Invasive Approaches to Treatment of Venous Thromboembolism

Abstract

Abstract-Deep vein thrombosis (DVT) occurs in one-quarter of a million individuals annually in the United States and results in significant disability from pulmonary embolism and chronic venous insufficiency, especially when the proximal iliofemoral is involved. Treatment has centered on early institution of adequate anticoagulation to prevent thrombus propagation and embolism, but anticoagulation alone does not always restore venous patency and many patients are left with venous outflow obstruction and valvular incompetence-the anatomic underpinnings of the postthrombotic syndrome. Various strategies have been used to restore patency of thrombosed veins, including open surgical thrombectomy, pharmacological thrombolysis, and percutaneous mechanical thrombectomy. Each modality has benefits and shortcomings. Surgical thrombectomy had previously been abandoned secondary to poor long-term results.More recently, with improved techniques and better patient selection, surgical thrombectomy has regained a therapeutic role in treating acute DVT in young patients with short segment occlusions. The advent of percutaneous techniques has allowed thrombolysis, percutaneous mechanical thrombectomy, and stenting to be used in conjunction with each other-allowing for better resolution of venous clot burden than when an individual modality is used alone. Practitioners who treat patients with DVT should be familiar with all the options available to restore venous patency, preserve valvular function, and thereby minimize the risk of late postthrombotic complications.

How I treat venous thrombosis in children

“…54,55 Increasingly, adolescents and larger children with high-risk clots are being referred to interventional radiology for endovascular thrombectomy using the Angiojet system (Possis, Minneapolis, MN) or the Amplatz Clot Buster system (EV3, Plymouth, MN) and/or local thrombolysis as primary therapy. Smaller children with high-risk clots, particularly SVC obstructions, can be treated with catheterdirected thrombolysis by pediatric cardiologists or radiologists skilled in interventional procedures.…”

Human complement receptor type 1–directed loading of tissue plasminogen activator on circulating erythrocytes for prophylactic fibrinolysis

“…[1][2][3][4] Yet, although their effectiveness is incomplete, safety concerns limit dosing, frequency, and duration of treatment. [5][6][7][8][9] If feasible, means to accelerate the lysis of nascent thrombi shortly after clotting and prevent permanent vascular occlusion may complement existing approaches to thromboprophylaxis.…”

Implications and limitations of the PREPIC2 study—the interventionist’s perspective

“…Implications and limitations of the PREPIC2 study-the interventionist's perspective critically ill and hemodynamically unstable may not be able to compensate for even a small embolus traveling into the pulmonary vasculature, and may therefore benefit most from IVC filter placement (8,9). The lack of correlation between IVC filter efficacy and systemic clot burden is a further limitation of PREPIC2.…”