Comparison of Direct Iliofemoral Stenting Following AngioJet Rheolytic Thrombectomy vs Staged Stenting After AngioJet Rheolytic Thrombectomy Plus Catheter-Directed Thrombolysis in Patients With Acute Deep Vein Thrombosis
Restricted accessResearch articleFirst published online February, 2018
Comparison of Direct Iliofemoral Stenting Following AngioJet Rheolytic Thrombectomy vs Staged Stenting After AngioJet Rheolytic Thrombectomy Plus Catheter-Directed Thrombolysis in Patients With Acute Deep Vein Thrombosis
Purpose: To compare the treatment outcomes in patients with acute proximal deep vein thrombosis (DVT) and iliofemoral stenosis who underwent either direct stenting after AngioJet rheolytic thrombectomy or staged stenting after AngioJet thrombectomy plus catheter-directed thrombolysis with urokinase. Methods: From June 2014 to February 2016, 91 DVT patients underwent 2 treatments for duplex-verified iliofemoral stenosis: direct stenting (n = 46; mean age 54.8 years; 32 men) or staged stenting (n = 45; mean age 56.5 years; 27 men). The degree of patency after thrombectomy or thrombolysis was evaluated using the Venous Registry Index (VRI), while the risk of postthrombotic syndrome (PTS) was evaluated according to the Villalta scale. Patients were followed with periodic duplex ultrasound scans up to 1 year. Results: The technical success rates were 100% in both groups; there was no 30-day mortality. Immediate (24-hour) clinical improvement was achieved in 42 (91%) of 46 direct group patients vs 33 (73%) of 45 staged group patients (p<0.001). A significant reduction (p<0.001) in the length of hospital stay was noted in the direct group (4.59±0.91) compared with that in the staged group (5.8±1.6). The stents used in the direct group were longer but with similar diameter compared with the staged group. The thrombolysis rates were 81.50%±5.76% in the direct group and 85.67%±3.84% in the staged group (p<0.001). The VRIs declined (improved) significantly in both groups (11.68±1.92 to 3.21±1.44 in the direct group and 12.17±2.29 to 2.36±1.19 in the staged group, both p<0.001). The Villalta scores were significantly better in the staged group (p<0.001). Recurrent DVT occurred in 2 patients in the direct group. The primary patency rates at 1 year were 93.5% in the direct group and 97.8% in the staged group (p=0.323). Conclusion: Both direct and staged stenting are effective treatment modalities for patients with acute proximal DVT. Compared with staged stenting, direct stenting provides similar treatment success and a significant reduction in the length of hospital stay; however, it has lower thrombolysis efficacy, and the risk of PTS at 1 year is greater with direct stenting.
KearonC.Natural history of venous thromboembolism. Circulation. 2003;107(23suppl 1):I22–I30.
2.
BeckmanMGHooperWCCritchleySEet al. Venous thromboembolism: a public health concern. Am J Prev Med. 2010;38(4Suppl):S495–S501.
3.
CohenATAgnelliGAndersonFAet al; VTE Impact Assessment Group in Europe (VITAE). Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost. 2007;98:756–764.
4.
ComerotaAJ.Thrombolysis for deep venous thrombosis. J Vasc Surg. 2012;55:607–611.
5.
AkessonHBrudinLDahlströmJAet al. Venous function assessed during a 5-year period after acute iliofemoral venous thrombosis treated with anticoagulation. Eur J Vasc Surg. 1990;4:43–48.
6.
DelisKTBountouroglouDMansfieldAO.Venous claudication in iliofemoral thrombosis: long-term effects on venous hemodynamics, clinical status, and quality of life. Ann Surg. 2004;23:118–126.
7.
ComerotaAJ.Randomized trial evidence supporting a strategy of thrombus removal for acute DVT. Semin Vasc Surg. 2010;23:192–198.
8.
VedanthamS.Catheter-directed thrombolysis for deep vein thrombosis. Curr Opin Hematol. 2010;17:464–468.
9.
HaigYEndenTGrøttaOet 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:e64–e71.
10.
MeissnerMHGloviczkiPComerotaAJet al. Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2012;55:1449–1462.
11.
KahnSRShrierIJulianJAet al. Determinants and time course of the postthrombotic syndrome after acute deep venous thrombosis. Ann Intern Med. 2008;149:698–707.
12.
DouketisJDCrowtherMAFosterGAet al. Does the location of thrombosis determine the risk of disease recurrence in patients with proximal deep vein thrombosis?Am J Med. 2001;110:515–519.
13.
KearonCKahnSRAgnelliGet al. Antithrombotic therapy for venous thromboembolic disease: ACCP evidence-based clinical practice guidelines (8th ed). Chest. 2008;133(6suppl):454S–545S.
14.
ScottLRSilvaJAWhiteCet al. Rheolytic thrombectomy: a new treatment for stent thrombosis. Catheter Cardiovasc Interv. 1999;47:97–101.
15.
WagnerHJMuller-HulsbeckSPittonMBet al. Rapid thrombectomy with a hydrodynamic catheter: results from a prospective, multicenter trial. Radiology. 1997;205:675–681.
16.
VedanthamSSistaAKKleinSJet al. Quality improvement guidelines for the treatment of lower-extremity deep vein thrombosis with use of endovascular thrombus removal. J Vasc Interv Radiol. 2014;25:1317–1325.
17.
JaffMRMcMurtryMSArcherSLet al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123:1788–1830.
18.
LinPHJohnsonCKPulliumJKet al. l-Arginine improves endothelial vasoreactivity and reduces thrombogenicity after thrombolysis in experimental deep venous thrombosis. J Vasc Surg. 2003;38:1396–1403.
19.
ChoJSMartelliEMozesGet al. Effects of thrombolysis and venous thrombectomy on valvular competence, thrombogenicity, venous wall morphology, and function. J Vasc Surg. 1998;28:787–799.
20.
LinPHZhouWDardikAet al. Catheter-direct thrombolysis versus pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis. Am J Surg. 2006;192:782–788.
21.
VogelDWalshMEChenJTet al. Comparison of vein valve function following pharmacomechanical thrombolysis versus simple catheter-directed thrombolysis for iliofemoral deep vein thrombosis. J Vasc Surg. 2012;56:1351–1354.
22.
KasirajanKGrayBOurielK.Percutaneous AngioJet thrombectomy in the management of extensive deep venous thrombosis. J Vasc Interv Radiol. 2001;12:179–185.
23.
HuangCYHsuHLKuoTTet al. Percutaneous pharmacomechanical thrombectomy offers lower risk of post-thrombotic syndrome than catheter-directed thrombolysis in patients with acute deep vein thrombosis of the lower limb. Ann Vasc Surg. 2015;29:995–1002.
24.
GarciaMJLooksteinRMalhotraRet al. Peripheral use of AngioJet Rheolytic Thrombectomy with a variety of catheter lengths) registry. 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;26:777–785.
25.
Vascular Surgery Group of Surgery of Chinese Medical Association. Guidelines for the diagnosis and treatment of deep venous thrombosis (2nd edition). Chin J Gen Surg. 2012;27:605–607.
26.
HaenenJHWollersheimHJanssenMCet al. Evolution of deep venous thrombosis: a 2-year follow-up using duplex ultrasound scan and strain-gauge plethysmography. J Vasc Surg. 2001;34:649–655.
27.
VedanthamSGrassiCJFerralHet al. Reporting standards for endovascular treatment of lower extremity deep vein thrombosis. J Vasc Interv Radiol. 2006;17:417–434.
28.
MarderVJSoulenRLAtichartakarnVet al. Quantitative venographic assessment of deep vein thrombosis in the evaluation of streptokinase and heparin therapy. J Lab Clin Med. 1977;89:1018–1029.
29.
MewissenMWSeabrookGRMeissnerMHet al. Catheter directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry. Radiology. 1999;211:39–49.
30.
VasquezMAMunschauerCE.Venous Clinical Severity Score and quality-of-life assessment tools: application to vein practice. Phlebology. 2008;23:259–275.
31.
BushRLLinPHBatesJTet al. Pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis: safety and feasibility study. J Vasc Surg. 2004;40:965–970.
32.
SevittS.The structure and growth of valve-pocket thrombi in femoral veins. J Clin Pathol. 1974;27:517–528.
33.
GrewalNKMartinezJTAndrewsLet al. Quantity of clot lysed after catheter-directed thrombolysis for iliofemoral deep venous thrombosis correlates with post-thrombotic morbidity. J Vasc Surg. 2010;51:1209–1214.
