Skip to main content
SpringerLink
Log in

The Role of Interventional Radiology in the Management of Deep Venous Thrombosis: Advanced Therapy

  • Review
  • Published:
CardioVascular and Interventional Radiology Aims and scope Submit manuscript

Abstract

Deep vein thrombosis (DVT) is often managed with a health care pathway that funnels patients to anticoagulation therapy alone. This “usual treatment” is designed to stop propagation and embolisation of venous thrombus but not remove it. Surgical thrombectomy was once the only option in severe cases in which limbs were threatened, but thrombus removal is no longer restricted to emergency cases. Interventional radiologists are now using advanced endovascular techniques to achieve thrombus removal in a minimally invasive manner in a very short treatment time, thereby quickly restoring patency, relieving acute symptoms, and potentially limiting the subsequent development of postthrombotic syndrome when followed with anticoagulation and compression regimens. This article provides an overview of the interventions available for treating DVT. One of the newer “single-session” techniques is isolated pharmacomechanical thrombolysis, which is described here in detail with supporting cases.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Vedantham S, Millward SF, Cardella JF et al (2009) Society of Interventional Radiology position statement: treatment of acute iliofemoral deep vein thrombosis with use of adjunctive catheter-directed intrathrombus thrombolysis. J Vasc Interv Radiol 20(Suppl 7):s332–s335

    Article  PubMed  Google Scholar 

  2. Grunwald MR, Hofmann LV (2004) Comparison of urokinase, alteplase, and reteplase for catheter-directed thrombolysis of deep venous thrombosis. J Vasc Interv Radiol 15:347–352

    PubMed  Google Scholar 

  3. Kasirajan K, Gray B, Ouriel K (2001) Percutaneous AngioJet thrombectomy in the management of extensive deep venous thrombosis. J Vasc Interv Radiol 12:179–185

    Article  PubMed  CAS  Google Scholar 

  4. Kearon C (2003) Natural history of venous thromboembolism. Circulation 107(23 Suppl 1):I22–I30

    PubMed  Google Scholar 

  5. Pianta MJ, Thomson KR (2010) Catheter-directed thrombolysis of lower limb thrombosis. Cardiovasc Intervent Radiol. doi:10.1007/s00270-010-9877-z

  6. Cook D, Meade M, Guyatt G et al (2004) Clinically important deep vein thrombosis in the intensive care unit: a survey of intensivists. Crit Care 8:R145–R152

    Article  PubMed  Google Scholar 

  7. Snow V, Qaseem A, Barry P et al (2007) Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Fam Med 5:74–80

    Article  PubMed  Google Scholar 

  8. Büller HR, Ten Cate-Hoek AJ, Hoes AW et al (2009) Safely ruling out deep venous thrombosis in primary care. Ann Intern Med 150:229–235

    PubMed  Google Scholar 

  9. Winter M, Keeling D, Sharpen F et al (2005) Haemostasis and Thrombosis Task Force of the British Committee for Standards in Haematology. Procedures for the outpatient management of patients with deep venous thrombosis. Clin Lab Haematol 27:61–66

    Article  PubMed  CAS  Google Scholar 

  10. Nazir SA, Ganeshan A, Nazir S et al (2009) Endovascular treatment options in the management of lower limb deep venous thrombosis. Cardiovasc Intervent Radiol 32:861–876

    Article  PubMed  Google Scholar 

  11. Geersing GJ, Janssen KJ, Oudega R et al (2009) Excluding venous thromboembolism using point of care D-dimer tests in outpatients: a diagnostic meta-analysis. Br Med J 14(339):b2990

    Article  Google Scholar 

  12. Zwiebel WJ, Priest DL (1990) Color Doppler sonography of the extremity veins. Semin Ultrasound CT MR 11:136–167

    PubMed  CAS  Google Scholar 

  13. O’Sullivan GJ (2000) Endovascular management of chronic iliac vein occlusion. Tech Vasc Interv Radiol 3:45–53

    Article  Google Scholar 

  14. Anderson ML III (2007) Deep vein thrombosis: will you know it when you see it? Emerg Med 39:24. Available at: http://www.emedmag.com/html/pre/cov/covers/039040024.asp. Accessed 10 March 2010

  15. Kearon C, Kahn SR, Agnelli G et al (2008) Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest 133(Suppl 6):454s–545s

    Article  PubMed  CAS  Google Scholar 

  16. Vedantham S (2008) Interventions for deep vein thrombosis: reemergence of a promising therapy. Am J Med 121(Suppl 11A):28–39

    Article  Google Scholar 

  17. Barritt DW, Jordan SC (1960) Anticoagulant drugs in the treatment of pulmonary embolism: a controlled trial. Lancet 1(7138):1309–1312

    Article  PubMed  CAS  Google Scholar 

  18. Alpert JS, Smith R, Carlson J et al (1976) Mortality in patients treated for pulmonary embolism. JAMA 236(13):1477–1480

    Article  PubMed  CAS  Google Scholar 

  19. Kanis JA (1974) Heparin in the treatment of pulmonary thromboembolism. Thrombos Diath Haemorrh 32(2–3):519–527

    CAS  Google Scholar 

  20. Kernohan RJ, Todd C (1966) Heparin therapy in thromboembolic disease. Lancet 1(7438):621–623

    Article  PubMed  CAS  Google Scholar 

  21. Elsharawy M, Elzayat E (2002) Early results of thrombolysis vs anticoagulation in iliofemoral venous thrombosis. A randomised clinical trial. Eur J Vasc Endovasc Surg 24:209–214

    Article  PubMed  CAS  Google Scholar 

  22. Young L, Ockelford P, Milne D et al (2006) Post-treatment residual thrombus increases the risk of recurrent deep vein thrombosis and mortality. J Thromb Haemost 4:1919–1924

    Article  PubMed  CAS  Google Scholar 

  23. Arko FR (2007) Initiating and building a DVT practice: how to educate physicians and use a single-setting treatment to advance therapy for DVT patients. Endovasc Today Oct:33–38

  24. Eklöf B, Rutherford RB, Bergan JJ et al (2004) Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg 40:1248–1252

    Article  PubMed  Google Scholar 

  25. Rao AS, Konig G, Leers SA et al (2009) Pharmacomechanical thrombectomy for iliofemoral deep vein thrombosis: an alternative in patients with contraindications to thrombolysis. J Vasc Surg 50:1092–1098

    Article  PubMed  Google Scholar 

  26. Jeon UB, Chung JW, Jae HJ et al (2008) Abstract No. 64: common iliac vein stent for May-Thurner syndrome with acute thrombosis: evaluation of patency with CT venography. J Vasc Interv Radiol 19(Suppl 2):s26

    Article  Google Scholar 

  27. Lookstein R (2007) Treating deep vein thrombosis: devices, techniques, and side effects to keep in mind when treating DVT. Endovasc Today Buyer’s Guide:66–67

  28. Kanne JP, Lalani TA (2004) Role of computed tomography and magnetic resonance imaging for deep venous thrombosis and pulmonary embolism. Circulation 109(12 suppl 1):115–121

    Google Scholar 

  29. Katz DS, Loud PA, Bruce D et al (2002) Combined CT venography and pulmonary angiography: a comprehensive review. Radiographics 22(Spec No):s3–s24

    PubMed  Google Scholar 

  30. Roditi G, Chandramohan S (2010) Imaging of the deep venous system—venography/magnetic resonance venography/computed tomography venography. In: Greenhalgh RM (ed) Vascular and endovascular challenges update (Charing Cross). BIBA Publishing, London, pp 432–447

    Google Scholar 

  31. Orbell JH, Smith A, Burnand KG, Waltham M (2008) Imaging of deep vein thrombosis. Br J Surg 95:137–146

    Article  PubMed  CAS  Google Scholar 

  32. Raju S (2008/2004) Venous reconstruction in post-thrombotic syndrome. In: Ascher E, Hollier LH, Strandness DE et al (eds) Haimovici’s vascular surgery, 5th edn. Blackwell Science. Available at: http://www3.interscience.wiley.com/cgi-bin/summary/117878654/SUMMARY. Accessed 5 Jan 2010

  33. Martinez Trabal JL, Comerota AJ, LaPorte FB et al (2008) The quantitative benefit of isolated, segmental, pharmacomechanical thrombolysis (ISPMT) for iliofemoral venous thrombosis. J Vasc Surg 48:1532–1537

    Article  PubMed  Google Scholar 

  34. Laiho MK, Oinonen A, Sugano N et al (2004) Preservation of venous valve function after catheter-directed and systemic thrombolysis for deep venous thrombosis. Eur J Vasc Endovasc Surg 28:391–396

    Article  PubMed  CAS  Google Scholar 

  35. AbuRahma AF, Perkins SE, Wulu JT et al (2001) Iliofemoral deep vein thrombosis: conventional therapy versus lysis and percutaneous transluminal angioplasty and stenting. Ann Surg 233:752–760

    Article  PubMed  CAS  Google Scholar 

  36. Comerota AJ, Paolini D (2007) Treatment of acute iliofemoral deep venous thrombosis: a strategy of thrombus removal. Eur J Vasc Endovasc Surg 33:351–362

    Article  PubMed  CAS  Google Scholar 

  37. Vedantham S, Thorpe PE, Cardella JF et al (2009) Quality improvement guidelines for the treatment of lower extremity deep vein thrombosis with use of endovascular thrombus removal. J Vasc Interv Radiol 20(Suppl 7):s227–s239

    Article  PubMed  Google Scholar 

  38. Chouhan VD, Comerota AJ, Sun L et al (1999) Inhibition of tissue factor pathway during intermittent pneumatic compression: a possible mechanism for antithrombotic effect. Arterioscler Thromb Vasc Biol 19:2812–2817

    PubMed  CAS  Google Scholar 

  39. O’Sullivan GJ, Semba CP, Bittner CA et al (2000) Endovascular management of iliac vein compression (May-Thurner) syndrome. J Vasc Interv Radiol 11:823–836

    Article  PubMed  Google Scholar 

  40. Messina LM, Sarpa MS, Smith MA et al (1993) Clinical significance of routine imaging of iliac and calf veins by color flow duplex scanning in patients suspected of having acute lower extremity deep venous thrombosis. Surgery 114:921–927

    PubMed  CAS  Google Scholar 

  41. Kluetz PG, White CS (2006) Acute pulmonary embolism: imaging in the emergency department. Radiol Clin North Am 44:259–271

    Article  PubMed  Google Scholar 

  42. Lohan DG, Cronin CG, Meehan CP (2007) Massive pulmonary embolus with hemodynamic compromise: therapeutic options. Emerg Radiol 13:161–169

    Article  PubMed  Google Scholar 

  43. O’Sullivan GJ (2010) Isolated pharmacomechanical thrombolysis using the Trellis system. In: Greenhalgh RM (ed) Vascular and endovascular challenges update (Charing Cross). BIBA Publishing, London, pp 552–564

    Google Scholar 

  44. Sadowski EA, Bennett LK, Chan MR et al (2007) Nephrogenic systemic fibrosis: risk factors and incidence estimation. Radiology 243:148–157

    Article  PubMed  Google Scholar 

  45. Vedantham S (2009) Deep venous thrombosis: the opportunity at hand. AJR Am J Roentgenol 193:922–927

    Article  PubMed  Google Scholar 

  46. Righini M, Bounameaux H (2008) Clinical relevance of distal deep vein thrombosis. Curr Opin Pulm Med 14:408–413

    Article  PubMed  Google Scholar 

  47. O’Sullivan GJ, Lohan DG, Gough N et al (2007) Pharmacomechanical thrombectomy of acute deep vein thrombosis with the Trellis-8 isolated thrombolysis catheter. J Vasc Interv Radiol 18:715–724

    Article  PubMed  Google Scholar 

  48. Arko FR, Davis CM 3rd, Murphy EH et al (2007) Aggressive percutaneous mechanical thrombectomy of deep venous thrombosis: early clinical results. Arch Surg 142:513–519

    Article  PubMed  Google Scholar 

  49. Augustinos P, Ouriel K (2004) Invasive approaches to treatment of venous thromboembolism. Circulation 110(9 Suppl 1):i27–i34

    Article  PubMed  Google Scholar 

  50. Comerota AJ, Gravett MH (2009) Do randomized trials of thrombolysis versus open revascularization still apply to current management: What has changed? Semin Vasc Surg 22:41–46

    Article  PubMed  Google Scholar 

  51. Cynamon J, Stein EG, Dym RJ et al (2006) A new method for aggressive management of deep vein thrombosis: Retrospective study of the power pulse technique. J Vasc Interv Radiol 17:1043–1049

    Article  PubMed  Google Scholar 

  52. Dukkipati R, Yang EH, Adler S (2009) Acute kidney injury caused by intravascular hemolysis after mechanical thrombectomy. Nat Clin Pract Nephrol 5:112–116

    Article  PubMed  Google Scholar 

  53. Hilleman DE, Razavi MK (2008) Clinical and economic evaluation of the Trellis-8 infusion catheter for deep vein thrombosis. J Vasc Interv Radiol 19:377–383

    Article  PubMed  Google Scholar 

  54. Kasirajan K, Milner R, Chaikof EL (2006) Combination therapies for deep venous thrombosis. Semin Vasc Surg 19:116–121

    Article  PubMed  Google Scholar 

  55. Kim HS, Patra A, Paxton BE (2006) Adjunctive percutaneous mechanical thrombectomy for lower-extremity deep vein thrombosis: clinical and economic outcomes. J Vasc Interv Radiol 17:1099–1104

    Article  PubMed  Google Scholar 

  56. Lee KH, Han H, Lee KJ et al (2006) Mechanical thrombectomy of acute iliofemoral deep vein thrombosis with use of an Arrow-Trerotola percutaneous thrombectomy device. J Vasc Interv Radiol 17:487–495

    Article  PubMed  Google Scholar 

  57. Mewissen MW, Seabrook GR, Meissner MH et al (1999) Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry. Radiology 211:39–49

    PubMed  CAS  Google Scholar 

  58. Parikh S, Motarjeme A, McNamara T et al (2008) Ultrasound-accelerated thrombolysis for the treatment of deep vein thrombosis: initial clinical experience. J Vasc Interv Radiol 19:521–528

    Article  PubMed  Google Scholar 

  59. Semba CP, Dake MD (1994) Iliofemoral deep venous thrombosis: aggressive therapy with catheter-directed thrombolysis. Radiology 191:487–494

    PubMed  CAS  Google Scholar 

  60. Vedantham S, Vesely TM, Parti N et al (2002) Lower extremity venous thrombolysis with adjunctive mechanical thrombectomy. J Vasc Interv Radiol 13:1001–1008

    Article  PubMed  Google Scholar 

  61. Kamphausen M, Barbera L, Mumme A et al (2005) Clinical and functional results after transfemoral thrombectomy for iliofemoral deep venous thrombosis: a 5-year-follow-up. Zentralbl Chir 130:454–462

    Article  PubMed  CAS  Google Scholar 

  62. Geier B, Asciutto G, Strohmann B et al (2009) Long-term results after transfemoral venous thrombectomy for iliofemoral deep venous thrombosis. Abstract 46. In: Annual meeting XXIII, European Society for Vascular Surgery (ESVS), Oslo, Norway, 3–6 September, 2009

  63. Hölper P, Kotelis D, Attigah N et al (2010) Long-term results after surgical thrombectomy and simultaneous stenting for symptomatic iliofemoral venous thrombosis. Eur J Vasc Endovasc Surg 39:349–355

    Article  PubMed  Google Scholar 

  64. Blättler W, Heller G, Largiadèr J et al (2004) Combined regional thrombolysis and surgical thrombectomy for treatment of iliofemoral vein thrombosis. J Vasc Surg 40:620–625

    Article  PubMed  Google Scholar 

  65. Plate G, Eklöf B, Norgren L et al (1997) Venous thrombectomy for iliofemoral vein thrombosis—10-year results of a prospective randomised study. Eur J Vasc Endovasc Surg 14:367–374

    Article  PubMed  CAS  Google Scholar 

  66. Juhan CM, Alimi YS, Barthelemy PJ et al (1997) Late results of iliofemoral venous thrombectomy. J Vasc Surg 25:417–422

    Article  PubMed  CAS  Google Scholar 

  67. Mair DC, Eastlund T, Rosen G et al (2005) Hemolysis during percutaneous mechanical thrombectomy can mimic a hemolytic transfusion reaction. Transfusion 45:1291–1294

    Article  PubMed  CAS  Google Scholar 

  68. Danetz JS, McLafferty RB, Ayerdi J et al (2004) Pancreatitis caused by rheolytic thrombolysis: an unexpected complication. J Vasc Interv Radiol 15:857–860

    PubMed  Google Scholar 

  69. Lookstein R, Blitz L, Simoni E (2010) Mid term results of the PEARL (Peripheral Use of AngioJet Rheolytic Thrombectomy With Mid-Length Catheters) registry for deep vein thrombosis. Abstract 145. J Vasc Interv Radiol 21(Suppl 2):s57

    Article  Google Scholar 

  70. Tsai J, Georgiades CS, Hong K et al (2006) Presumed pulmonary embolism following power-pulse spray thrombectomy of extremity venous thrombosis. Cardiovasc Intervent Radiol 29:678–680

    Article  PubMed  Google Scholar 

  71. O’Sullivan GJ, Mhuircheartaigh JN, Ferguson D et al (2010) Isolated pharmacomechanical thrombolysis plus primary stenting in a single procedure to treat acute thrombotic superior vena cava syndrome. J Endovasc Ther 7:115–123

    Article  Google Scholar 

  72. Dietzek AM (2010) Isolated pharmacomechanical thrombolysis of deep venous thrombosis utilizing a peripheral infusion system: manufacturer’s voluntary registry report 2005–2009. Int Angiol 29:308–316

    PubMed  CAS  Google Scholar 

  73. Vedantham S, Grassi CJ, Ferral H et al (2009) Technology Assessment Committee of the Society of Interventional Radiology Reporting standards for endovascular treatment of lower extremity deep vein thrombosis. J Vasc Interv Radiol 20(Suppl 7):s391–s408

    Article  PubMed  Google Scholar 

  74. Allie DE, Hebert CJ, Lirtzman MD et al (2004) Novel simultaneous combination chemical thrombolysis/rheolytic thrombectomy therapy for acute critical limb ischemia: the power-pulse spray technique. Catheter Cardiovasc Interv 63:512–522

    Article  PubMed  Google Scholar 

  75. Biuckians A, Meier GH 3rd (2007) Treatment of symptomatic lower extremity acute deep venous thrombosis: Role of mechanical thrombectomy. Vascular 15:297–303

    Article  PubMed  Google Scholar 

  76. Bush RL, Lin PH, Bates JT et al (2004) Pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis: safety and feasibility study. J Vasc Surg 40:965–970

    Article  PubMed  Google Scholar 

  77. Bush RL, Lin PH (2004) Percutaneous mechanical thrombectomy combined with thrombolysis for the treatment of deep venous thromboses. Vasc Dis Manage 1:29–32

    Google Scholar 

  78. Shah AD, Bajakian DR, Olin JW et al (2007) Power-pulse spray thrombectomy for treatment of Paget-Schroetter syndrome. AJR Am J Roentgenol 188:1215–1217

    Article  PubMed  Google Scholar 

  79. Shammas NW (2007) An overview of pharmacotherapy during percutaneous peripheral interventions of thrombotic lesions. Vasc Dis Manage Mar/Apr(Suppl C):6C–12C

  80. Silva JA, Ramee SR, Collins TJ et al (1998) Rheolytic thrombectomy in the treatment of acute limb-threatening ischemia: immediate results and six-month follow-up of the multicenter AngioJet registry. Possis Peripheral AngioJet Study AngioJet Investigators. Cathet Cardiovasc Diagn 45:386–393

    Article  PubMed  CAS  Google Scholar 

  81. Keeling AN, Kinney TB, Lee MJ (2008) Optional inferior vena caval filters: where are we now? Eur Radiol 18:1556–1568

    Article  PubMed  CAS  Google Scholar 

  82. Kwak HS, Han YM, Lee YS et al (2005) Stents in common iliac vein obstruction with acute ipsilateral deep venous thrombosis: early and late results. J Vasc Interv Radiol 16:815–822

    PubMed  Google Scholar 

  83. Neglén P, Hollis KC, Olivier J, Raju S (2007) Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical, and hemodynamic result. J Vasc Surg 46:979–990

    Article  PubMed  Google Scholar 

  84. O’Riordan C, McWeeney DM, Walshe TM et al (2009) Radial Hoop strength of large diameter stents: application for venous circulation at sites of venous flexion (Abstract P–543). Presented at CIRSE, Lisbon, Portugal, 19–23 September 2009

  85. Murphy EH, Davis CM, Journeycake JM et al (2009) Symptomatic ileofemoral DVT after onset of oral contraceptive use in women with previously undiagnosed May-Thurner Syndrome. J Vasc Surg 49:697–703

    Article  PubMed  Google Scholar 

  86. Joffe HV, Goldhaber SZ (2002) Upper-extremity deep vein thrombosis. Circulation 106:1874–1880

    Article  PubMed  Google Scholar 

  87. Vedantham S (2009) The ATTRACT trial: an update on the future of DVT therapy. Endovasc Today July:61–65

Download references

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Section of Interventional Radiology, Department of Radiology, University College Hospital Galway, Newcastle Road, Galway, Ireland

    Gerard J. O’Sullivan

Authors
  1. Gerard J. O’Sullivan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Gerard J. O’Sullivan.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1 (MPG 13444 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

O’Sullivan, G.J. The Role of Interventional Radiology in the Management of Deep Venous Thrombosis: Advanced Therapy. Cardiovasc Intervent Radiol 34, 445–461 (2011). https://doi.org/10.1007/s00270-010-9977-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00270-010-9977-9

Keywords

Search

Navigation