J Korean Soc Radiol.  2010 Jul;63(1):19-28. 10.3348/jksr.2010.63.1.19.

Endovascular Treatment of Left Iliofemoral Deep Vein Thrombosis Using Urokinase Thrombolysis and Adjunctive Aspiration Thrombectomy

• Suh SH
• Lee DY
• Won JY

• KMID: 2208881
• DOI: http://doi.org/10.3348/jksr.2010.63.1.19

Abstract

PURPOSE
To evaluate the efficacy of adjunctive aspiration thrombectomy for the treatment of iliofemoral deep vein thrombosis (DVT).
MATERIALS AND METHODS
24 patients (9 males and 15 females; mean age, 53 years), treated by aspiration thrombectomy were enrolled in this study. The day after undergoing urokinase (UK) thrombolysis, any residual thrombus over a long segment was treated by aspiration thrombectomy using a 12 Fr long sheath. Residual short-segment (< 10 cm) iliac vein thrombus and/or stenosis were treated with a stent. The evaluation of venous patency was conducted by color Doppler ultrasonography, venography and/or computed tomography.
RESULTS
The technical and clinical success rates were 100% and 92%, respectively. Twenty-three patients were treated by UK thrombolysis and iliac stent. The overall patency rate at 1, 2 and 3 years was 85%, 82% and 81%, respectively. Over the course of the follow-up period, occlusion was observed in 4 cases (1 acute and 3 chronic cases). Periprocedural complication occurred in 4 cases (17%) in the form of a minimal hematoma or pain on the puncture site as well as a case of pulmonary embolism at one month after treatment.
CONCLUSION
The adjunctive aspiration thrombectomy with conventional thrombolysis and stent placement can be an effective and safe method in the treatment of left iliofemoral DVT.

MeSH Terms

Constriction, Pathologic
Follow-Up Studies
Hematoma
Humans
Iliac Vein
Male
Phlebography
Pulmonary Embolism
Punctures
Stents
Thrombectomy
Thrombolytic Therapy
Thrombosis
Ultrasonography, Doppler, Color
Urokinase-Type Plasminogen Activator
Venous Thrombosis
Urokinase-Type Plasminogen Activator

Figure

• 

  Fig. 1 Acute deep vein thrombosis; 65-years-old female with iliac vein compression syndrome. A. Venogram showed occlusion of left iliac vein with pelvic collaterals. B. 5 Fr infusion catheter was located into the occluded segment and distal inferior vena cava. C. After 20 hours of urokinase infusion, venography showed residual thrombus in left iliac vein. D. Aspiration thrombectomy with 12 Fr long sheath was performed. E. Focal stenosis was noted at the proximal iliac vein, suggesting Iliac vein compression syndrome (white arrow) and there was residual thrombus in the left iliac vein. F. After stent insertion, final and (G) follow-up venogram after 18 months showed good patency of iliac vein.

• 

  Fig. 2 Chronic deep vein thrombosis (>300 days); 50-years-old male due to immobilization. A. Initial venogram showed obliteration of left iliofemoral vein with multiple collaterals. B. Catheter-directed thrombolysis with urokinase (30,000 IU/hr) was attempted through 5 Fr infusion catheter. C. Balloon angioplasty and aspiration thrombectomy were done due to the narrowed iliofemoral segment. D. After angioplasty, patency of iliofemoral segment was observed. E. Segmental occlusion was seen at the left proximal iliac vein. F. After deployment of stent, good patency was seen in the left iliac vein without residual thrombus or stenosis. G. 20 months after treatment, follow-up venogram showed the same patency in left iliac vein.

• 

  Fig. 3 Complication; 46-years-old female with cervix cancer A. Venogram showed patent left iliac vein and stent without residual thrombus. B. 1 month after treatment, CT showed massive pulmonary embolism (white arrows) owing to tumor invasion into left common iliac vein.

Reference

1. Nordstrom M, Lindblad B, Bergqvist D, Kjellstrom T. A prospective study of the incidence of deep-vein thrombosis within a defined urban population. J Intern Med. 1992; 232:155–160.

2. Anderson FA Jr, Wheeler HB, Goldberg RJ, Hosmer DW, Patwardhan NA, Jovanovic B, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. 1991; 151:933–938.

3. O'Donnell TF Jr, Browse NL, Burnand KG, Thomas ML. The socioeconomic effects of an iliofemoral venous thrombosis. J Surg Res. 1977; 22:483–488.

4. Krupski WC, Bass A, Dilley RB, Bernstein EF, Otis SM. Propagation of deep venous thrombosis identified by duplex ultrasonography. J Vasc Surg. 1990; 12:467–474.

5. Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med. 1997; 336:1506–1511.

6. Gonzalez-Fajardo JA, Arreba E, Castrodeza J, Perez JL, Fernancez L, Agundez I, et al. Venographic comparison of subcutaneous lowmolecular weight heparin with oral anticoagulant therapy in the long-term treatment of deep venous thrombosis. J Vasc Surg. 1999; 30:283–292.

7. Comerota AJ, Aldridge SC. Thrombolytic therapy for deep venous thrombosis: a clinical review. Can J Surg. 1993; 36:359–364.

8. McNamara TO, Fischer JR. Thrombolysis of peripheral arterial and graft occlusions: improved results using high-dose urokinase. AJR Am J Roentgenol. 1985; 144:769–775.

9. Semba CP, Dake MD. Iliofemoral deep venous thrombosis: aggressive therapy with catheter-directed thrombolysis. Radiology. 1994; 191:487–494.

10. Becker GJ, Holden RW, Rabe FE, Castaneda-Zuniga WR, Sears N, Dilley RS, et al. Local thrombolytic therapy for subclavian and axillary vein thrombosis. Treatment of the thoracic inlet syndrome. Radiology. 1983; 149:419–423.

11. Grossman C, McPherson S. Safety and efficacy of catheter-directed thrombolysis for iliofemoral venous thrombosis. AJR Am J Roentgenol. 1999; 172:667–672.

12. Comerota AJ. Quality-of-life improvement using thrombolytic therapy for iliofemoral deep venous thrombosis. Rev Cardiovasc Med. 2002; 3:Suppl 2. S61–S67.

13. Verhaeghe R, Stockx L, Lacroix H, Vermylen J, Baert AL. Catheterdirected lysis of iliofemoral vein thrombosis with use of rt-PA. Eur Radiol. 1997; 7:996–1001.

14. Vedantham S, Vesely TM, Parti N, Darcy M, Hovsepian DM, Picus D. Lower extremity venous thrombolysis with adjunctive mechanical thrombectomy. J Vasc Interv Radiol. 2002; 13:1001–1008.

15. Vedantham S, Vesely TM, Sicard GA, Brown D, Rubin B, Sanchez LA, et al. Pharmacomechanical thrombolysis and early stent placement for iliofemoral deep vein thrombosis. J Vasc Interv Radiol. 2004; 15:565–574.

16. Frisoli JK, Sze D. Mechanical thrombectomy for the treatment of lower extremity deep vein thrombosis. Tech Vasc Interv Radiol. 2003; 6:49–52.

17. Ramaiah V, Del Santo PB, Rodriguez-Lopez JA, Gowda RG, Perkowski PE, Diethrich EB. Trellis thrombectomy system for the treatment of iliofemoral deep venous thrombosis. J Endovasc Ther. 2003; 10:585–589.

18. Augustinos P, Ouriel K. Invasive approaches to treatment of venous thromboembolism. Circulation. 2004; 110:9 Suppl 1. I27–I34.

19. Hood DB, Alexander JQ. Endovascular management of iliofemoral venous occlusive disease. Surg Clin North Am. 2004; 84:1381–1396.

20. May R, Thurner J. The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology. 1957; 8:419–427.

21. Berger A, Jaffe JW, York TN. Iliac compression syndrome treated with stent placement. J Vasc Surg. 1995; 21:510–514.

22. Bjarnason H, Kruse JR, Asinger DA, Nazarian GK, Dietz CA, Caldwell MD, et al. Iliofemoral deep venous thrombosis: safety and efficacy outcome during 5 years of catheter-directed thrombolytic therapy. J Vasc Interv Radiol. 1997; 8:405–418.

23. Mewissen MW, Seabrook GR, Meissner MH, Cynamon J, Labropoulos N, Haughton SH. Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry. Radiology. 1999; 211:39–49.

24. Johnson BF, Manzo RA, Bergelin RO, Strandness DE Jr. Relationship between changes in the deep venous system and the development of the postthrombotic syndrome after an acute episode of lower limb deep vein thrombosis: a one- to six-year follow-up. J Vasc Surg. 1995; 21:307–312.

25. Chang R, Cannon RO 3rd, Chen CC, Doppman JL, Shawker TH, Mayo DJ, et al. Daily catheter-directed single dosing of t-PA in treatment of acute deep venous thrombosis of the lower extremity. J Vasc Interv Radiol. 2001; 12:247–252.

26. Uflacker R. Mechanical thrombectomy in acute and subacute thrombosis with use of the Amplatz device: arterial and venous applications. J Vasc Interv Radiol. 1997; 8:923–932.

27. Kasirajan K, Gray B, Ouriel K. Percutaneous angioJet thrombectomy in the management of extensive deep venous thrombosis. J Vasc Interv Radiol. 2001; 12:179–185.