Fast Track Thrombolysis for Acute Iliofemoral Venous Occlusions: A Novel Approach to Minimize Complications of Standard Thrombolytic Therapy
Syed Ali Rizvi, D.O., Artur Rozentsvit, B.A., Anil Hingorani, M.D., Enrico Ascher, M.D., Natalie Marks, M.D..
NYU Lutheran Medical Center, Brooklyn, NY, USA.
Catheter directed thrombolysis (CDT) in the treatment of acute venous thrombosis may require prolonged periods of time to achieve successful lysis. Prolonged thrombolysis increases the incidence of intracranial or gastrointestinal bleed and local complications. It is expensive and increases length of stay. To minimize negative outcomes we developed an aggressive Fast Track Approach (FTA) that included the use of balloon angioplasty and stenting before the thrombus was completely lysed. The goal of FTA is to restore patency during the first procedure thus eliminating the need for repeated thrombolysis.
Retrospective review of 20 consecutive patients treated with FTA for iliofemoral venous thrombosis from January 2014 to August 2016 was analyzed. The FTA protocol included a venogram of the inflow, outflow vessels and segmentally alongside the occluded segment. This was followed by intra-clot infusion of thrombolytic agent and percutaneous mechanical thrombectomy (Angiojet). Balloon angioplasty of the occluded segment(s) and stenting, in case of recoil, were performed.
20 procedures were performed in 20 patients. The median age was 66 (51-93) years. Of these, 75% were females. The indication for lytic therapy was iliofemoral venous thrombosis (25%) or venous stent occlusion (75%). Co-morbidities included hypertension, diabetes mellitus, hypercholesterolemia and DVT in 55.0%, 25.0%, 25.0%, and 20.0% of patients, respectively.
The distribution of access site was CFV, FV, PV, PTV, GSV, or SSV in 25%, 20%, 35%, 5%, 5%, 10%, respectively. The average operating room time was 116 minutes (60-249 min). Median alteplase and heparin required per procedure was 10 mg (4-20 mg) and 5,000 units (3000-7000 units), respectively. Average procedural cost for interventional tools and medications was $5,374.45. Median post-operative length of stay was 1 day (1-45 days). Successful FTA, a widely patent venous inflow and outflow at discharge, occurred in 90% (18 of 20). Periprocedural complications included 1 patient that required blood transfusion. No deaths, limb loss, pulmonary embolism, myocardial infarction, intracranial hemorrhage, nor compartment syndrome occurred in this series. Differences in extent of the thrombotic process, gender, CEAP score, or duration of symptoms were not related to outcome of FTA.
This preliminary data suggest that an aggressive approach at balloon angioplasty and stenting prior to complete lysis of the thrombotic event can generate acceptable results and minimize complications related to prolonged thrombolytic therapy.
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