Catheter-directed thrombolysis (CDT)

Catheter-directed thrombolysis is an endovascular approach to the treatment of acute iliofemoral deep vein thrombosis. It involves the administration of a lytic agent directly into a thrombus. 

Indications
  • precise diagnosis of iliofemoral deep vein thrombosis 
    • first episode of acute iliofemoral DVT
    • symptomatic patients
    • onset of symptoms <14 days
  • low bleed risk
  • ambulatory patients with good functional capacity and acceptable life expectancy
  • phlegmasia cerulea dolens
Contraindications
  • cerebral disease
  • previous ipsilateral DVT
  • uncontrolled hypertension
  • bleeding disorders
  • isolated femoral - popliteal deep vein thrombosis should be managed with conventional anticoagulation therapy
Procedure

Ultrasound-guided micropuncture technique of a deep vein of the lower limb is performed, usually the popliteal vein. There are a wide range of catheters and they usually have multiple holes employing a pulse-spray technique of the thrombolytic agent.

Recombinant tissue plasminogen activator (rt-PA) is the thrombolytic agent of choice, it has a half life of 3-5 minutes and 90% first pass elimination in the liver. This results in targeted activation of plasminogen on the clot with the intent to dissolve fibrin. Doses range between 1-2 mg/hr up to a total dose of 30mg. Heparin is used to maintain venous patency. 

Successful catheter-directed thrombolysis results in a patent vein on venogram, spontaneous outflow of injected contrast and disappearance of venous collaterals.

Complications

So far studies have shown no mortality or pulmonary embolism associated with catheter-directed thrombolysis. Major bleeding rates are 1-2% while minor bleeding was found to be <25%.

 

 

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rID: 54699
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