Aspiration thrombectomy for the management of acute deep venous thrombosis in the setting of venous thoracic outlet syndrome

Abstract

Objectives Venous thoracic outlet syndrome, known by the eponym Paget–Schroetter syndrome, is seen in healthy, young individuals with “effort-induced thrombosis.” Endovascular therapies, including catheter-directed thrombolysis, have been described in the acute management of the upper extremity deep venous thrombosis; however, we assessed the technical success of treating this entity using a mechanical aspiration thrombectomy system. Methods This was a multi-center retrospective review of patients with venous thoracic outlet syndrome with acute thrombosis treated with the Indigo continuous aspiration mechanical thrombectomy system. Charts from patients with venous thoracic outlet syndrome and acute deep venous thrombosis treated with this system at our institution along with three data sharing locations were reviewed for demographics, deep venous thrombosis risk factors, imaging modalities used for diagnosis, extent of axillosubclavian deep venous thrombosis, treatment details, adjunctive therapies, and complications. The primary outcome was technical success (resolution of >70% of thrombus). Results There were 16 patients (50% male) with a mean age of 33 years (range 17–69 years). Six patients had underlying venous thromboembolism risk factors including use of contraceptives ( n = 2), prior deep venous thrombosis ( n = 3), and known thrombophilia ( n = 1). Fifteen patients had complete venous occlusion, and the extent of venous involvement included subclavian ( n = 14), axillary ( n = 16), and brachial ( n = 7). The majority (81.25%) of patients were treated in a single setting, and technical success was achieved in all cases with the use of adjunctive therapies. Only three patients required additional overnight thrombolytic therapy. Conclusions The Penumbra Indigo system, often in combination with adjunctive catheter-directed thrombolysis and venoplasty, is a safe and effective device for the treatment of acute upper extremity deep venous thrombosis in the setting of Paget–Schroetter syndrome. No patients experienced central embolization or post-operative renal insufficiency. One-third of patients avoided any additional catheter-directed thrombolysis exposure, and technical success was achieved in all cases. A single bleeding complication was observed in a patient undergoing overnight adjunctive catheter-directed thrombolysis. All patients maintained patency until time of first rib resection.

Novel Percutaneous Mechanical Thrombectomy Device for Treating Upper Extremity Deep Vein Thrombosis in Patient With Paget-Schroetter Syndrome

“…However, the two Indigo procedures resulted in an EBL of 600cc. While this procedural blood loss is in line with what has been reported with Indigo aspiration thrombectomy for PSS, 7 the additional thoracoscopic evacuation of the hematoma yielded a total EBL of 2400cc (Table 1). Furthermore, as a consequence of the extended treatment timeline due to the hemothorax and interruptions to the anticoagulation regime, organized subacute thrombus accumulated within the brachial vein.…”

Surgical Considerations in the Treatment of Axillary-Subclavian Venous Thrombosis in the Era of COVID-19

“…Investigators have previously described the use of percutaneous aspiration and thrombectomy devices for the treatment of axillary-subclavian venous thrombosis with adjunctive thrombolysis. [6][7][8][9][10] However, to the best of our knowledge, successful use of the CAT 8 Indigo catheter in this location without concomitant use of thrombolytic agents has not been previously reported. The ability to clear the clot burden without adjunctive use of a lytic agent increases the potential of this treatment paradigm, particularly of benefit in those patients with high risk for bleeding.…”

Percutaneous thrombectomy in the management of early rethrombosis in venous thoracic outlet syndrome: two case reports

“…Onethird of patients, primary treated with the Indigo continuous aspiration mechanical thrombectomy system, avoided any additional catheter-directed thrombolysis exposure. Only three out of sixteen patients required additional overnight thrombolytic therapy (Teter et al 2020).…”

“…Different pharmacomechanical thrombectomy devices have also been successfully used for the treatment of upper extremity deep venous thrombosis (Kärkkäinen et al 2016;Mahmoud et al 2018;Kim et al 2006;Papantoniou et al 2013). When there is a need to avoid or minimize exposure to rtPA, aspiration and mechanical thrombectomy systems can aspirate thrombus without the use of rtPA, resulting in decreased bleeding risk (Teter et al 2020). Kosai described a case of Paget-Schroetter Syndrome treated with Aspirex thrombectomy device (Kosai et al 2017).…”