Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 6  |  Page : 168-171

Pharmacomechanical catheter-directed thrombolysis: An emerging therapy for deep vein thrombosis – A case series


Department of Cardiology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India

Date of Submission04-Jan-2021
Date of Decision19-Apr-2021
Date of Acceptance04-Jun-2021
Date of Web Publication20-Jan-2022

Correspondence Address:
Srinivasan Giridharan
Department of Cardiology, Mahatma Gandhi Medical College and Research Institute, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_1_21

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  Abstract 


Venous thromboembolism comprising pulmonary embolism and deep-vein thrombosis (DVT) is a major health problem with DVT accounting for two-third of them. Lower extremity DVTs account for 25%–50% of them and have long-term chronic venous complications which are termed as postthrombotic syndrome. The armamentarium in DVT management includes systemic anticoagulation, mechanical thrombectomy, and catheter-directed thrombolysis (CDT). Despite the benefits of therapy, CDT has its own limitations. Pharmacomechanical CDT (PMCDT) is an emerging percutaneous therapy which improves the treatment efficacy and reduces the incidence of long-term complications. Here, we present a series of three cases where PMCDT was used in acute to subacute DVT with poor response to anticoagulation therapy.

Keywords: Deep-vein thrombosis, pharmacomechanical, postthrombotic syndrome


How to cite this article:
Aashish A, Ganesh BA, Karthikeyan S, Giridharan S. Pharmacomechanical catheter-directed thrombolysis: An emerging therapy for deep vein thrombosis – A case series. Indian J Vasc Endovasc Surg 2021;8, Suppl S2:168-71

How to cite this URL:
Aashish A, Ganesh BA, Karthikeyan S, Giridharan S. Pharmacomechanical catheter-directed thrombolysis: An emerging therapy for deep vein thrombosis – A case series. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Jul 4];8, Suppl S2:168-71. Available from: https://www.indjvascsurg.org/text.asp?2021/8/6/168/336010




  Introduction Top


Venous thromboembolic disorders which include deep-vein thrombosis (DVT) and pulmonary embolism (PE) are a major health problem. Lower extremity cases account for 25%–50% of DVT and cause long-term chronic venous complications which are termed as postthrombotic syndrome (PTS) and proximal diseases comprise 80% of PTS cases.[1],[2],[3] The mainstay of treatment of acute DVT is to avoid or decrease the chances of developing PTS which have a detrimental quality of life.[2] Various strategies available for DVT management are systemic anticoagulation (SA), mechanical thrombectomy (MT), catheter-directed thrombolysis (CDT), and pharmacomechanical CDT(PMCDT).[1],[2],[4] However despite the benefits of therapy, CDT has its own limitations. PMCDT is an emerging percutaneous therapy which combines mechanical technology to aspirate thrombus and also delivers low-dose thrombolytic agent, thereby improving the treatment efficacy and reducing the incidence of complications and limitations of CDT.[5] Here, we present a series of three cases where PMCDT was used in acute and subacute DVT with poor response to anticoagulation therapy. We could not find any reported cases of using PMCDT in India so far.


  Case Top


Case 1

A 48-year-old female presented with sudden-onset progressive swelling of the left lower limb. In view of poor response to SA, she underwent PMCDT using Rheolytic AngioJet system. Check venogram showed Grade 2 angiographic result with underlying May–Thurner syndrome. Following staged venoplasty and stenting [Figure 1], she had excellent venographic results with no recurrence up to 2 years [Table 1].
Figure 1: (a) Prestenting venogram image of May–Thurner syndrome, (b) stenting of common iliac vein to external iliac vein, (c) poststenting image revealing excellent angiographic result

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Table 1: Patient information

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Case 2

A 41-year-old female presented with submassive PE and was thrombolysed with tenecteplase. She was diagnosed to have associated DVT. Two weeks post thrombolysis and OAC therapy, she had persisting limb swelling and extensive thrombus. Check venogram confirmed thrombus extending from left CIV to PV appearing subacute and organized. Multiple segmental thromboaspirations were made using the Indigo Penumbra CAT 8 system [Figure 2] and [Figure 3]. Check venogram showed minimal stenosis with brisk flow at CIV-EIV junction which was balloon dilated with 10 mm × 40 mm RIVAL balloon. The final venogram revealed excelled angiographic results with no recurrence after 1 year [Table 1].
Figure 2: (a) High thrombus load in femoral vein, (b) thrombus occupying the iliac veins, (c) Penumbra catheter and separator

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Figure 3: Aspirated thrombus through Penumbra Indigo CAT8 system

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Case 3

A 54-year-old male with proximal DVT had poor response to low molecular weight heparin. Venogram showed thrombus extending from the left CIV to PV. Thromboaspiration was done using the Penumbra CAT 8 system. Due to Grade 1 response, he was started on STK infusion through a pig tail catheter. After completion of infusion, his pain subsided with good resolution of swelling of the lower limb [Table 1]. His postprocedure period was complicated with acute kidney injury and hematuria which improved with conservative management After 2 weeks, his renal parameters stabilized and he underwent computed tomography venogram which revealed no underlying stenosis with good flow and no residual thrombus. On follow-up after 6 months, there was no recurrence.


  Discussion Top


Eight percent of acute DVT are proximal diseases leading to high risk of life-threatening PE in up to 10%–25%.[1],[2],[3],[5] The complications include early, intermediate, and long term. Early and immediate complications are thrombus extension, PE and DVT recurrence, especially within the first 6 months. About 25%–50% of DVT involving the lower extremities develop PTS in spite of adequate anticoagulation therapy. Their symptoms are pain, heaviness, swelling, venous claudication, and venous ulcers.[3]

The various treatment strategies for management of acute DVT are SA, CDT, MT, and PMCDT.[1],[2],[4] Standard immediate treatment for acute DVT is SA therapy with unfractionated heparin or LMWH.[6] SA therapy prevents further clot propagation and PE, but it does not dissolve the existing clot because it relies on endogenous fibrinolysis to do it. The main goal of using these other modalities when there is a poor response to anticoagulation is to remove the existing clot and decrease the chances of PTS.[5]

Despite multiple studies demonstrating the efficacy of CDT in establishing venous patency, it has its own limitations such as bleeding, prolonged hospital stays, multiple catheterization visits, and ICU observation.[1] The importance and benefits of achieving venous patency with significant thrombus reduction in acute DVT correlate directly with reducing the mortality and morbidity, especially PTS.[6] The emerging MT techniques [Table 2] employ percutaneous mechanical thrombus aspiration with or without local thrombolysis based on the technique. Additional CDT following MT can be given based on the thrombus reduction visible angiographically. Angiographically, thrombus reduction is graded as Grade 1, Grade 2, and Grade 3 for <50%, 50%–99%, and 100% reduction, respectively. When there is Grade 1 thrombus burden post-MT, additional CDT for 12–24 h can be used as an adjunctive therapy to achieve greater results.[5] Unlike primary CDT, in CDT following the MT techniques, we create a tract for the thrombolytic agent to dwell well to achieve optimal results. There is also a reduced amount of thrombolytic agent needed in this scenario thereby reducing its complications. PMCDT techniques significantly reduce hospital stay and achieve greater optimal results and long-term complications.[1],[2],[7]
Table 2: Mechanical thrombectomy techniques and their principle[1],[2],[4]

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In our case series, we used the Rheolytic AngioJet system in one patient where local thrombolysis was done with streptokinase followed by aspiration which resulted in good flow with >50% reduction in thrombus load. It also revealed underlying May–Thurner syndrome as the cause of DVT; hence, she was successfully stented from CIV to EIV followed by NOAC therapy.

The other two underwent suction thrombectomy through the Penumbra Indigo CAT8 system. The third patient had suboptimal results angiographically requiring additional CDT for 24 h.

In acute and subacute DVT patients who failed to respond to parenteral anticoagulation, PMCDT provides symptomatic relief as well as angiographic success. The need for additional CDT/venoplasty can be individualized based on the response to mechanical aspiration and underlying etiology.


  Conclusion Top


PMCDT is proven to be effective in the treatment of acute and subacute DVT in achieving optimal results, reduced hospital stay, and decreased life-threatening and long-term complications. Following PMCDT, additional CDT can be administered if there are suboptimal results. To date, we could not find any reported case of PMCDT therapy for DVT in India. Based on our experience, both Rheolytic AngioJet and Penumbra Indigo system were effective in acute and subacute DVT management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fleck D, Albadawi H, Shamoun F, Knuttinen G, Naidu S, Oklu R. Catheter-directed thrombolysis of deep vein thrombosis: Literature review and practice considerations. Cardiovasc Diagn Ther 2017;7:S228-37.  Back to cited text no. 1
    
2.
Kohi MP, Kohlbrenner R, Kolli KP, Lehrman E, Taylor AG, Fidelman N. Catheter directed interventions for acute deep vein thrombosis. Cardiovasc Diagn Ther 2016;6:599-611.  Back to cited text no. 2
    
3.
Mazzolai L, Aboyans V, Ageno W, Agnelli G, Alatri A, Bauersachs R, et al. Diagnosis and management of acute deep vein thrombosis: A joint consensus document from the European Society of Cardiology working groups of aorta and peripheral vascular diseases and pulmonary circulation and right ventricular function. Eur Heart J 2018;39:4208-18.  Back to cited text no. 3
    
4.
Lopez R, DeMartino R, Fleming M, Bjarnason H, Neisen M. Aspiration thrombectomy for acute iliofemoral or central deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2019;7:162-8.  Back to cited text no. 4
    
5.
Garcia MJ, Lookstein R, Malhotra R, Amin A, Blitz LR, Leung DA, et al. Endovascular management of deep vein thrombosis with rheolytic thrombectomy: Final report of the prospective multicenter PEARL (peripheral use of angiojet rheolytic thrombectomy with a variety of catheter lengths) registry. J Vasc Interv Radiol 2015;26:777-85.  Back to cited text no. 5
    
6.
Karthikesalingam A, Young EL, Hinchliffe RJ, Loftus IM, Thompson MM, Holt PJ. A systematic review of percutaneous mechanical thrombectomy in the treatment of deep venous thrombosis. Eur J Vasc Endovasc Surg 2011;41:554-65.  Back to cited text no. 6
    
7.
Chen JX, Sudheendra D, Stavropoulos SW, Nadolski GJ. Role of catheter-directed thrombolysis in management of iliofemoral deep venous thrombosis. Radiographics 2016;36:1565-75.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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