Comparative analysis of catheter-directed thrombolysis and mechanical thrombectomy in iliofemoral deep vein thrombosis: clinical evidence and perspectives – a narrative review
DOI:
https://doi.org/10.48750/acv.651Keywords:
Deep Vein Thrombosis, Catheter-Directed Thrombolysis, Mechanical Thrombectomy, Endovascular Treatment, Post-Thrombotic SyndromeAbstract
BACKGROUND: Illofemoral deep vein thrombosis (DVT) involves thrombus formation in the iliac and/or femoral veins and can lead to significant morbidity, including pulmonary embolism and post-thrombotic syndrome (PTS). Traditional anticoagulation remains the standard treatment, but newer endovascular techniques such as catheter-directed thrombolysis (CDT), percutaneous mechanical thrombectomy (PMT), and pharmacomechanical thrombolysis (PMT) are gaining prominence for their potential benefits in clot removal and limb preservation.
OBJECTIVE: This review aims to compare the efficacy and safety of these minimally invasive endovascular modalities in the management of illofemoral DVT.
METHODS: A comprehensive literature review was conducted, analysing articles published between June 2019 and June 2024 from PubMed, Lilacs, and Cochrane Library databases. Inclusion criteria comprised clinical studies, systematic reviews, and meta-analyses in English, Portuguese, or Spanish. Data from 50 selected articles were synthesised qualitatively, focusing on treatment success, vessel patency, symptom relief, incidence of PTS, and complications.
RESULTS: Both CDT and PMT demonstrated high success rates, with complete thrombus removal in 82% and 72% of cases, respectively. Combined approaches such as pharmacomechanical thrombolysis showed promising short- and medium-term patency and symptom improvement. Studies highlighted reduced PTS severity using advanced techniques like ultrasound-assisted thrombolysis and Angiolet thrombectomy, though long-term data remain limited. Safety profiles revealed low complication rates, primarily minor bleeding, with serious adverse events being infrequent.
CONCLUSION: Endovascular interventions, including CDT and PMT, offer effective, minimally invasive alternatives to anticoagulation in illofemoral DVT, with advantages in early thrombus removal and limb salvage. Careful patient selection and procedure planning are critical to optimise outcomes, and long-term studies are warranted to further assess durability and complication rates.
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References
Liu D, Peterson E, Dooner J, Baerloicher M, Zypchen L, Gagnon J, et al. Diagnosis and management of illofemoral deep vein thrombosis: clinical practice guideline. CMAJ. 2015;187:188–96.
Brasil. Ministerio da Saúde. Datasus. Available from: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sim/envbb10ufdef. Accessed 15 Jul 2024.
Sridharan GK, Vegunta R, Rokkam VRP, Meyyur Aravamudan V, Vegunta R, Khan SR, et al. Venous thromboembolism in hospitalized COVID-19 patients. Am J Ther. 2020;27:e599–610.
Pérola Hospital. Trombose nas pernas: o que é, sintomas e prevenção. 2024. Available from: https://hospitalperola.com.br/trombose-nas-pernas/. Accessed 15 Jul 2024.
McLendon K, Coyal A, Artia M. Deep venous thrombosis risk factors. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023.
Kakkos SK, Gohel M, Baekgaard N, Bauersachs R, Bellmunt-Montoya S, Black SA, Ten Cate-Hoek AJ, et al. ESVS 2021 clinical practice guidelines on venous thrombosis. Eur J Vasc Endovasc Surg. 2021;61:9–82.
Ortel TL, Neumann I, Ageno W, Beyth R, Clark NP, Culker A, et al. American Society of Hematology. Guidelines for venous thromboembolism management. Blood Adv. 2020;44:683–738.
Kearon C, Gu CS, Julian JA, Goldhaber SZ, Comerota AJ, Gornik HL, et al. Stratified analysis of pharmacomechanical catheter-directed thrombolysis in acute femoral-popliteal deep vein thrombosis. Thromb Haemost. 2019;119:633–44.
Burihan MC, Junior WC. Consenso e atualização na profilaxia e no tratamento do tromboembolismo venoso. Rio de Janeiro: Guanahara Koogan; 2019.
Fleck D, Albadawi H, Shamour F, Knuttinen G, Naidu S, Oklu P. Catheter-directed thrombolysis of deep vein thrombosis: literature review and practice considerations. Cardiovasc Diagn Ther. 2017;7(Suppl 3):S300–10.
Karthikesalingam A, Young EL, Hinchliffe RJ, Loftus IM, Thompson MM, Holt PJ. Percutaneous mechanical thrombectomy in deep venous thrombosis: systematic review. Eur J Vasc Endovasc Surg. 2011;41:S54–65.
Zhu J, Ni CF, Dai ZY, Yao LZ, Li WH. Angiolet rheolytic thrombectomy and catheter-directed thrombolysis for lower extremity DVT: case-controlled study. Vasc. 2020;281:77–82.
Baekgaard N, van Rijn MOF. The background and role of catheter-directed thrombolysis evolving procedures for acute illofemoral deep venous thrombosis. J Cardiovasc Surg. 2024;65:12–22.
Li OQ, Wang L, Zhang XC. Angiolet versus catheter-directed thrombolysis for lower limb DVT: meta-analysis. Clin Appl Thromb Hemost. 2021;271:0760296211005548.
Xu YD, Zhong BY, Yang C, Cai XS, Hu B, Wang XY, et al. Comparison of catheter-directed thrombolysis with and without percutaneous mechanical thrombectomy for subacute illofemoral deep vein thrombosis Phlebology. 2020;35:589–96.
Abramowitz S, Burne MC, Maldonado TS, Skripochnik E, Gandhi S, Mouawad NJ, et al. Mechanical vs pharmacomechanical thrombolysis in illofemoral DVT: 12-month outcomes. Eur J Vasc Endovasc Surg. 2024;67:S33–602.
Tsai CJ, Lee CY. Catheter-directed thrombolysis plus rivaroxaban vs rivaroxaban alone for acute illofemoral DVT. J Chin Med Assoc. 2019;82:902–8.
Budak AB, Cunertem DE, Ozisik K, Gunaydin S. Pharmacomechanical catheter-directed thrombolysis for acute illofemoral deep vein thrombosis in a large study population. J Vasc Surg Venous Lymphat Disord. 2022;10:818–25.
Thukrai S, Salter A, Lancia S, Kahn SR, Vedantham S. Predictors of Clinical Outcomes of Pharmacomechanical Catheter-Directed Thrombolysis for Acute Illofemoral Deep Vein Thrombosis: Analysis of a Multicenter Randomized Trial. J Vasc Interv Radiol. 2022;33:1170–70.
Fletcher SE, Jasuja S, Lawler LP, Moriarty JM. Catheter directed thrombolysis and mechanical intervention in deep venous thrombosis: What is the status after the ATTRACT Trial? Postgrad Med. 2021;133(suppl):42–50.
Weinberg I, Vedantham S, Salter A, Hadley G, Al-Hammadi N, Kearon C, et al. ATTRACT Trial Investigators. Relationships between the use of pharmacomechanical catheter-directed thrombolysis, sonographic findings, and clinical outcomes in patients with acute proximal DVT. Results from the ATTRACT Multicenter Randomized Trial. Vasc Med. 2019;24:442–51.
Wortmann JK, Barco S, Fumagalli RM, Voci D, Higgel U, Cola R. Coagulation-monitored, dose-adjusted catheter-directed thrombolysis or pharmacomechanical thrombus removal in deep vein thrombosis. Vasa. 2023;52:46–22.
Vedantham S, Salter A, Lancia S, Lewis L, Thukrai S, Kahn SR. Clinical Outcomes of a Pharmacomechanical Catheter-Directed Venous Thrombolysis Strategy that Included Rheolytic Thrombectomy in a Multicenter Randomized Trial. J Vasc Interv Radiol. 2021;32:1296–309.
Notten D, de Smet ALEA, Tick LW, van de Poel MHW, Wikleeling ORM, Vleming LJ, et al. CAVA (Ultrasound-Accelerated Catheter-Directed Thrombolysis on Preventing Post-Thrombotic Syndrome) Trial: Long-Term Follow-Up Results. J Am Heart Assoc. 2021;10:e018973.
Farrokhi M, Khurshid M, Mohammadi S, Yarmohammadi B, Bahramwand V, Nasrollahi E, et al. Comparison of ultrasound-accelerated versus conventional catheter-directed thrombolysis for deep vein thrombosis: A systematic review and meta-analysis. Vascular. 2022;30:365–74.
Nakamura H, Anzai H, Kadotani M. Less frequent post-thrombotic syndrome after successful catheter-directed thrombolysis for acute illofemoral deep vein thrombosis. Cardiovasc Interv Ther. 2021;36:237–45.
Tian Y, Huang Z, Luo K, Zhang N, Yuan B. A Retrospective Comparison of Catheter-Directed Thrombolysis versus Pharmacomechanical Thrombolysis for Treatment of Acute Lower Extremity Deep Venous Thrombosis. Ann Vasc Surg. 2021;74:306–14.
