Catheter directed thrombolysis in treatment of acute iliofemoral deep venous thrombosis: determinants of outcome

Background: Acute deep vein thrombosis [DVT] of the lower limbs occurs in about 1.0 person per 1000 population per year and is associated with substantial morbidity. Although anticoagulation effectively prevents thrombus extension, pulmonary embolism, death, and recurrence may occur. Moreover, many patients develop venous dysfunction resulting in post-thrombotic syndrome [PTS]. PTS is associated with reduced individual health-related quality of life and a substantially increased economic burden. Hence, additional and more aggressive treatment, including systemic thrombolysis, thrombectomy, and catheter- directed thrombolysis [CDT], has been introduced to accelerate thrombus removal. Numerous studies suggest that additional CDT may provide highly effective clot lysis. There is little doubt that the overall benefit of thrombolysis depends on multiple factors, including predisposing risks, symptom duration, thrombus extension, and technical approaches and interventional success

Aim of the Work: This study aimed to define predictors of immediate and mid-long-term anatomic and clinical failures to guide patient selection and to set a standard for patient and physician expectations

Patients and Methods: This is a prospective observational cohort study that enrolled 20 patients [22 limbs] who presented to the Ain Shams University hospitals in the period from 7/2015 to 7/2017 with acute iliofemoral deep venous thrombosis [IFDVT] and fulfilled the inclusion criteria [mentioned below]. Intrathrombus catheter directed thrombolysis [CDT] was done. Assessments of predictors of immediate periprocedural success was based on degree of clot lysis and resolution of symptoms and signs. Incidence of postthrombotic syndrome [PTS] was calculated at 6 months postoperative using Villalta score [>/=5 vs <5]

Results: During the study duration, 20 patients [22 limbs] were recruited. The mean age was 40.95 +/- 12.35 years old, 11 patients [12 limbs] were women. The indication for CDT was severe progressive pain/swelling [18 limbs], and phlegmasia cerulea dolens [4 limbs]. 5 patients [7 limbs] had IVC thrombosis at the initial venography. 5 limbs had balloon dilatation only while iliac stenting was done in 12 limbs. 15 patients received CDT for 48 hours while 5 patients [7 limbs] received CDT for 24 hours [mean duration of CDT was 1.68 days]. As regards bleeding, only 2 cases of those who had CDT for 24 hours had bleeding, while bleeding occurred in 12 cases of those who had CDT for 48 hours. There were no recurrent DVT, intra or postoperative pulmonary embolism nor death within the study population till the end of the follow up period [6months]. 6 months post intervention, 7 limbs were free of PTS [Villalta score < 5], 15 limbs had mild to moderate PTS, and no patients had severe PTS. The mean Villalta score was 5.14 +/- 1.859

Conclusion: In our study, determinants of outcome following CDT for acute IFDVT were: 1] access site, 2] dose of thrombolytic agent used, 3] duration of thrombolysis, and 4] thrombus score at the end of the procedure. More studies should be done comparing not only the effect of CDT on incidence of PTS but also its effect on its severity [e.g. Villalta score] on short and long term

Endovascular versus open surgical reconstruction in long segment superficial femoral artery occlusive disease

Background: The concept of endovascular intervention has been well supported by the continuous advance in technology in long segment [superficial femoral artery] SFA occlusions. The rapid evolution of stent design, deployment approaches and adjunctive therapy made the practice of [percutaneous transluminal angioplasty] PTA safer and more predictable and has reduced superficial femoral artey surgery

Objectives: To compare the safety and effectiveness of endovascular treatment versus open surgical bypass in treatment of superficial femoral artery occlusive disease

Patients and Methods: This prospective study included 30 patients presenting to the Vascular Department in Cairo University Hospitals with femoropopliteal occlusive disease for whom percutaneous transluminal angioplasty with or without stenting was done for 15 cases. Femoropopliteal bypass surgery with saphenous or synthetic graft was done for 15 cases between March 2017 and January 2018. The procedure, possible complications, benefits, risks and other alternative interventions were all explained to the patients and an informed consent was obtained

Results: In endovascular cases: 1/15[6.66%] cases, developed small haematoma at the site of puncture which resolved by conservative management. After 6 months follow up,6/15 cases [40%] had intact pedal pulsation, 6/15 cases [40%] had popliteal pulsation with marked improvement of their complaints [disappearance of rest pain in 3 cases, the other 3 cases which had gangrene, line of demarcation appeared]. 1/15 case [6.66%] showed popliteal pulse at 3 months follow up which disappeared at 6 months but the patient had good circulation with improvement of rest pain. So, successful cases were 13/15[86.66%] at 6 months follow up. 2 /15 cases[13.33%] showed occlusion, by Duplex 1 case of them showed occlusion of stent and 1 case showed return to original occlusion. In open surgical cases: Postoperative wound infection at groin incision developed in 3/15[20%] cases, 2 cases of them were managed conservatively by IV antibiotic and repeated dressing, and one developed secondary haemorrhage in which ligation of femoral artery was done and the limb became gangrenous and Above knee amputation was done. After 6 months follow up, 5/15 cases [33.33%] had intact pedal pulsation, 7/15 cases [46.66%] had popliteal pulsation with marked improvement of their complaints. Disappearance of rest pain occurred in 3 cases, while 3 cases which had gangrene, line of demarcation appeared and 1 case which had non healing ulcer, healing of ulcer started to occur. So successful cases 12/15[80%] at 6 months follow up. Thus, 3/15 cases [20%] failed, 1 case developed wound infection at groin incision followed by secondary haemorrhage in which ligation of the graft was done, the limb was worsen ended in above knee amputation. The other 2 cases showed occlusion of graft, 1 case ended in above knee amputation, the other below knee amputation was done in which the stump became gangrenous followed by above knee amputation

Conclusion: Percutaneous transluminal angioplasty [PTA] has obtained a definite place in the management of peripheral arterial occlusive disease of the lower limb. It was widely accepted as a first line of treatment for many patients with SFA occlusive disease. The low complication rate and relatively non-invasive nature of PTA made it an increasing popular intervention