Invasive controlled treatment of deep venous thrombosis

Overview

Objective:
Targeted administration of thrombolytics via endovascular catheters placement directly to thrombi under the control of duplex sonography is presented in the paper. 

Patients and Methods:
Patients with extensive thrombosis of venous system with the possibility of thrombolysis administration without known contraindications were indicated for interventions. Time duration from distinct clinical manifestations of the disease was 5 to 21 days. Unilateral ileofemoral thromboses were found in 25 cases. Ileofemoral thrombosis with shared thrombosis of vena cava inferior was solved 3-times, in 2 cases in paediatric patients with hepatic veins thrombosis (Budd-Chiari syndrome). Bilateral ileofemoral thrombosis was found in one case. Thrombosis of v. subclaviae was found 3-times, together with thrombosis of v. axilaris and proximal part of v. cephalica, in 2 cases even together with vv. jugulares on the same side. The intervention was performed within 10 days after surgery in 2 cases, namely in 7 days (thrombectomy) and 10 days (cholecystectomy). The puncture of appropriate access vein was performed under ultrasound control. It was prevailingly v. poplitea, but also v. saphena parva, v. tibialis posterior, v. saphena magna in the area of mid thigh. Vv. radialis were chosen to be access vessels in the case of thromboses of v. subclaviae and jugular veins. Thrombolyses of hepatic veins were performed via the access from v. saphena magna and v. subclaviae. 4F instrumentarium was used introduced to thrombi and fibrinolytic agent was applied directly to sites of thrombotic occlusions. Concomitantly nonfractionated or low-molecular weight i.v. heparin was administered systemically. Regular DxSG checking of patient's condition were made in 8–12-hour intervals with eventual reposition of catheter's end in sites with remaining thrombi to continued target administration of thrombolytics. Possibilities of target area imaging in various axes using probes with working frequencies 5–8 MHz and 3–6 MHz were used. Thrombolysis was maintained 48 to 120 hours (2–5 days with the range of 1–7 days) in connection with the extent and duration of affection. 

Results:
There were no bleeding complications in access sites aside from local haematomas in some cases. Clinically significant pulmonary embolism did not occurred in any case. Blood flow was restored in fibrinolysed areas of femoral and pelvic circulation in all cases. Complete or substantial recanalization of magistral veins with full clinical status recovery occurred in total 18 cases, 8 cases reached partial but substantial patency of deep venous system, and 6 cases reached mild patency of stem veins but with opening of collaterals. In cases of two children with Budd-Chiari syndrome all hepatic veins were unblocked in one case and ascites gradually disappeared which subsequently enabled bone marrow transplantation from other causes to be performed. In other case the patency of proximal part of vena cava inferior and one of hepatic veins was reached and subsequent TIPS was performed. 

Conclusion:
Completion of local thrombolysis under ultrasound control is possible to perform in extensive deep venous thromboses. Target administration of thrombolytics directly to sites of thrombi and catheter manipulation is possible under ultrasound control. Interventions without X-rays are to be appreciated in particular in management of paediatric and adolescent patients. Consumption of thrombolytics was decreased compared to cases with systemic administration. No bleeding complications were present during responsible dosage and regular clinical and laboratory checking. Interventions in vena cava inferior and hepatic veins (Budd-Chiari syndrome) are possible to be performed too.

Key words:
deep venous thrombosis – target thrombolysis – duplex sonography – Budd-Chiari syndrome