Thrombolysis For Deep Vein Thrombosis Research Articles

Catheter-Directed Thrombolysis for Deep Vein Thrombosis: Serving at Break Point.

Catheter-Directed Thrombolysis for Deep Vein Thrombosis: Serving at Break Point.

Association of vena cava filters and catheter-directed thrombolysis for deep vein thrombosis with hospital readmissions

BackgroundAcute deep vein thrombosis (DVT) affects >350,000 patients each year in the United States. Contemporary rehospitalization rates and predictors of acute DVT have not been well-characterized. We aimed to evaluate the all-cause 30-day readmission rate and its association with catheter-directed thrombolysis and vena cava filters in patients with proximal and caval DVT. MethodsPatients with an index hospitalization for acute proximal lower extremity DVT were evaluated for unplanned readmission rates at 30 days using the Nationwide Readmission Database from 2016 to 2017. We used Cox proportional hazard model to determine the predictors of 30-day readmissions and their association with inferior vena cava (IVC) filter and CDT use. ResultsWe identified 58,306 adult patients with an index hospitalization for acute proximal DVT. The unplanned 30-day rehospitalization rate was 14.7% (95% confidence interval [CI], 14.5-15.0%). There were 4995 patients (10.0%) who underwent CDT and 6085 (12.2%) who underwent IVC filter placement. In multivariable analysis, only CDT was associated with a lower hazard for rehospitalization (hazard ratio [HR], 0.77; 95% CI, 0.71-0.84; P < .001), whereas IVC filter placement (HR, 1.26; 95% CI, 1.19-1.34; P < .001), Charlson Comorbidity Index of >3 (HR, 1.47; 95% CI, 1.38-1.56; P < .001), malignancy (HR, 1.45; 95% CI, 1.34-1.57; P < .001), and length of stay >5 days (HR, 1.39; 95% CI, 1.33-1.46; P < .001), and acute kidney injury (HR, 1.18; 95% CI, 1.11-1.25; P < .001) were associated with higher readmission rates. ConclusionsThe 30-day unplanned rehospitalization rate continues to be high in patients with acute proximal DVT. CDT was associated with lower rehospitalization rates, whereas IVC filter placement was associated with increased rehospitalization rates.

Catheter directed thrombolysis for deep vein thrombosis in 2022: Rationale, evidence base and future directions

IntroductionCatheter directed thrombolysis (CDT) has evolved as a treatment modality for patients diagnosed with proximal and caval deep vein thrombosis (DVT) and has shown to be superior in certain subset of patient population despite conflicting evidence as seen in the large 4 randomized controlled trials. Rationale for CDT in acute DVT patientsDVT adversely affects the quality of life and adds significantly to the treatment and hospitalization costs. CDT and pharmaco-mechanical catheter directed thrombolysis (PCDT) has been shown to accelerate symptom resolution, decrease symptom severity and decrease recurrence rates with successful procedures in certain patients. Randomized clinical trials (RCTs)Four RCTs have evaluated the use of CDT and PCDT in acute proximal DVT patients suggesting clinical benefit compared to anticoagulation alone. These trials suggested using CDT for proximal DVT patients with a lower bleeding risk as CDT may decrease PTS. Successful CDT treatment showed improvement in moderate to severe symptoms of post thrombotic syndrome (PTS). However, these studies have limitations including the use of non-standard techniques, different equipment and different endpoints. Future directions and conclusionOur goal is to highlight the factors which can potentially improve CDT outcomes in proximal DVT patients. Based on studies, patients with proximal DVT and a low bleeding risk may benefit from early CDT by decreased symptom severity of PTS, however, improvement in procedural technique, equipment and procedural success rates is necessary. With appropriate patient selection, and objective endpoints, we can further establish the benefit of CDT and PCDT in acute DVT patients.

High-Pressure Low-Frequency Lateral Mode Phased-Array Transducer System for the Treatment of Deep Vein Thrombosis: An In Vitro Study.

Deep vein thrombosis (DVT) can lead to a fatal disease known as pulmonary embolism. Application of high-power ultrasound has been successful in studies to mechanically fragment the clots. Single-element ultrasound transducers were used in most of the studies. Challenges associated with phased arrays, such as high electrical impedance and element breakdown at high voltages, were addressed in the previous study, and a high-power 64-element transducer module was designed and fabricated. In this study, a cylindrical array of 16 modules with the frequency of 260 kHz was modeled and constructed for DVT thrombolysis. The maximum pressure, focal size, and steering ability of the array were examined. In vitro experiments were conducted to assess the performance of the array. The simulated pressure amplitude of 34 MPa at the depth of 55 mm (average femoral vein (FV) distance from the inner surface of the thigh) was in consistent with the experiments and satisfied the purpose of this study. Moreover, the employed module distribution resulted in a focal spot dimension of 2.4×2.8×7.3 mm3 (at the 75% pressure amplitude level) that can be confined in a human FV with the average diameter of 12 mm. In vitro experiments manifested a partial and complete clot breakdown at 11.5- and 15-MPa pressure at the focus. The design and engineering of the array system was succeeded in maintaining the desired pressure and focal size even when steered. The results presented in this study suggest the potential of the designed array system for clinical applications.

Catheter-directed thrombolysis for deep vein thrombosis: 2021 update.

Catheter-directed thrombolysis (CDT) has been utilized as an adjunct to anticoagulant therapy in selected patients with deep vein thrombosis (DVT) for approximately 30 years. CDT used to be limited to patients with DVT causing acute limb threat and those exhibiting failure of initial anticoagulation, but has expanded over time. Randomized trials evaluating the first-line use of CDT for proximal DVT have demonstrated that CDT does not produce a major reduction in the occurrence of post-thrombotic syndrome (PTS) and that it is poorly suited for elderly patients and those with limited thrombus extent or major risk factors for bleeding. However, CDT does offer selected patients with acute iliofemoral DVT improvement in reducing early DVT symptoms, in achieving reduction in PTS severity, and in producing an improvement in health-related quality of life (QOL). Clinical practice guidelines from medical and surgical societies are now largely aligned with the randomized trial results. This review offers the reader an update on the results of recently completed clinical trials, and additional guidance on appropriate selection of patients with DVT for catheter-directed thrombolytic therapy.

Application of Inferior Vena Cava Nanofilter Combined with Thrombolytic Catheter for Intravenous Thrombolysis in Deep Vein Thrombosis of Lower Extremities

Deep vein thrombosis (DVT) of the lower extremities has a high incidence and is insidiously fatal. Detachment of the thrombus can quickly cause death. Early detection and timely treatment are key to the treatment of DVT. This study is the first to report the clinical value of an inferior vena cava nanofilter combined with thrombolytic catheter for intravenous thrombolysis in DVT. The study found that the inferior vena cava nanofilter combined with the thrombolytic catheter has a significant effect on the treatment of DVT, which greatly reduces the circumference difference of the upper and lower legs, reduces the levels of fibrinogen, high-sensitivity C-reactive protein, and D-dimer, reduces the occurrence of complications, and is safe and worthwhile promotion.

Association of Vena Cava Filters and Catheter-Directed Thrombolysis for Deep Vein Thrombosis With Hospital Readmissions

OBJECTIVES: The objective was to evaluate all-cause 30 days readmission rate and its association with inferior vena cava filters (IVCF) placement and catheter-directed thrombolysis (CDT) in patients with proximal and caval DVT.  BACKGROUND: The rehospitalization rates and its predictors in acute proximal DVT have not been well characterized, including the impact of IVCF placement and CDT.METHODS: Patients with index hospitalization for acute proximal lower extremity DVT were evaluated for unplanned readmission rates at 30 days using Nationwide Readmission Database from 2016 to 2017. We used Cox proportional hazard model to determine the predictors of 30-days readmissions and its association with IVCF and CDT use. RESULTS: 58,306 adult patients were identified with an index hospitalization for acute proximal DVT. 533 patients died during the index admission or within 30 day from initial discharge. The unplanned 30-day rehospitalization rate among survivors of initial hospitalization was 14.7% (95% confidence interval [CI]: 14.5-15.0%). In multivariable analysis, only CDT was associated with a lower hazard for rehospitalization (HR 0.77, 0.71-0.84), whereas IVCF placement (HR 1.26, P<0.001, 95% CI 1.19-1.34), malignancy (HR 1.45, P<0.001, 95% CI 1.34-1.57), and length of stay more than 5 days (HR 1.39, P<0.001, 95% CI 1.33-1.46) were associated with higher readmission rates. CONCLUSIONS: The 30-day unplanned rehospitalization rate continues to be high in patients with acute proximal DVT. CDT was associated with lower rehospitalization rates, while IVCF placement was associated with increased rehospitalization rates. FUNDING STATEMENT: This research was funded by the Division of Cardiovascular Disease, Temple University Hospital. DECLARATION OF INTERESTS: Dr Bashir has equity interest in Thrombolex Inc. Dr. Bikdeli reports that he is a consulting expert, on behalf of the plaintiff, for litigation related to specific brand models of IVC filters. Dr. Anthony J. Comerota is an unpaid member of the Scientific Advisory Board of Thrombolex, Inc. No other disclosures are reported. ETHICS APPROVAL STATEMENT: NRD is publicly available and contains deidentified patient information, hence, the study was exempted from institutional review board assessment.

Comparison of ultrasound-accelerated versus conventional catheter-directed thrombolysis for deep vein thrombosis: A systematic review and meta-analysis.

Recent in vitro and clinical studies have shown that ultrasound-accelerated catheter-directed thrombolysis (USACDT) can accelerate thrombolysis. Therefore, in this meta-analysis, we aimed to compare the efficacy and safety of USACDT with conventional catheter-directed thrombolysis in patients with deep vein thrombosis. A systematic search of the following electronic databases was performed from their dates of inception to 20 June 2020: MEDLINE, Scopus, Google Scholar, CINAHL, Cochrane Library, and EMBASE. All randomized controlled trials that directly compared the complications and efficacy of USACDT and conventional catheter-directed thrombolysis in patients with deep vein thrombosis were identified. The statistical analysis was performed using comprehensive meta-analysis software. Finally, 18 studies with a total of 597 participants were included in our meta-analysis according to the eligibility criteria. Pooled proportion of USACDT success in patients with deep vein thrombosis was 87.8% (18 studies; 95% CI: 83.1-91.3). Success rate was significantly higher in USACDT treatment than in conventional catheter-directed thrombolysis treatment (seven studies; OR: 2.96; 95% CI: 1.69-5.16; P < 0.01)). Although the mean infusion time was higher in catheter-directed thrombolysis treatment compared to USACDT treatment, this difference was not statistically significant (three studies; MD: -1.46; 95% CI: -3.25-0.32; P = 0.10). Moreover, pooled rate of complications was lower in USACDT than catheter-directed thrombolysis which was not statistically significant (seven studies; OR: 0.49; 95% CI: 0.13-1.76; P = 0.27). This meta-analysis revealed that USACDT significantly increased the success rate of thrombolysis compared to conventional catheter-directed thrombolysis. Furthermore, USACDT was associated with lower rate of complication and infusion time. Taken together, these findings confirm the superiority of this novel intervention over conventional catheter-directed thrombolysis in treatment of patients with deep vein thrombosis.

Successful thrombectomy and thrombolysis of deep vein thrombosis in a patient with acute phlegmasia cerulea dolens with May-Thurner anatomy

Phlegmasia cerulea dolens (PCD) is a rare and important diagnosis to consider in the setting of a painful, swollen, and cyanotic lower extremity. We report a 59-year-old female diagnosed with PCD 3 days status post extended head and neck surgery with additional imaging findings concerning for May-Thurner anatomy. This case presentation is pathognomonic for PCD. Risk factors, pathogenesis, and management are described.

Thrombolytic strategies versus standard anticoagulation for acute deep vein thrombosis of the lower limb.

Standard treatment for deep vein thrombosis (DVT) aims to reduce immediate complications. Use of thrombolytic clot removal strategies (i.e. thrombolysis (clot dissolving drugs), with or without additional endovascular techniques), could reduce the long-term complications of post-thrombotic syndrome (PTS) including pain, swelling, skin discolouration, or venous ulceration in the affected leg. This is the fourth update of a Cochrane Review first published in 2004. To assess the effects of thrombolytic clot removal strategies and anticoagulation compared to anticoagulation alone for the management of people with acute deep vein thrombosis (DVT) of the lower limb. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries to 21 April 2020. We also checked the references of relevant articles to identify additional studies. We considered randomised controlled trials (RCTs) examining thrombolysis (with or without adjunctive clot removal strategies) and anticoagulation versus anticoagulation alone for acute DVT. We used standard methodological procedures as recommended by Cochrane. We assessed the risk of bias in included trials with the Cochrane 'Risk of bias' tool. Certainty of the evidence was evaluated using GRADE. For dichotomous outcomes, we calculated the risk ratio (RR) with the corresponding 95% confidence interval (CI). We pooled data using a fixed-effect model, unless we identified heterogeneity, in which case we used a random-effects model. The primary outcomes of interest were clot lysis, bleeding and post thrombotic syndrome. Two new studies were added for this update. Therefore, the review now includes a total of 19 RCTs, with 1943 participants. These studies differed with respect to the thrombolytic agent, the doses of the agent and the techniques used to deliver the agent. Systemic, loco-regional and catheter-directed thrombolysis (CDT) strategies were all included. For this update, CDT interventions also included those involving pharmacomechanical thrombolysis. Three of the 19 included studies reported one or more domain at high risk of bias. We combined the results as any (all) thrombolysis interventions compared to standard anticoagulation. Complete clot lysis occurred more frequently in the thrombolysis group at early follow-up (RR 4.75; 95% CI 1.83 to 12.33; 592 participants; eight studies) and at intermediate follow-up (RR 2.42; 95% CI 1.42 to 4.12; 654 participants; seven studies; moderate-certainty evidence). Two studies reported on clot lysis at late follow-up with no clear benefit from thrombolysis seen at this time point (RR 3.25, 95% CI 0.17 to 62.63; two studies). No differences between strategies (e.g. systemic, loco-regional and CDT) were detected by subgroup analysis at any of these time points (tests for subgroup differences: P = 0.41, P = 0.37 and P = 0.06 respectively). Those receiving thrombolysis had increased bleeding complications (6.7% versus 2.2%) (RR 2.45, 95% CI 1.58 to 3.78; 1943 participants, 19 studies; moderate-certainty evidence). No differences between strategies were detected by subgroup analysis (P = 0.25). Up to five years after treatment, slightly fewer cases of PTS occurred in those receiving thrombolysis; 50% compared with 53% in the standard anticoagulation (RR 0.78, 95% CI 0.66 to 0.93; 1393 participants, six studies; moderate-certainty evidence). This was still observed at late follow-up (beyond five years) in two studies (RR 0.56, 95% CI 0.43 to 0.73; 211 participants; moderate-certainty evidence). We used subgroup analysis to investigate if the level of DVT (iliofemoral, femoropopliteal or non-specified) had an effect on the incidence of PTS. No benefit of thrombolysis was seen for either iliofemoral or femoropopliteal DVT (six studies; test for subgroup differences: P = 0.29). Systemic thrombolysis and CDT had similar levels of effectiveness. Studies of CDT included four trials in femoral and iliofemoral DVT, and results from these are consistent with those from trials of systemic thrombolysis in DVT at other levels of occlusion. Complete clot lysis occurred more frequently after thrombolysis (with or without additional clot removal strategies) and PTS incidence was slightly reduced. Bleeding complications also increased with thrombolysis, but this risk has decreased over time with the use of stricter exclusion criteria of studies. Evidence suggests that systemic administration of thrombolytics and CDT have similar effectiveness. Using GRADE, we judged the evidence to be of moderate-certainty, due to many trials having small numbers of participants orevents, or both. Future studies are needed to investigate treatment regimes in terms of agent, dose and adjunctive clot removal methods; prioritising patient-important outcomes, including PTS and quality of life, to aid clinical decision making.

A CASE OF PHLEGMASIA CERULEA DOLENS AND MAY-THURNER SYNDROME IN A YOUNG MALE WITH TRIPLE-POSITIVE ANTIPHOSPHOLIPID ANTIBODY SYNDROME

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Phlegmasia cerulea dolens (PCD) is an uncommon form of deep vein thrombosis (DVT) typically presenting with acute limb swelling, pain, and cyanosis. Diagnosis of PCD should be made promptly as these patients may develop limb-threatening complications such as gangrene and compartment syndrome. We describe a young male presenting with his first episode of provoked venous thromboembolism (VTE) as PCD complicated with May-Thurner syndrome (MTS) and Antiphospholipid antibody syndrome (APS). CASE PRESENTATION: A 37-year-old obese male with type 2 diabetes, hypertension, and hyperlipidemia was directly admitted to the medicine floor with extensive left lower extremity DVT (including ileofemoral vein thrombosis) found on outpatient duplex ultrasonography. At initial hospitalization, he was tachycardic but without respiratory distress or hemodynamic instability. His left lower extremity was tender and edematous with cyanosis. Diagnosis of PCD was made and patient was treated with subcutaneous enoxaparin. He received catheter-directed thrombolysis for PCD with alteplase and heparin infusion. During left leg venogram, he was discovered to have MTS, and subsequently underwent stent placement of left common iliac vein, external iliac vein, and common femoral vein. After stent placement, patient received bridging to warfarin with enoxaparin and was discharged home two days later. Patient’s family history was significant for Systemic Lupus Erythematosus. During hospitalization, his antibody testing revealed positivity for anti-cardiolipin, anti-beta-2 glycoprotein antibodies in addition to positive functional lupus anticoagulant assay. Positivity confirmed with repeat testing of anti-cardiolipin antibodies and lupus anticoagulant assay at 15 weeks after hospitalization - confirming the diagnosis of triple-positive APS. DISCUSSION: Treatment of PCD is anticoagulation therapy with adjunctive catheter-directed thrombolysis. Outcomes comparing additional catheter-directed thrombolysis versus anticoagulation alone have shown that combination treatment reduces the incidence of post-thrombotic syndrome in patients with acute iliofemoral DVT. Recognition of DVT associated with MTS is important as treatment includes stent placement to maintain venous outflow. Recognition of triple-positive APS is an indication for extended anticoagulation as this portends a high risk of recurrent VTE. Patient was discharged with warfarin therapy because the use of direct oral anticoagulation in patients with APS remains controversial. Recent studies showed increased risk of recurrent thrombosis, particularly in patients with APS who are triple-positive. CONCLUSIONS: We reported a case, 37 year old male with phlegmasia cerulea dolens and May-Thurner syndrome resulting from triple-positive antiphospholipid antibody syndrome. Reference #1: Casey ET, Murad MH, Zumaeta-garcia M, et al. Treatment of acute iliofemoral deep vein thrombosis. J Vasc Surg. 2012;55(5):1463-73 Reference #2: Haig Y, Enden T, Grøtta O, et al. Post-thrombotic syndrome after catheter-directed thrombolysis for deep vein thrombosis (CaVenT): 5-year follow-up results of an open-label, randomised controlled trial. Lancet Haematol. 2016;3(2):e64-71 Reference #3: Dufrost V, Risse J, Reshetnyak T, et al. Increased risk of thrombosis in antiphospholipid syndrome patients treated with direct oral anticoagulants. Results from an international patient-level data meta-analysis. Autoimmun Rev. 2018;17(10):1011-1021 DISCLOSURES: No relevant relationships by Waqas Adeel, source=Web Response No relevant relationships by Robert Decker, source=Admin input No relevant relationships by Shuisen Li, source=Web Response No relevant relationships by Preysi Patel, source=Web Response No relevant relationships by Chun Siu, source=Web Response

Predictors of intracranial hemorrhage in patients treated with catheter-directed thrombolysis for deep vein thrombosis

BackgroundAlthough acute intracranial hemorrhage (ICH) is a rare complication of catheter-directed thrombolysis (CDT), it remains a major concern associated with the use of CDT. The incidence and clinical predictors of developing ICH in the setting of CDT are not known. MethodsThe National Inpatient Sample database was used to identify all patients with proximal lower extremity or caval deep vein thrombosis (DVT) from January 2005 to December 2013 in the United States. Multivariate logistic regression was performed to identify the clinical predictors of ICH between patients with DVT who had received anticoagulation therapy alone and those who had been treated with CDT plus anticoagulation therapy. ResultsOf 138,049 patients with proximal lower extremity or caval DVT, 7119 (5.2%) had received anticoagulation therapy and CDT. Of the patients treated with anticoagulation alone, ICH had occurred in 0.2% compared with 0.7% for those treated with CDT (P < .01). The independent predictors of ICH in the CDT cohort were a history of stroke (odds ratio [OR], 19.4; 95% confidence interval [CI], 8.8-42.8; P < .01), chronic kidney disease (OR, 2.2; 95% CI, 1.1-4.7; P = .03), age >74 years (OR, 2.2; 95% CI, 1.2-4.3; P = .02), male sex (OR, 1.8; 95% CI, 1.01-3.3; P = .048). Of those patients treated with anticoagulation alone, the risk factors for the development of ICH were a history of stroke, hospital teaching status, and age >74 years. ConclusionsThe results from the present nationwide observational study showed that of patients with DVT treated with CDT, the independent predictors for developing ICH were a history of stroke, chronic kidney disease, male sex, and age >74 years.

The short-term outcome of residual thrombus of the lower extremity after pharmacomechanical catheter-directed thrombolysis for deep vein thrombosis.

BackgroundThis study aimed to assess the short-term effect of residual thrombus of the lower extremity after pharmacomechanical catheter-directed thrombolysis (PCDT) on the incidence of post-thrombotic syndrome (PTS) and iliofemoral vein patency rate in patients who underwent PCDT.MethodsThere were 94 continuous patients with severe deep vein thrombosis (DVT) of the lower extremities admitted to our hospital between March 2016 and June 2018; 73 cases receiving PCDT and verified with iliac vein compression syndrome (IVCS) were assigned into two groups. Thirty-nine patients without thrombus of the popliteal and infrapopliteal veins were assigned to the proximal DVT group. The remaining 34 cases were placed in the extensive DVT group. The thrombus scores, including venous registry index (VRI) score, Marder score, and Society for Vascular Surgery (SVS) score before and after PCDT, the primary two years’ cumulative rate of iliofemoral patency, and the rate of PTS, and complications were analyzed retrospectively.ResultsUltimately, 27 patients in the proximal DVT group and 26 cases in the extensive DVT group completed the study. The two groups had no significant differences in terms of basic characteristics, complication and the rate of PTS (P>0.05). However, there were significant differences in terms of postoperative mean thrombus score and the mean degree of thrombosis removal score by Marder and SVS scores, residual thrombus by lower thrombosis classification (LET) and the two years’ cumulative iliofemoral vein patency rate (P<0.05). And the logistic regression analysis demonstrated the residual thrombus of LET class II [odds ratio (OR), 4.619, 95% confidence interval (CI), 1.090–19.567, P=0.038] was an independent risk factor for iliofemoral vein occlusion.ConclusionsThe residual thrombus of LET class II is an independent risk factor for iliofemoral vein occlusion. It is very important to keep the patency of the popliteal vein when deciding to use a stent to maintain iliofemoral vein patency. Furthermore, the anterior tibial vein approach and crisscross technique may be two important alternative methods that can be used to address the thrombus of popliteal vein for patients with extensive DVT.

A case of catheter-directed thrombolysis for deep vein thrombosis worsened after inferior vena cava filter placement

A case of catheter-directed thrombolysis for deep vein thrombosis worsened after inferior vena cava filter placement

Using it wisely: catheter-directed thrombolysis for deep vein thrombosis

Using it wisely: catheter-directed thrombolysis for deep vein thrombosis

OC2. Abstract Title: Comparison of Two Clinical Scales to Assess the Post-Thrombotic Syndrome: Secondary Analysis of a Multicenter Randomized Trial of Pharmacomechanical Catheter-Directed Thrombolysis for Deep Vein Thrombosis

<h3>Background</h3> Post-thrombotic syndrome (PTS) occurs in 20-50% of patients following proximal deep vein thrombosis (DVT), despite anticoagulation treatment. The International Society on Thrombosis and Haemostasis recommends using the Villalta scale to standardize the diagnosis of PTS and to quantify its severity. However, many investigators use the Venous Clinical Severity Score (VCSS) to assess PTS. Different to the Villalta score, the VCSS was developed as a measure for chronic venous disease and not PTS specifically. The aim of the study was to determine which of Villalta and VCSS best captures clinically important PTS and PTS severity by analyzing the relationship of each to QoL scores in the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial study population. <h3>Methods</h3> A secondary analysis of the ATTRACT randomized controlled clinical trial was conducted. 621 ATTRACT patients with symptomatic proximal DVT are included in this analysis. Correlations of the Villalta and VCSS scores with QoL scores (Short-Form Health Survey-36 physical component score/mental component score [SF-36 PCS/MCS]; the Venous Insufficiency Epidemiological and Economic Study-QoL/Symptoms [VEINES-QoL/Sym] questionnaire) were examined at study visits. The correlation of the random intercept (mean scores) and random slope (rate of change of the scores) between the Villalta, VCSS and the VEINES-QoL/Sym scores was assessed using a multivariate longitudinal model. <h3>Results</h3> The mean age at enrolment was 51 years of age, 78% were white, 62% were male, the mean BMI was 32 kg/m2, 57% had iliofemoral DVT, 19% had a previous ipsilateral DVT and 93% were taking one or more anticoagulation therapies prior to randomization. The median (range) correlation coefficients across all follow-up visits for the Villalta scale and VEINES-QOL and the Villalta scale and VEINES-Sym were -0.73 (0.51, -0.73) and -0.75 (-0.50, -0.76), respectively. The median (range) correlation coefficients for the Villalta scale and the SF-36 PCS or the SF-36 MCS across all follow-up visits were -0.51 (-0.35, -0.54) and -0.31 (-0.21, -0.38), respectively. In all correlation analyses between the Villalta scale and QoL measures, correlations at baseline were the weakest, and then increased until 6 months, after which the correlation coefficients remained relatively constant. The median correlation coefficient (range) across all follow-up visits for VCSS and VEINES-QOL and for VCSS and VEINES-Sym were -0.39 (-0.37, -0.39) and -0.41 (-0.36, -0.41), respectively. The median correlation (range) between VCSS and SF-36 PCS and for VCSS and MCS were -0.32 (-0.31, -0.32) and -0.12 (-0.12, -0.14), respectively. The magnitude of the correlations remained relatively constant from 6 months to 24 months follow-up visits. The Villalta scale had a strong negative correlation with VEINES-QoL and VEINES-Sym, a moderate negative correlation with SF-36 PCS, and a weak negative correlation with SF-36 MCS. Conversely, the VCSS had a weak negative correlation with VEINES-QoL, VEINES-Sym and SF-36 PCS, and a very weak negative correlation with SF-36 MCS. Adjustment for age, sex, ethnicity, race, extent of DVT and previous ipsilateral DVT did not change our findings. Each pair of disease severity scales and QoL scales were analyzed as a multivariate outcome in a multivariate longitudinal model. A random intercept (mean scores) and random slope (rate of change of the scores) were present in all these multivariate longitudinal models. The impact of covariates (i.e. age, sex and BMI) was also examined. The Villalta score and VCSS score have a positive correlation between their random intercept and random slope. This suggests that patients with a higher average Villalta score also tend to have a higher average VCSS score (correlation is 0.74 and 0.69 if adjusted). Those that have a higher rate of change in Villalta score over time tend to have a higher rate of change in VCSS (correlation is 0.72 and 0.84 if adjusted). The impact from covariate adjustment by age, sex and BMI was minor. <h3>Conclusion</h3> For all measures, the Villalta scale has a substantially higher correlation with QOL than the VCSS. Our findings support the use of the Villalta scale to assess PTS in preference to VCSS, as it better captures the impact of PTS on patient reported QoL, a key consideration in patients with chronic PTS.

Patient radiation exposure for endovascular deep venous interventions

ObjectiveThe study aimed to assess the cumulative radiation exposure from preoperative, periprocedural, and follow-up imaging to patients who underwent common endovascular deep venous interventions for acute and chronic central venous outflow obstructive diseases; namely, deep vein thrombosis (DVT) thrombolysis, unilateral chronic iliofemoral venous stenting, and inferior vena cava (IVC) reconstruction in a single center. MethodsPatients who had DVT thrombolysis of upper extremity (UE) DVT and lower extremity (LE) DVT, unilateral chronic iliofemoral venous stenting, and endovascular IVC reconstruction between May 1, 2012, and July 31, 2017, in a single unit were retrospectively reviewed. Demographic data, anatomic DVT, imaging, technical details of the index procedure, follow-up, and radiation exposure measured in dose-length product, dose-area product (DAP), and fluoroscopy time (FT) from related computed tomography scans and interventions were analyzed. Mann-Whitney U tests were performed to assess for significance of differences between subgroups. A P value of less than .05 was considered significant. ResultsIn total, 20 UE DVT thrombolysis, 91 LE DVT thrombolysis, 56 unilateral chronic iliofemoral venous stenting, and 39 endovascular IVC reconstruction patients were included in the study, with the following median ages: 39 years (range, 20-67 years), 44 years (range, 15-78 years), 45 years (range, 20-80 years), and 35 years (range, 18 -73 years), respectively. The median cumulative DAP for the index DVT thrombolysis was 9.2 Gycm2 (range, 0.2-176.0 Gycm2) for LE DVT and 2.0 Gycm2 (range, 0.1-11.7 Gycm2) for UE DVT (P < .0001). The median cumulative FT for the index thrombolysis was 981 seconds (range, 20-4890 seconds) and 837 seconds (range, 19-2895 seconds) for LE DVT and UE DVT, respectively (P = .18). For unilateral chronic iliofemoral venous stenting, the median cumulative DAP and FT were 32.4 Gycm2 (range, 0.1-289.6 Gycm2) and 660 seconds (range, 246-4200 seconds), respectively. Meanwhile, the median cumulative DAP and FT for the endovascular IVC reconstruction were 60.8 Gycm2 (range, 2.5-269.1 Gycm2) and 2846 seconds (range, 836-11682 seconds), respectively. The median DAP for secondary procedures during follow-up was 6.6 Gycm2 (range, 0.8 186.5 Gycm2), 1.9 Gycm2 (range, 0.2-111.7 Gycm2), and 24.3 Gycm2 (range, 0.2-157.5 Gycm2) for LE DVT thrombolysis, unilateral chronic iliofemoral venous stenting, and endovascular IVC reconstruction, respectively. ConclusionsPatient radiation exposure for endovascular deep venous interventions for central venous outflow obstruction measured in DAP and FT seemed to be less than and at most similar to anatomically comparable arterial interventions in the literature. However, these patients were usually much younger than those with arterial diseases and may need secondary interventions involving further radiation exposure in their lifetime.

The Role of May-Thurner Syndrome in Recurrent Thrombosis after Catheter-Directed Thrombolysis of Deep Vein Thrombosis

May-Thurner syndrome (MTS) leads to an increased incidence of deep vein thrombosis (DVT). Early thrombus removal decreases the post-thrombotic morbidities. Our aim was to better elucidate the relationship between MTS and venous patency after catheter-directed thrombolysis (CDT). The medical records of all patients who underwent CDT from January 2005 to December 2011 due to acute DVT were reviewed retrospectively. Patient characteristics and clinical variables were evaluated to determine association with vein patency. A total of 51 male and 31 female with a mean age of 34.9years were treated with CDT. During a median follow-up of 91.7months, primary patency and secondary patency of all patients were 79.3% and 87.3%, respectively. The presence of MTS was the only significant predictor factor of patency. The residual stenosis caused by MTS is a risk for recurrent DVT and should be treated with stenting to improve the outcome.

Contemporary Trends and Comparative Outcomes With Adjunctive Inferior Vena Cava Filter Placement in Patients Undergoing Catheter-Directed Thrombolysis for Deep Vein Thrombosis in the United States: Insights From the National Inpatient Sample

ObjectivesThe aim of this study was to investigate the contemporary trends and comparative effectiveness of adjunctive inferior vena cava filter (IVCF) placement in patients undergoing catheter-directed thrombolysis (CDT) for treatment of proximal lower extremity or caval deep vein thrombosis. BackgroundCDT is being increasingly used in the management of proximal deep vein thrombosis. Although a significant number of patients treated with CDT undergo adjunctive IVCF placement, the benefit of this practice remains unknown. MethodsThe National Inpatient Sample database was used to identify all patients with proximal or caval deep vein thrombosis who underwent CDT (with and without adjunctive IVCF placement) in the United States between January 2005 and December 2013. A propensity score–matching algorithm was then used to derive 2 matched groups of patients (IVCF and no IVCF) for comparative outcomes (mortality and major and minor bleeding) and resource use analysis. ResultsOf the 7,119 patients treated with CDT, 2,421 (34%) received IVCFs. There was no significant difference in in-hospital mortality (0.7% vs 1.0%; p = 0.20), procedure-related hemorrhage (1.4% vs. 1.0%; p = 0.23), or intracranial hemorrhage (0.7% vs. 0.6%; p = 0.70) between the IVCF (n = 2,259) and no-IVCF (n = 2,259) groups, respectively. Patients undergoing IVCF placement had higher rates of hematoma (3.4% vs 2.1%; p = 0.009), higher in-hospital charges ($104,049 ± 75,572 vs. $92,881 ± 80,194; p < 0.001) and increased length of stay (7.3 ± 5.6 days vs. 6.9 ± 6.9 days; p = 0.046) compared with the no-IVCF group. ConclusionsThis nationwide observational study suggests that one-third of all patients undergoing CDT receive IVCFs. IVCF use was not associated with a decrease in in-hospital mortality but was associated with higher inpatient charges and longer length of stay.

Malignancy Does not Affect Outcomes of Pharmacomechanical Thrombolysis in Acute Symptomatic Iliofemoral Deep Vein Thrombosis

Cancer patients demonstrate increased risk for venous thromboembolism (VTE), VTE recurrence, and anticoagulation-associated bleeding. Pharmacomechanical thrombolysis (PMT) aand thrombectomy improves venous patency, venous valve function, and quality of life in patients with acute iliofemoral deep vein thrombosis (DVT). It remains unknown whether pharmacomechanical thrombolysis can be used safely in patients with active cancer. We hypothesized that perioperative and short-term outcomes of pharmacomechanical iliofemoral DVT thrombolysis would not differ between patients with cancer and those without cancer. A retrospective chart review of consecutive patients with symptomatic iliofemoral DVT undergoing PMT by AngioJet Power Pulse spray and thrombectomy at a single tertiarycare university institution between December 2013 and December 2016 wasperformed. Outcomes between patients with cancer and without cancer were compared. We identified 22 limbs in 18 consecutive patients: 6 patients (7 limbs) with cancer and 12 patients (15 limbs) without cancer. Between these groups, the mean age was 60.5±4.3 vs. 53.8±26.8 years, respectively (P=0.5593), and females comprised 66.7% vs. 25.0%, respectively (P=0.0878). No significant difference in inferior vena cava (IVC) involvement between the groups (57.1% vs. 53.3%, P=0.8676) was noted. Grade II (50-94% lysis) and III (95% complete lysis) thrombus lysis with restoration of venous patency was achieved in both the groups. Overnight catheter-directed thrombolysis (CDT) was rarely used. Notably, stenting was more frequently employed in cancer patients than in those without cancer (57.1% vs. 13.3%, P=0.0316). The mean duration of follow-up was 3.42±4.41months for the cancer group and 4.50±2.43months for the noncancer group (P=0.5060). Overall outcomes were excellent as no patient in both the groups experienced recurrent DVT, major bleeding, or postthrombotic syndrome. There was no mortality associated with the endovascular thrombolysis procedures. The results of our study suggest that the presence of malignancy does not affect short-term outcomes of endovascular thrombolytic therapy in symptomatic DVT. Further follow-up is needed to evaluate long-term outcomes.