Simultaneous Thrombolysis and Venous Angioplasty in Acute Ilio-femoral Thrombosis after IVC filter Insertion and Novel Balloon Catheter Models

Abstract

Four patients with extensive acute iliofemoral and popliteal vein thrombosis and partially extending into the inferior venacava (IVC) with diffuse swelling of lower limb and gluteal region were studied. Initially, Gunther Tulip (Cook) IVC filter was placed in all patients. A 5F multipurpose catheter with side holes was placed in common iliac vein bifurcation and thrombolysis was done for 18 hours with diluted streptokinase infusion at 50,000 U/hr. Thereafter, a 5 mm × 4 cm peripheral balloon was advanced through the clots to mid or lower femoral vein level and thrombolysis was done for 18 hours with streptokinase infusion through the balloon's 035 wire port. The balloon was pulled back and multiple serial dilatations were done in all four procedures. Post procedure the venous channels were opened and were draining adequately. Limb edema subsided in 4 to 5 days and there were no bleeding or embolic complications in all patients. The first two patients are on follow up for 18 months, the third patient for 5 months, and the fourth patient for 2 weeks. Based on these observations, two novel balloon models for thrombolysis and to perform venous angioplasty simultaneously were developed. The piggyback model has a side lumen catheter with side holes attached to the shaft of the balloon catheter (5 mm width × 4 cm length ). The side lumen terminates before the balloon. The horseshoe models made of polyethylene terephthalate have a 10 cm long and 4 mm wide compliant balloon with a double lumen catheter and multiple side ports till the balloon tip. Gunther Tulip (Cook) IVC filter was placed in all patients, initially after performing an IVC angiogram. A 5F multipurpose catheter with side holes was placed in common iliac vein bifurcation, and thrombolysis was done for 18 hours with streptokinase at 50,000 U/ hr. Post thrombolysis IVC angiogram showed mild recanalization of left common iliac veins leaving a stump. On the next day, the left common iliac vein was cannulated through a 5F Torcon or 5F right Judkins catheter and a hydrophilic Terumo 035 J tipped wire was advanced through the clots. A 5 mm wide × 4 cm long peripheral balloon was advanced through the clots, and 18-hour thrombolysis with streptokinase was done at 50,000 U/hr through the port for 035 wire. The balloon was pulled back, and multiple serial dilatations were done in femoral, internal iliac and common iliac veins. In all patients, thrombolysis was started on the third day after the onset of symptoms. Venous angiograms were done through the balloons during the procedure. Figures 1 and 2 illustrate the procedures in a nutshell (Supplementary Video file). Simultaneous Thrombolysis and Venous Angioplasty inPost-procedure the patients were started on anticoagulation and therapeutic INR was maintained between 2 to 3. Echocardiography, chestroentogram, electrocardiography and venous Doppler of the common iliac veins, femoral veins and IVC were done. All patients were discharged on the 7 th day.

A Guitaring Technique with 035 Wire and Perforated Coronary Balloon for Thrombolysis in the Treatment of Acute Deep Vein Thrombosis

“…In a previous study conducted in our center, peripheral balloons were used for thrombolysis and venous angioplasty. 5 In this case, the IVC filter had been placed nine years before, the current clot formation was at the level of the iliofemoral veins, and the IVC filter was free of clots. This shows that angio-jet techniques.…”

Thrombolysis Through Punctured Coronary Balloon and 014 Wire Mediated Guitaring After IVC Filter Insertion in Iliofemoral Deep Vein Thrombosis

“…Systemic thrombolysis is associated with lower efficacy, and an increased risk of major bleeding manifestations [5] . For catheter-directed thrombolysis, various options are available [6][7][8] and this method is useful and effective in the dislodgement of clots and reducing symptoms [9] . Balloon maceration, balloon venous angioplasty, rheolytic thrombolysis with AngioJet™, isolated thrombolysis with Trellis, large-bore catheter aspiration are some of the common techniques used in pharmaco-invasive treatment of DVT [10] .…”

Thrombolysis Through Punctured Coronary Balloon and 014 wire mediated guitaring after IVC filter insertion in Ilio-femoral Deep Vein Thrombosis

“…Systemic thrombolysis is associated with lower efficacy, and it is associated with an increased risk of major bleeding manifestations. 5 For catheter directed thrombolysis various options are available, [6][7][8] and this method is useful and effective in dislodgement of clots and reducing symptoms. 9 Balloon maceration, balloon venous angioplasty, rheolytic thrombolysis with angiojet, isolated thrombolysis with Trellis, large bore catheter aspiration are some of the common techniques used in pharmaco-invasive treatment of DVT.…”