Concurrent Interventional Treatment of Deep Venous Thrombosis and Pulmonary Embolus
Hunter M. Ray, MD, Harleen K. Sandhu, MD, MPH, Charles C. Miller, PhD, Stuart A. Harlin, MD.
The University of Texas Medical School at Houston, Houston, TX, USA.
Over 900,000 cases of fatal and nonfatal venous thromboembolism (VTE), comprising deep venous thrombosis (DVT) or pulmonary embolus (PE), occur per year in the United States. Several clinical guidelines have recognized the role of thrombolytic therapy in management of acute VTE. However, there is no consensus on thrombolysis in patients with concomitant sub-massive PE and DVT.
We evaluated our experience with management of simultaneous diagnosis of lower extremity DVT and PE. Only those cases with an acute presentation of both DVT and a sub-massive PE were reviewed.
In the past one year, we managed 3-cases with bilateral extensive PE and significant coincident lower extremity DVT. There was no gender or race based predisposition for incidence of concurrent PE+DVT. The mean age was 49 (range: 19-73) years. There were no factor-V leiden deficiencies. All patients had some combination of known risk factors for VTE including, older age, recent travel, immobilization following surgery, sedentary lifestyle, chronic lung disease, female, oral contraceptive use, prior history of DVT, and obesity. All patients underwent simultaneous catheter-directed thrombolytic therapy for infusion of tPA into pulmonary arteries and peripheral veins (external iliac vein and innominate). Concomitant procedures included IVC filter-placement in all and mechanical venous thrombectomy for cases with lower-limb DVT. Median total duration of thrombolytic treatment was 30hrs and total tPA dose was 26mg. There were no major bleeding or pulmonary complications. Median ICU-stay was 2-days and hospital- stay was 5-days. Over a median follow-up of 6-months no recurrence of events was reported.
Catheter-directed infusion of thrombolytic-therapy is a feasible option for simultaneous management of concurrent acute DVT+PE. Further studies are required to assess the outcomes and associated factors to identify the target population for this approach.
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