The Role of Thrombolysis in Acute DVT

Yahya Albeer, MD, FRCS

Interventional Radiology

St. Mary Mercy Hospital

Livonia, Michigan

Clinical presentation

50 year-old female, sent to ER from primary care center. C/O of pain in the left hip after playing tennis 4 days prior to ER visit. Seen by PMD, x-rays were negative, treated for sciatica with Vioxx. Then developed a swelling initially in the left leg rapidly extended to left thigh and groin area over 2-3 days.

Clinical presentation

Venous Doppler at primary care clinic showed DVT from popliteal fossa to CFV.

Denies SOB, CP, N/V

PMH: MVP

PSH: Abdominal liposuction 10 weeks ago, Breast Bx. (benign)

Clinical presentation

Medications: Vioxx , No contraceptive pills

NKDA

Temp. 97.6 B.P. 131/85 RR: 14 PR: 71 O2 Sat. 97% on RA

Clinical presentationHEENT : WNL

Heart: RRR

Lungs: CTA

Neurological: No focal deficit

Extremities: Marked swelling of the Lt. Lower extremity from the groin to the toes.

Peripheral Pulses: palpable B/L

Labs

Antithrombin III normal

Protien C normal

Protien S normal

Lupus anticoagulant negative

CEA normal

CA19-9 normal

CA-125 normal

DVT

More than 600,000 cases of venous thromboembolism are estimated to occur each year in the United States.DVT of the LE has traditionally been treated with anticoagulation. Anticoagulation is used to prevent the progression of DVT to PE and to limit clot propagation.

Anticoagulation in DVT

Anticoagulation alone results in complete clot lysis in less than 4% of cases.

Anticoagulation is not effective for preventing the long-term sequelae of venous stasis disease.

Catheter-directed thrombolysis help to relieve symptoms and prevent venous wall and valve injury.

Indications for Thrombolysis

Patients with phlegmasia cerulea dolens

Patients with acute, extensive DVT

Younger patients should be more aggressively treated because of their potential for long-term complications from venous stasis disease.

Contraindications To Thrombolysis

Obsolute Active bleeding IC lesions(Stroke,

tumor, recent surgery)

Pregnancy Nonviable limb

Relative Bleeding diathesis Mal. HTN Recent Major

Surgery Postpartum

Complications of Thrombolysis

Major hemorrhage (IC bleed, massive puncture site bleed)

Distal embolization

Pericatheter thrombosis

Thrombolysis

Approach to the clot Pedal approachDirect administration into the clot

The entire thrombosed segment should be crossed and treated in order to achieve thrombolysis.

Thrombolysis

The patient is evaluated every 8-12 hours to assess the state of lysis. If no significant lysis has occurred in 24-36 hours, then successful thrombolysis is unlikely and the infusion should be ended. The procedures commonly take 2-3 days.

IVC Filter and LE Thrombolysis

IVC filters has been placed prior to thrombolysis to prevent PE.

Filter are not felt necessary prior to thrombolysis.

There is a place for temporary filters in some cases.

Venogram show complete thrombosis of the lt. Ilio-femoral vein

Management

Infusion catheter placed in the left iliac vein.

TPA infusion started at 1mg/hr.

Heparin infusion through the side arm of the vascular sheath at 500 units/hr.

Patient transferred to ICU for close monitoring.

Management

Close observation for bleeding.

Neuro-checks.

Serial labs to monitor for coagulopathy.

Serial H & H for bleeding.

6 hours post TPA infusion show some improvement

16 hours post TPA infusion show further improvement with some residual clots

28 hours post TPA infusion, there is complete lysis of the clots, there is however extrinsic compression of the left common iliac vein

May-Thurner syndrome

Iliac Vein Compression Syndrome

Post stenting and angioplasty

May-Thurner syndrome

• Isolated left lower extremity swelling secondary to left iliac vein compression

• First described by McMurrich in 1908.Defined anatomically by May and Thurner in

1957.Defined clinically by Cockett and Thomas in 1965

• The left iliac vein is usually located posterior to the right iliac artery and can be compressed between the artery and the fifth lumbar vertebrae.

Endovascular management of acute extensive iliofemoral deep venous thrombosis caused by May-Thurner

syndrome.• During a 1-year period, 10 symptomatic women

treated with thrombolysis plus angioplasty/ stenting.

• Patients F/U clinically and by doppler U/S at 1, 3, 6, and 12 months.

• All patients had to be stented because of failure of initial angioplasty.

• Initial clinical success 100%.• Complete resolution of symptoms in all

patients.• J Vasc Interv Radiol. 2000 Nov-Dec;11(10):1297-302.

Endovascular management of acute extensive iliofemoral deep venous thrombosis caused by May-Thurner

syndrome.One patient was hypercoagulable, had

recurrent symptomatic acute DVT 1 month after therapy.

• Mean follow-up of 15.2 months (range, 6-36 months).

Serial U/S in all 10 patients no evidence of valvular insufficiency in the femoral and popliteal veins..

• Vasc Interv Radiol. 2000 Nov-Dec;11(10):1297-302.

Endovascular management of acute extensive iliofemoral deep venous thrombosis caused by May-Thurner

syndrome.

CONCLUSION: Catheter-directed thrombolytic therapy for the treatment of acute extensive iliofemoral DVT due to May-Thurner syndrome is an effective method for restoring venous patency and provides relief of the acute symptoms. The underlying left common iliac vein lesion invariably needs to undergo stent placement.

J Vasc Interv Radiol. 2000 Nov-Dec;11(10):1297-302.

Endovascular Management of Iliac Vein Compression (May-

Thurner) Syndrome

39 patients (29 women, 10 men; median age, 46 years)

19 pts presented with acute DVT and 20 pts presented with chronic symptoms.

Acute DVT treated with catheter thrombolysis plus angioplasty/stenting.

Chronic pts treated with angioplasty/ stenting alone.

J Vasc Interv Radiol 2000 11: 1297-1302

Endovascular Management of Iliac Vein Compression (May-

Thurner) Syndrome

Initial technical success was achieved in 34 of 39 patients (87%).

1-year patency rate for pts with acute DVT was 91.6%

pts with chronic symptoms, 1-year patency rate was 93.9%.

J Vasc Interv Radiol 2000 11: 1297-1302

Endovascular Management of Iliac Vein Compression (May-

Thurner) SyndromeMajor complications included acute iliac vein rethrombosis (< 24 hours) requiring reintervention Minor complications included perisheath hematomas (n = 4) and minor bleeding (n = 1).no deaths, pulmonary embolus, cerebral hemorrhage, or major bleeding complications

J Vasc Interv Radiol 2000 11: 1297-1302

Endovascular Management of Iliac Vein Compression (May-

Thurner) Syndrome

CONCLUSION: Endovascular reconstruction of occluded iliac veins

secondary to IVCS (May-Thurner) appears to be safe and effective.

J Vasc Interv Radiol 2000 11: 1297-1302

Effort thrombosis or Paget-Schroetter syndrome

Compression of the subclavian vein between the clavicle and the subclavius muscle anteriorly and the first rib and scalenus muscle posteriorly.

Treatment include combination of catheter directed thrombolytic therapy to restore venous patency and surgical correction of the anatomic abnormality is the most effective treatment.

Effort thrombosis or Paget-Schroetter syndrome

An example of Paget Schroetter Sy.

The compression best seen during hyperabduction.

This condition can be bilateral