Endo Treatment Aids in Acute IVC Thrombosis

SCOTTSDALE, ARIZ. – Endovascular treatment of acute, symptomatic inferior vena cava thrombosis produced "good" short-term clinical results, according to investigators who retrospectively studied 19 patients.

This aggressive approach to treating acute caval thrombosis seemed warranted even in the presence of a thrombosed inferior vena cava filter, Dr. Charles C. Sticco said. The risk of a poor prognosis appeared to be higher in patients with phlegmasia cerulea dolens, he said at the annual meeting of the Southern Association for Vascular Surgery.

Photos courtesy of Dr. Quinhua Pu

Dr. Sticco, of Staten Island (N.Y.) University Hospital, and his associates reviewed the records of all patients treated for acute thrombosis of the inferior vena cava (AT-IVC) between 2004 and 2011. Patients had been symptomatic for an average of 6 days before endovascular treatment. All patients had a history of deep vein thrombosis.

Endovascular treatment of the AT-IVC was successful in all 19 patients. Two of eight patients who presented with phlegmasia cerulea dolens died of multiorgan system failure in the immediate postoperative period. During a mean follow-up of 6 months, three patients were lost to follow-up.

Among the remaining 14 patients, 6 had complete relief of symptoms (43%), and 8 had partial symptom relief (57%), Dr. Sticco said. The American Venous Registry index (also known as Mewissen score) decreased from nearly 14 before treatment to approximately 3 after treatment.

Follow-up ultrasound evaluations showed no evidence of deep vein thrombosis in six patients (43%), chronic deep vein thrombosis in six patients (43%), and recurrent acute deep vein thrombosis in two patients (14%). Valve reflux was seen in three patients (21%). Two patients developed recurrent inferior vena cava thrombosis.

The 6-month follow-up findings were "promising," he said. On the CEAP (Clinical, Etiologic, Anatomic, and Pathophysiologic) classification of venous insufficiency, patients had a mean classification of 2.2 out of 6. On the Villalta scale, a clinical assessment of post-thrombosis syndrome, patients had a mean score of 3.4, suggesting no post-thrombotic syndrome on average.

Eleven of the 14 patients were free of new acute DVT (80%), and 11 were free of post-thrombotic symptoms (80%) at 6 months, Dr. Sticco said.

A "low incidence of complications" in the whole cohort of 19 patients included major bleeding in two patients (11%) and minor bleeding in five patients (26%), he said. Eight patients received a blood transfusion (42%). Six patients developed renal insufficiency (32%), and one patient each had a nonfatal arrhythmia, fasciotomy, above-knee amputation secondary to venous gangrene (in a patient who presented with phlegmasia), or pulmonary embolism.

All patients had presented with both swelling and pain. Eight had phlegmasia cerulea dolens (42%), 14 showed motor dysfunction (74%), and 12 had sensory deficits (63%). Risk factors included a history of pulmonary embolism in 14 patients, a hypercoagulable state in 11, cancer in 6 patients, immobility in 4, and recent surgery in 2.

Fifteen patients had a prior IVC filter placed (79%). "At our institution, we have seen an increase in the insertion of IVC filters, and an increase in occlusion of these filters with associated caval thrombosis," Dr. Sticco said.

The thrombosis extended to the iliac veins in a majority of patients (10, or 53%).

For management of the AT-IVC, all patients were continued on their medical therapy for anticoagulation and were transitioned to warfarin therapy. Five patients who were on warfarin therapy when they developed AT-IVC had a subtherapeutic International Normalized Ratio, he noted. All patients received fluid resuscitation, leg elevation, and an aggressive IV heparin bolus that was maintained at therapeutic levels.

Endovascular treatment under conscious sedation and local anesthesia consisted of catheter-directed thrombolysis (with tissue plasminogen activator) in 3 patients and catheter-directed thrombolysis plus pharmacomechanical thrombectomy in 13. Two patients were treated solely with pharmacomechanical thrombectomy, using the AngioJet Rheolytic Thrombectomy System alone in one patient and the AngioJet plus the Trellis Peripheral Infusion System in one patient.

Adjunctive procedures included angioplasty in 14 patients (74%) and stent placement in 9 (47%). At discharge all patients were given thigh-high compression stockings.

AT-IVC is known to cause post-thrombotic syndrome, limb loss, pulmonary embolism, and death. Endovascular treatment of AT-IVC provided immediate symptom relief, and may reduce the incidence of these complications, he said.

Dr. Sticco reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Endovascular treatment of acute, symptomatic inferior vena cava thrombosis produced "good" short-term clinical results, according to investigators who retrospectively studied 19 patients.

This aggressive approach to treating acute caval thrombosis seemed warranted even in the presence of a thrombosed inferior vena cava filter, Dr. Charles C. Sticco said. The risk of a poor prognosis appeared to be higher in patients with phlegmasia cerulea dolens, he said at the annual meeting of the Southern Association for Vascular Surgery.

Photos courtesy of Dr. Quinhua Pu

Dr. Sticco, of Staten Island (N.Y.) University Hospital, and his associates reviewed the records of all patients treated for acute thrombosis of the inferior vena cava (AT-IVC) between 2004 and 2011. Patients had been symptomatic for an average of 6 days before endovascular treatment. All patients had a history of deep vein thrombosis.

Endovascular treatment of the AT-IVC was successful in all 19 patients. Two of eight patients who presented with phlegmasia cerulea dolens died of multiorgan system failure in the immediate postoperative period. During a mean follow-up of 6 months, three patients were lost to follow-up.

Among the remaining 14 patients, 6 had complete relief of symptoms (43%), and 8 had partial symptom relief (57%), Dr. Sticco said. The American Venous Registry index (also known as Mewissen score) decreased from nearly 14 before treatment to approximately 3 after treatment.

Follow-up ultrasound evaluations showed no evidence of deep vein thrombosis in six patients (43%), chronic deep vein thrombosis in six patients (43%), and recurrent acute deep vein thrombosis in two patients (14%). Valve reflux was seen in three patients (21%). Two patients developed recurrent inferior vena cava thrombosis.

The 6-month follow-up findings were "promising," he said. On the CEAP (Clinical, Etiologic, Anatomic, and Pathophysiologic) classification of venous insufficiency, patients had a mean classification of 2.2 out of 6. On the Villalta scale, a clinical assessment of post-thrombosis syndrome, patients had a mean score of 3.4, suggesting no post-thrombotic syndrome on average.

Eleven of the 14 patients were free of new acute DVT (80%), and 11 were free of post-thrombotic symptoms (80%) at 6 months, Dr. Sticco said.

A "low incidence of complications" in the whole cohort of 19 patients included major bleeding in two patients (11%) and minor bleeding in five patients (26%), he said. Eight patients received a blood transfusion (42%). Six patients developed renal insufficiency (32%), and one patient each had a nonfatal arrhythmia, fasciotomy, above-knee amputation secondary to venous gangrene (in a patient who presented with phlegmasia), or pulmonary embolism.

All patients had presented with both swelling and pain. Eight had phlegmasia cerulea dolens (42%), 14 showed motor dysfunction (74%), and 12 had sensory deficits (63%). Risk factors included a history of pulmonary embolism in 14 patients, a hypercoagulable state in 11, cancer in 6 patients, immobility in 4, and recent surgery in 2.

Fifteen patients had a prior IVC filter placed (79%). "At our institution, we have seen an increase in the insertion of IVC filters, and an increase in occlusion of these filters with associated caval thrombosis," Dr. Sticco said.

The thrombosis extended to the iliac veins in a majority of patients (10, or 53%).

For management of the AT-IVC, all patients were continued on their medical therapy for anticoagulation and were transitioned to warfarin therapy. Five patients who were on warfarin therapy when they developed AT-IVC had a subtherapeutic International Normalized Ratio, he noted. All patients received fluid resuscitation, leg elevation, and an aggressive IV heparin bolus that was maintained at therapeutic levels.

Endovascular treatment under conscious sedation and local anesthesia consisted of catheter-directed thrombolysis (with tissue plasminogen activator) in 3 patients and catheter-directed thrombolysis plus pharmacomechanical thrombectomy in 13. Two patients were treated solely with pharmacomechanical thrombectomy, using the AngioJet Rheolytic Thrombectomy System alone in one patient and the AngioJet plus the Trellis Peripheral Infusion System in one patient.

Adjunctive procedures included angioplasty in 14 patients (74%) and stent placement in 9 (47%). At discharge all patients were given thigh-high compression stockings.

AT-IVC is known to cause post-thrombotic syndrome, limb loss, pulmonary embolism, and death. Endovascular treatment of AT-IVC provided immediate symptom relief, and may reduce the incidence of these complications, he said.

Dr. Sticco reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Endovascular treatment of acute, symptomatic inferior vena cava thrombosis produced "good" short-term clinical results, according to investigators who retrospectively studied 19 patients.

This aggressive approach to treating acute caval thrombosis seemed warranted even in the presence of a thrombosed inferior vena cava filter, Dr. Charles C. Sticco said. The risk of a poor prognosis appeared to be higher in patients with phlegmasia cerulea dolens, he said at the annual meeting of the Southern Association for Vascular Surgery.

Photos courtesy of Dr. Quinhua Pu

Dr. Sticco, of Staten Island (N.Y.) University Hospital, and his associates reviewed the records of all patients treated for acute thrombosis of the inferior vena cava (AT-IVC) between 2004 and 2011. Patients had been symptomatic for an average of 6 days before endovascular treatment. All patients had a history of deep vein thrombosis.

Endovascular treatment of the AT-IVC was successful in all 19 patients. Two of eight patients who presented with phlegmasia cerulea dolens died of multiorgan system failure in the immediate postoperative period. During a mean follow-up of 6 months, three patients were lost to follow-up.

Among the remaining 14 patients, 6 had complete relief of symptoms (43%), and 8 had partial symptom relief (57%), Dr. Sticco said. The American Venous Registry index (also known as Mewissen score) decreased from nearly 14 before treatment to approximately 3 after treatment.

Follow-up ultrasound evaluations showed no evidence of deep vein thrombosis in six patients (43%), chronic deep vein thrombosis in six patients (43%), and recurrent acute deep vein thrombosis in two patients (14%). Valve reflux was seen in three patients (21%). Two patients developed recurrent inferior vena cava thrombosis.

The 6-month follow-up findings were "promising," he said. On the CEAP (Clinical, Etiologic, Anatomic, and Pathophysiologic) classification of venous insufficiency, patients had a mean classification of 2.2 out of 6. On the Villalta scale, a clinical assessment of post-thrombosis syndrome, patients had a mean score of 3.4, suggesting no post-thrombotic syndrome on average.

Eleven of the 14 patients were free of new acute DVT (80%), and 11 were free of post-thrombotic symptoms (80%) at 6 months, Dr. Sticco said.

A "low incidence of complications" in the whole cohort of 19 patients included major bleeding in two patients (11%) and minor bleeding in five patients (26%), he said. Eight patients received a blood transfusion (42%). Six patients developed renal insufficiency (32%), and one patient each had a nonfatal arrhythmia, fasciotomy, above-knee amputation secondary to venous gangrene (in a patient who presented with phlegmasia), or pulmonary embolism.

All patients had presented with both swelling and pain. Eight had phlegmasia cerulea dolens (42%), 14 showed motor dysfunction (74%), and 12 had sensory deficits (63%). Risk factors included a history of pulmonary embolism in 14 patients, a hypercoagulable state in 11, cancer in 6 patients, immobility in 4, and recent surgery in 2.

Fifteen patients had a prior IVC filter placed (79%). "At our institution, we have seen an increase in the insertion of IVC filters, and an increase in occlusion of these filters with associated caval thrombosis," Dr. Sticco said.

The thrombosis extended to the iliac veins in a majority of patients (10, or 53%).

For management of the AT-IVC, all patients were continued on their medical therapy for anticoagulation and were transitioned to warfarin therapy. Five patients who were on warfarin therapy when they developed AT-IVC had a subtherapeutic International Normalized Ratio, he noted. All patients received fluid resuscitation, leg elevation, and an aggressive IV heparin bolus that was maintained at therapeutic levels.

Endovascular treatment under conscious sedation and local anesthesia consisted of catheter-directed thrombolysis (with tissue plasminogen activator) in 3 patients and catheter-directed thrombolysis plus pharmacomechanical thrombectomy in 13. Two patients were treated solely with pharmacomechanical thrombectomy, using the AngioJet Rheolytic Thrombectomy System alone in one patient and the AngioJet plus the Trellis Peripheral Infusion System in one patient.

Adjunctive procedures included angioplasty in 14 patients (74%) and stent placement in 9 (47%). At discharge all patients were given thigh-high compression stockings.

AT-IVC is known to cause post-thrombotic syndrome, limb loss, pulmonary embolism, and death. Endovascular treatment of AT-IVC provided immediate symptom relief, and may reduce the incidence of these complications, he said.

Dr. Sticco reported having no financial disclosures.