The Role of Thrombolysis in Acute DVT

1. The Role of Thrombolysis in Acute DVT Yahya Albeer, MD, FRCS Interventional Radiology St. Mary Mercy Hospital Livonia, Michigan

2. 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.

3. 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)

4. Clinical presentation • Medications: Vioxx , No contraceptive pills • NKDA • Temp. 97.6 B.P. 131/85 RR: 14 PR: 71 O2 Sat. 97% on RA

5. Clinical presentation • HEENT: 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

6. Labs • Antithrombin III normal • Protien C normal • Protien S normal • Lupus anticoagulant negative • CEA normal • CA19-9 normal • CA-125 normal

7. 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.

8. 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.

9. 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.

10. Obsolute Active bleeding IC lesions(Stroke, tumor, recent surgery) Pregnancy Nonviable limb Relative Bleeding diathesis Mal. HTN Recent Major Surgery Postpartum Contraindications To Thrombolysis

11. Complications of Thrombolysis • Major hemorrhage (IC bleed, massive puncture site bleed) • Distal embolization • Pericatheter thrombosis

12. Thrombolysis • Approach to the clot • Pedal approach • Direct administration into the clot • The entire thrombosed segment should be crossed and treated in order to achieve thrombolysis.

13. 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.

14. 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.

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

16. 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.

17. Management • Close observation for bleeding. • Neuro-checks. • Serial labs to monitor for coagulopathy. • Serial H & H for bleeding.

18. 6 hours post TPA infusion show some improvement

19. 16 hours post TPA infusion show further improvement with some residual clots

20. 28 hours post TPA infusion, there is complete lysis of the clots, there is however extrinsic compression of the left common iliac vein

21. May-Thurner syndrome Iliac Vein Compression Syndrome

26. Post stenting and angioplasty

27. 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.

28. 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.

29. 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.

30. 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.

31. Endovascular Management of Iliac Vein Compression (May-Thurner) Syndrome • 39 patients(29 women, 10 men; median age, 46 years) • 19 pts presented withacute DVT and 20 pts presented withchronic 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

32. Endovascular Management of Iliac Vein Compression (May-Thurner) Syndrome • Initial technical success was achieved in 34 of 39patients (87%). • 1-year patency rate forpts 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

33. Endovascular Management of Iliac Vein Compression (May-Thurner) Syndrome • Major complications included acute iliac vein rethrombosis (<24 hours) requiring reintervention • Minor complicationsincluded 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

34. Endovascular Management of Iliac Vein Compression (May-Thurner) Syndrome • CONCLUSION: Endovascular reconstruction of occluded iliac veinssecondary to IVCS (May-Thurner) appears to be safe and effective. • J Vasc Interv Radiol 2000 11: 1297-1302

35. 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.

36. Effort thrombosis or Paget-Schroetter syndrome • An example of Paget Schroetter Sy. • The compression best seen during hyperabduction. • This condition can be bilateral