Effective single-session percutaneous nonpharmacologic mechanical thrombectomy for phlegmasia cerulea dolens

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Abstract

Phlegmasia cerulea dolens can be a potentially devastating complication of severe deep venous thrombosis leading to limb ischemia and tissue necrosis. This report describes a patient presenting with phlegmasia cerulea dolens of the right lower extremity. Because of the urgent nature of the condition, percutaneous nonpharmacologic mechanical thrombectomy in a single session was pursued. Extensive thrombus burden was removed from the patient, and vessel patency was restored after balloon venoplasty. The patient's symptoms rapidly resolved, and the targeted vessels remain patent at 3-month follow-up.

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Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis

David J. Cohen, Michael R Jaff, Susan R. Kahn … (2017)

The post-thrombotic syndrome frequently develops in patients with proximal deep-vein thrombosis despite treatment with anticoagulant therapy. Pharmacomechanical catheter-directed thrombolysis (hereafter "pharmacomechanical thrombolysis") rapidly removes thrombus and is hypothesized to reduce the risk of the post-thrombotic syndrome.

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Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum.

Mark H Meissner, Peter Gloviczki, Anthony Comerota … (2012)

The anticoagulant treatment of acute deep venous thrombosis (DVT) has been historically directed toward the prevention of recurrent venous thromboembolism. However, such treatment imperfectly protects against late manifestations of the postthrombotic syndrome. By restoring venous patency and preserving valvular function, early thrombus removal strategies can potentially decrease postthrombotic morbidity. A committee of experts in venous disease was charged by the Society for Vascular Surgery and the American Venous Forum to develop evidence-based practice guidelines for early thrombus removal strategies, including catheter-directed pharmacologic thrombolysis, pharmacomechanical thrombolysis, and surgical thrombectomy. Evidence-based recommendations are based on a systematic review and meta-analysis of the relevant literature, supplemented when necessary by less rigorous data. Recommendations are made according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, incorporating the strength of the recommendation (strong: 1; weak: 2) and an evaluation of the level of the evidence (A to C). On the basis of the best evidence currently available, we recommend against routine use of the term "proximal venous thrombosis" in favor of more precise characterization of thrombi as involving the iliofemoral or femoropopliteal venous segments (Grade 1A). We further suggest the use of early thrombus removal strategies in ambulatory patients with good functional capacity and a first episode of iliofemoral DVT of <14 days in duration (Grade 2C) and strongly recommend their use in patients with limb-threatening ischemia due to iliofemoral venous outflow obstruction (Grade 1A). We suggest pharmacomechanical strategies over catheter-directed pharmacologic thrombolysis alone if resources are available and that surgical thrombectomy be considered if thrombolytic therapy is contraindicated (Grade 2C). Most data regarding early thrombus removal strategies are of low quality but do suggest patient-important benefits with respect to reducing postthrombotic morbidity. We anticipate revision of these guidelines as additional evidence becomes available. Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

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Catheter-directed thrombolysis vs. anticoagulant therapy alone in deep vein thrombosis: results of an open randomized, controlled trial reporting on short-term patency.

, W Ghanima, G Sandbaek … (2009)

Approximately one in four patients with acute proximal deep vein thrombosis (DVT) given anticoagulation and compression therapy develop post-thrombotic syndrome (PTS). Accelerated removal of thrombus by thrombolytic agents may increase patency and prevent PTS. To assess short-term efficacy of additional catheter-directed thrombolysis (CDT) compared with standard treatment alone. Open, multicenter, randomized, controlled trial. Patients (18-75 years) with iliofemoral DVT and symptoms < 21 days were randomized to receive additional CDT or standard treatment alone. After 6 months, iliofemoral patency was investigated using duplex ultrasound and air-plethysmography assessed by an investigator blinded to previous treatment. One hundred and three patients (64 men, mean age 52 years) were allocated additional CDT (n = 50) or standard treatment alone (n = 53). After CDT, grade III (complete) lysis was achieved in 24 and grade II (50%-90%) lysis in 20 patients. One patient suffered major bleeding and two had clinically relevant bleeding related to the CDT procedure. After 6 months, iliofemoral patency was found in 32 (64.0%) in the CDT group vs. 19 (35.8%) controls, corresponding to an absolute risk reduction (RR) of 28.2% (95% CI: 9.7%-46.7%; P = 0.004). Venous obstruction was found in 10 (20.0%) in the CDT group vs. 26 (49.1%) controls; absolute RR 29.1% (95% CI: 20.0%-38.0%; P = 0.004). Femoral venous insufficiency did not differ between the two groups. After 6 months, additional CDT increased iliofemoral patency from 36% to 64%. The ongoing long-term follow-up of this study will document whether patency is related to improved functional outcome.

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Contributors

Nicolas J. Mouawad

Journal

Journal ID (nlm-ta): J Vasc Surg Cases Innov Tech

Journal ID (iso-abbrev): J Vasc Surg Cases Innov Tech

Title: Journal of Vascular Surgery Cases and Innovative Techniques

Publisher: Elsevier

ISSN (Electronic): 2468-4287

Publication date PMC-release: 15 April 2020

Publication date Collection: June 2020

Publication date (Electronic): 15 April 2020

Volume: 6

Issue: 2

Pages: 212-215

Affiliations

[1]Division of Vascular and Endovascular Surgery, Department of Surgery, McLaren Bay Region, Bay City, Mich

Author notes

[∗ ]Correspondence: Nicolas J. Mouawad, MD, MPH, MBA, FSVS, FRCS, FACS, RPVI, McLaren Bay Region, 1900 Columbus Ave, 4th Fl, South Tower, Bay City, MI 48708 nmouawad@ 123456gmail.com

Article

Publisher ID: S2468-4287(20)30026-5

DOI: 10.1016/j.jvscit.2020.02.008

PMC ID: 7162958

SO-VID: fa75d3a9-099d-44fb-98ba-12a09ac68963

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Effective single-session percutaneous nonpharmacologic mechanical thrombectomy for phlegmasia cerulea dolens

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Most cited references 9

Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis

Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum.

Catheter-directed thrombolysis vs. anticoagulant therapy alone in deep vein thrombosis: results of an open randomized, controlled trial reporting on short-term patency.

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