomy for the treatment of postoperative distal extremity embolization of the right lower limb owing to open repair of a ruptured abdominal aortic aneurysm. Mechanical thrombectomy was performed from the popliteal artery but residual embolic occlusion of all three tibial arteries remained. The limb was elevated, exsanguinated, and a blood cuff was placed below the knee and inflated to suprasystolic pressure to isolate the limb from systemic circulation. An 18-gauge infusion catheter was introduced to the exposed dorsalis pedis artery. Subsequently, the exposed great saphenous vein was cannulated and drained. A total of 100 mg of recombinant tissue-type plasminogen activator diluted in 500 mL of saline was infused into the anterior tibial artery with a slow hand infusion for 30 minutes. The infusion was continuously collected through the great saphenous cannulation and a closed loop was confirmed by angiogram. The limb was flushed with heparin and saline solution. Infusion catheter was extracted and the great saphenous vein was ligated. Blood cuff was removed, arterial flow was re-established, and a postprocedural arteriogram confirmed successful revascularization. This method may be an alternative to microtibial embolectomy at the foot ankle level after severe lower limb embolization after acute open repair of a ruptured abdominal aortic aneurysm.

Delivering regional thrombolysis via a hub-and-spoke model

Audits in the United Kingdom and other countries show that only a small proportion of eligible stroke patients receive thrombolysis. Providing 24-hour thrombolysis cover presents major challenges in both infrastructure and staffing. One model for improving access is to provide out-of-hours cover in a regional centre but this may present problems including greater delays to hospital admissions. Evaluation of the introduction of a 'hub-and-spoke' model of thrombolysis to increase access to thrombolysis for patients in south west London. One-year data are presented. A network in south-west London comprised of a hub hospital and three district 'spoke' hospitals. All suspected stroke admissions to a regional stroke centre. Main outcome measures Thrombolysis rates for acute stroke. Increased out-of-hours thrombolysis rates were achieved with only a small increase in stroke admissions (approximately 10%) in the hub hospital. Thrombolysis rates increased from 1.2 per 100 stroke admissions for the local daytime service to 6 per 100 admissions for the regional service. Most patients thrombolysed were not local to the hub hospital. Only 1 in 4 patients considered for thrombolysis was thrombolysed, in line with previous data. Ten percent of all thrombolysis calls were not stroke but represented stroke mimics. Median length of stay was 6 days (target was 3 days). Fifty percent of the thrombolysed patients from spoke hospitals were discharged directly home. In an urban area, a hub-and-spoke thrombolysis model increased access to thrombolysis without resulting in a marked increase in overall stroke admission numbers for the hub hospital. Proactive plans to repatriate patients back to district hospitals are required, and repatriation protocols have to prioritize regional patients over other targets in spoke hospitals to facilitate capacity in the hub hospital.

Postoperative pulmonary embolism in a three year old with Klippel&amp;ndash;Trenaunay syndrome

Massive pulmonary embolism (PE) in a small child is a rare event and unified guidelines for its treatment are missing. Timely diagnosis and management of massive pulmonary embolism is of crucial importance for a good outcome. We describe a unique management of PE causing oxygenation failure using a combination of catheter extraction technique, and regional thrombolysis on top of systemic heparin administration and inferior vena cava filter placement. Pulmonary hypertension was treated with inhaled nitric oxide. We believe that catheter extraction technique and regional thrombolysis is an option to consider provided that resources and expertise are available. Preoperative placement of an inferior vena cava filter should be contemplated in such high risk situations.

Stenting of Common Iliac Vein Obstructions Combined with Regional Thrombolysis and Thrombectomy in Acute Deep Vein Thrombosis

Stenting of Common Iliac Vein Obstructions Combined with Regional Thrombolysis and Thrombectomy in Acute Deep Vein Thrombosis

Stenting of Common Iliac Vein Obstructions Combined with Regional Thrombolysis and Thrombectomy in Acute Deep Vein Thrombosis

To evaluate the efficacy of stent placement after infrainguinal loco-regional thrombolysis and iliac thrombectomy (surgical TT) of acute deep vein thrombosis (DVT) in patients with May-Thurner-Syndrome. We retrospectively analysed a group of 11 patients (9 women) (mean age 34 years, range 16-64 years) with surgical TT and additional intra-operative stenting due to compression of the common iliac vein. Patients underwent venography to demonstrate outflow patency after surgical TT, and to identify any obstruction at the level of the left-sided common iliac vein ("Beckenvenen-Sporn"). Obstruction at the level of arterial crossing was treated using Wallstents placed via an introducer sheath from the inguinal access site. Stents were fully deployed using balloons adjusted to the size of vein. Patients were treated with oral anticoagulants for 6 months, and followed using duplex ultrasonography. Technical success defined as complete vein patency and normal valve function was documented in all 11 patients. One patient needed early stent extension due to residual stenosis. At 6 months follow-up one patient (9%) had an asymptomatic occlusion of the stented common iliac vein. In all 11/11 (100%) patients the femoral segment was found to be patent, and in 1/11 (9%) there was mild reflux with few clinical symptoms of post-thrombotic syndrome. The calculated cumulative primary patency rate for venous iliac stents was 82%, and assisted patency rate was 91%, which remained unchanged over a mean follow-up of 22 months. Combining surgical TT and stenting of common iliac vein obstructions in DVT is safe, effective, and results in a acceptable venous patency.

Treatment of Acute Iliofemoral Deep Venous Thrombosis by Thrombus Removal

Treatment of Acute Iliofemoral Deep Venous Thrombosis by Thrombus Removal

Combined Percutaneous Aspiration Thrombectomy and Rheolytic Thrombectomy in Massive Subacute Vena Cava Thrombosis With IVC Filter Occlusion

To report the combined use of percutaneous aspiration thrombectomy and rheolytic thrombectomy in the setting of extensive inferior vena cava (IVC) thrombosis and filter occlusion. A 28-year-old paraplegic man with a vena cava filter in situ for previous deep vein thrombosis (DVT) was referred to our center for evaluation of dyspnea and right leg edema and swelling. Computed tomography excluded a pulmonary embolism and revealed severe, massive DVT of both iliac veins and the IVC, including the vena cava filter. Percutaneous aspiration thrombectomy was attempted because intravenous heparin therapy was ineffective, and moderate anemia contraindicated regional thrombolysis. Several passes of a guiding catheter proximally and distally to the filter, with suction provided by a 50-mL syringe, achieved minimal IVC recanalization. Subsequently, a 6-F AngioJet catheter was passed via the guiding catheter through the filter, the IVC, and both iliac veins, obtaining a satisfactory result. The patient was discharged after 7 days and did very well at 6-month follow-up, with no recurrent DVT. This case demonstrates the usefulness of combined percutaneous aspiration and rheolytic thrombectomy in treating extensive IVC thrombosis and occluded IVC filters, especially when thrombolytic therapy cannot be used.

Combined Regional Thrombolysis and Surgical Thrombectomy for Treatment of Iliofemoral Vein Thrombosis

Combined Regional Thrombolysis and Surgical Thrombectomy for Treatment of Iliofemoral Vein Thrombosis

Hypothenar-Hammer-Syndrom als Ursache einer schweren digitalen Ischämie

A 69-year-old amateur carpenter complained of a sudden stabbing pain and a white discoloration of D4 and D5 of the right hand while shoveling snow. On admission in our clinic twelve days later, clinical inspection showed a gangrene of the distal bone of D5 and proximal garland-shaped radial and ulnar subcutaneous haemorrhage and already ischemic contracture. D4 showed pale livid colour. According to the results of an arteriography acral pulse oscillography revealed a occlusion of the digital arteries. Duplex sonography showed a thrombotic occluded aneurysm of the right ulnar artery over the hypothenar area. Hypothenar hammer syndrome with a thrombotic occlusion of an aneurysm of the distal ulnar artery and multiple thromboembolic occlusions of the digital arteries of D4 and D5 of the right hand. After initial therapy with Iloprost, treatment of pain and local treatment, an intraarterial locoregional lysis therapy with urokinase was performed. Acral blood circulation improved significantly and the patient was completely painless after treatment. In case of an acute onset of unilateral digital ischemia hypothenar hammer syndrome should be considered. Regional thrombolysis can be performed in case of severe digital ischemia.