DVT Case Study 1

Isolated Thrombolysis for DVT Symptom Relief

Background

The patient is a 22 year old female that presented to the hospital with significant pain and swelling in her right lower extremity that began 4 days prior to presentation. She reported no significant past medical history. After discussing the treatment alternatives, risks, and benefits with the patient, an isolated pharmacomechanical approach was chosen using the Trellis®-8 Peripheral Infusion System for treatment of the deep vein thrombosis (DVT).

Procedure

Access was obtained via the popliteal vein using ultrasound guidance and a 9Fr sheath was inserted. An initial venogram was performed and revealed patency of the popliteal and superficial femoral vein but complete occlusion of the common femoral, external iliac and common iliac vein (Figure 1). Large collaterals were also observed (Figure 2).

A Trellis catheter with a 30cm treatment zone was placed from the common iliac vein to the superficial femoral vein. A stepped bolus infusion of 6mg t-PA over 10 minutes was administered. This was repeated a second time for residual thrombus. Balloon maceration and catheter thrombectomy were also performed to remove the residual clot.

Ultimately a 12mm x 60mm stent was deployed in the right iliac vein (Figure 3). After the stent implantation, a completion venogram was performed documenting no residual thrombosis and excellent flow through the femoral and iliac venous system.

Conclusion

Before removing the patient from the table there was marked improvement in the patient’s leg swelling and pain. At one month follow up she had no signs or symptoms of DVT. In this case, patency of the iliac and superficial venous system was restored. Most convincing was the immediate relief of both pain and swelling without the need for a thrombolytic drip in the intensive care unit.

Isolated pharmacomechanical thrombolysis using the Trellis-8 Peripheral Infusion System is a safe and effective method for thrombus removal associated with DVT. This procedure may now be performed in most cases within a single setting of approximately 90 minutes.

Discussion

The risk for Post Thrombotic Syndrome (PTS) has likely been reduced as a result of early thrombus removal and restoration of flow within the vein (1). PTS is a symptom complex that commonly includes chronic limb edema, heaviness, pain, lifestyle-limiting venous claudication, stasis dermatitis, and, in advanced cases, venous ulceration.

Stand-alone anticoagulant therapy fails to prevent PTS in a significant proportion of patients with acute proximal DVT, leading to significant quality of life (QOL) impairment, disability, and socioeconomic costs (2). Recent prospective studies have found a PTS prevalence of 60% within 2 years after a first episode of symptomatic proximal DVT in patients treated with only anticoagulation (3).

Reference List
1. Comerota AJ, Throm RC, Mathias SD, et al. Catheter-directed thrombolysis for iliofemoral deep venous thrombosis
improves health-related quality of life. J Vasc Surg 2000; 32:130–137.
2. Goldhaber. Lancet 1999;353:1386-1389
3. Kahn SR, Ginsberg JS. Relationship between deep venous thrombosis and the postthrombotic syndrome. Arch Intern
Med 2004; 164:17–26.

Figure 1

Figure 2

Figure 3