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Embolization During Pharmacomechanical Thrombectomy of Iliofemoral DVT: Is Routine Preoperative IVC Filter Placement Warranted?
Adam J. Nadelson, MD, Ross Ratner, MD, Kenneth Goldstein, MD, Luis R. Davila-Santini, MD.
Montefiore Medical Center, Bronx, NY, USA.

OBJECTIVES: At our institution, pharmachomechanical thrombectom(PMT) for acute iliofemoral(IF) DVT has become standard. We reviewed our experience with PMT of IF DVT and thromboembolic events to determine if a change in practice towards routine preoperative IVC filter(IVCF) placement is warranted.
METHODS: Using a prospectively maintained database, we identified all patients who underwent PMT for acute IF DVT between June 2008 and August 2011. All procedures were performed at our institution, with the Trellis®(Covidien, Dublin, Ireland/ Massachusetts, USA)device. IF DVT was diagnosed with venous duplex. Patients were placed prone and percutaneous popliteal vein access achieved. Our initial patient cohort did not undergo IVCF placement. Observation of thromboembolic events caused some patients to recieve preoperative IVCF. Completion venogram was performed of the IVC to evaluate for thrombus within the IVCF. tPA was used as the pharmacologic agent. A 7FR multipurpose catheter was used to remove thrombus. Angioplasty/stenting of iliac, femoral or IVC was performed selectively. Demographic data, etiology of thrombus,comorbidities and length of stay were recorded. Study endpoints included pulmonary embolus(PE), thrombus within IVCF and technical success. Technical success was defined as significant thrombus retrieval, adequate outflow through iliac veins and significant symptom improvement. All patients were systemically anticoagulated during and after the procedure.
RESULTS:
A total of 23 legs were treated in 19 patients. Median age was 42 years(range 21-85). Median follow up was 17 months(range 2-37). Median length of stay was 5 days(range 2-9). Technical success was 100%, with significant symptom improvement in 18/19(95%)patients. Four of 19(21%) cases were bilateral. One of 19 (5%) patients required thrombolysis infusion overnight. Eight of 19(42%) cases were related to either May Thurner’s syndrome or an underlying stenosis. One of 19(5%) patients developed symptomatic PE, and 1/19(5%) patients were incidentally found to have asymptomatic PE. Four of 19(21%) patients had IVCF in place prior to the procedure. Nine of 19(47%) patients had preoperative placement of a retrievable IVCF. Fifteen of 19(79%) patients required angioplasty with or without stent placement. Seven of 19(37%) patients had thrombus within the IVCF. Seventeen of 19(89%) patients had patent iliac veins during follow up.
CONCLUSIONS:PMT of IF DVT improves venous outflow in patients with acute thrombus. The mechanical part of PMT may cause significant rates of embolization and we recommend considering IVCF placement preoperatively.


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