After a 20-minute incubation period, a thrombectomy was performed several times along the femoral vein and popliteal vein, using an AngioJet device. A follow-up venogram revealed a small amount of residual thrombi in the right suprageniculate popliteal vein and right femoral vein. This entire segment was further treated with angioplasty, and a postintervention venogram demonstrated patency of the right suprageniculate popliteal vein and right femoral vein with minimal residual thrombi and with brisk venous flow (Figure 1B). Immediately after the procedure, the patient’s RLE pain significantly improved. On day 2 postprocedure, the patient’s RLE edema resolved, and the patient was able to resume normal ambulation. There were no bleeding complications. The patient was discharged with oral anticoagulation therapy.
Case 2
A male aged 78 years with a history of hypertension, hyperlipidemia, and benign prostatic hypertrophy presented to the ED with 10 days of progressive pain and swelling in the left lower extremity (LLE). The patient noted decreased mobility over recent months and was using a front wheel walker while recovering from surgical repair of a hamstring tendon injury. He reported taking a transcontinental flight around the same time that his LLE pain began. The patient reported no prior history of VTE or family history of thrombophilia.
A physical examination was notable for stable vital signs with a normal cardiopulmonary examination. There was extensive LLE edema up to the proximal thigh without erythema or cyanosis, and his skin was taut and tender. Neurovascular examination of the LLE was normal. Laboratory studies were unremarkable. Compression ultrasonography with Doppler of the LLE demonstrated an extensive acute occlusive thrombus within the left common femoral, entire left femoral, and left popliteal veins.
After evaluating the patient, the Vascular Surgery service did not feel there was evidence of compartment syndrome nor PCD. The patient received unfractionated heparin anticoagulation therapy and the LLE was elevated continuously. After 24 hours of anticoagulation therapy, the patient continued to have significant pain and was unable to ambulate. The case was presented in a joint Interventional Radiology/Vascular Surgery conference and the decision was made to pursue pharmacomechanic thrombolysis given the significant extent of thrombotic burden.
The patient underwent successful catheter-directed pharmacomechanic thrombolysis via pulse-spray thrombolysis of 15 mg of tPA using the Boston Scientific AngioJet Thrombectomy System, and angioplasty with no immediate complications (Figure 2). The patient noted dramatic improvement in LLE pain and swelling 1 day postprocedure and was able to ambulate. He developed mild asymptomatic hematuria, which resolved within 12 hours and without an associated drop in hemoglobin. The patient was transitioned to oral anticoagulation and discharged to an acute rehabilitation unit on postprocedure day 2.
Discussion
Anticoagulation is the preferred therapy for most patients with acute uncomplicated lower extremity DVT. PCD is the only widely accepted indication for thrombolytic therapy in patients with acute lower extremity DVT. However, in the absence of PCD, management of complicated DVT where there are either significant symptoms, extensive clot burden, or proximal location is less clear due to the paucity of clinical data. For example, in the case of iliofemoral DVT, thrombosis of the iliofemoral region is associated with an increased risk of pulmonary embolism, limb malperfusion, and PTS when compared with other types of DVT.5,6Furthermore, despite the use of anticoagulant therapy, PTS develops within 2 years in about half of patients with proximal DVT, which can progress to major disability and impaired quality of life.9
Earlier retrospective observational studies in patients with acute DVT found that the addition of either systemic thrombolysis or catheter-directed thrombolysis to anticoagulation increased rates of clot lysis but did not lead to a reduction in clinical outcomes such as recurrent thromboembolism, mortality, or the rate of PTS.10-12 Additionally, both systemic thrombolytic therapy and catheter-directed thrombolytic therapy were associated with higher rates of major bleeding. However, these studies included all patients with acute DVT without selecting for criteria, such as proximal location of DVT, severe symptoms, or extensive clot burden. Because thrombolytic therapy is proven to provide more rapid and immediate clot lysis (whereas conventional anticoagulation prevents thrombus extension and recurrence but does not dissolve the clot), it is reasonable to suggest that a subpopulation of patients with extensive or symptomatic DVT may benefit from immediate clot lysis, thereby restoring limb perfusion and avoiding limb gangrene while preserving venous function and preventing PTS.
