Initial Experiences with Posterior Tibial Vein Access for Catheter-Directed Thrombolysis of Lower Extremity Deep Vein Thrombosis
Kinning Alison J, Kuhn Brian A, Recht Matthew R, and Muck Patrick E
Background: Lower extremity deep vein thrombosis (DVT) can lead to significant valvular dysfunction, reflux and, ultimately, post-thrombotic syndrome (PTS). Studies have suggested a beneficial role for catheter-directed thrombolysis (CDT) for thrombus removal and preservation of valve function. The popliteal vein is often the access site for CDT; however, this vein is oftentimes occluded, as are the calf veins. In addition, there is evidence that popliteal as well as calf vein thrombosis may contribute to PTS. Our institution is accessing the posterior tibial vein (PTV) under ultrasound guidance for CDT of extensive iliofemoral and popliteal DVT.
Methods: A retrospective review was performed to assess the safety and efficacy of CDT via PTV access. Access was achieved with a pedal access micropuncture kit using ultrasound guidance. Venography was performed, and a treatment catheter was left in place for CDT using tPA. Adjunctive procedures to facilitate iliofemoral vein clearance were used at the discretion of the surgeon. Safety was defined as freedom from access site complications. Efficacy was defined radiographic evidence of thrombus clearance from the popliteal and iliofemoral veins after CDT and any necessary adjunctive procedures.
Results: Between July 2012 and August 2016, PTV access for CDT was attempted on 16 patients (17 limbs) presenting with iliofemoral and popliteal DVT. PTV access was successful in 12 of the 16 patients. There were no significant access site complications in the patients who underwent CDT via PTV access (11 patients, 12 limbs). One procedure was complicated by inadvertent arterial puncture; however, there was no morbidity associated with this. Following CDT and adjunctive procedures, patency was achieved in 100% of limbs treated in both the iliofemoral and popliteal segments.
Conclusions: In patients with lower extremity DVT who undergo CDT, the posterior tibial vein may safely be used as the access site for endovascular interventions. Our initial experiences suggest that it is a viable alternative to accessing a thrombosed popliteal vein. It also eradicates the thrombus burden in the inflow veins as well as the more proximal veins. Higher powered studies are needed to substantiate these results.