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.
- 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
- cerebral disease
- previous ipsilateral DVT
- uncontrolled hypertension
- bleeding disorders
- isolated femoral - popliteal deep vein thrombosis should be managed with conventional anticoagulation therapy
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.
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%.
- Meissner M.H., Gloviczki P., Comerota A.J., Dalsing M.C., Eklof B.G., Gillespie D.L., Lohr J.M., McLafferty R.B., Murad M.H., Padberg F., Pappas P., Raffetto J.D., Wakefield T.W.; Society for Vascular Surgery; American Venous Forum. Early thrombus removal strategies for acute deep venous thrombosis: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2012; 55: 1449- 1462. �
- Kahn S.R., Comerota A.J., Cushman M., Evans N.S., Ginsberg J.S., Goldenberg N.A., Gupta D.K., Prandoni P., Vedantham S., Walsh M.E., Weitz J.I.; American Heart Association Council on Peripheral Vascular Disease, Council on Clinical Cardiology, and Council on Cardiovascular and Stroke Nursing. The postthrombotic syndrome: evidence-based prevention, diagnosis, and treatment strategies: a scientific statement from the American Heart Association. Circulation 2014; 130: 1636-1661. �