Korean J Radiol.  2011 Feb;12(1):97-106. 10.3348/kjr.2011.12.1.97.

Catheter-Directed Thrombolysis with a Continuous Infusion of Low-Dose Urokinase for Non-Acute Deep Venous Thrombosis of the Lower Extremity

• Gao B
• Zhang J
• Wu X
• Han Z
• Zhou H
• Dong D
• Jin X

• KMID: 991687
• DOI: http://doi.org/10.3348/kjr.2011.12.1.97

Abstract

OBJECTIVE
We wanted to evaluate the feasibility of catheter-directed thrombolysis with a continuous infusion of low-dose urokinase for treating non-acute (less than 14 days) deep venous thrombosis of the lower extremity.
MATERIALS AND METHODS
The clinical data of 110 patients who were treated by catheter-directed thrombolysis with a continuous infusion of low-dose urokinase for lower extremity deep venous thrombosis was analysed. Adjunctive angioplasty or/and stenting was performed for the residual stenosis. Venous recanalization was graded by pre- and post-treatment venography. Follow-up was performed by clinical evaluation and Doppler ultrasound.
RESULTS
A total of 112 limbs with deep venous thrombosis with a mean symptom duration of 22.7 days (range: 15-38 days) were treated with a urokinase infusion (mean: 3.5 million IU) for a mean of 196 hours. After thrombolysis, stent placement was performed in 25 iliac vein lesions and percutaneous angioplasty (PTA) alone was done in five iliac veins. Clinically significant recanalization was achieved in 81% (90 of 112) of the treated limbs; complete recanalization was achieved in 28% (31 of 112) and partial recanalization was achieved in 53% (59 of 112). Minor bleeding occurred in 14 (13%) patients, but none of the patients suffered from major bleeding or symptomatic pulmonary embolism. During follow-up (mean: 15.2 months, range: 3-24 months), the veins were patent in 74 (67%) limbs. Thirty seven limbs (32%) showed progression of the stenosis with luminal narrowing more than 50%, including three with rethrombosis, while one revealed an asymptomatic iliac vein occlusion; 25 limbs (22%) developed mild post-thrombotic syndrome, and none had severe post-thrombotic syndrome. Valvular reflux occurred in 24 (21%) limbs.
CONCLUSION
Catheter-directed thrombolysis with a continuous infusion of low-dose urokinase combined with adjunctive iliac vein stenting is safe and effective for removal of the clot burden and for restoration of the venous flow in patients with non-acute lower extremity deep venous thrombosis.

Keyword

Non-acute lower extremity deep venous thrombosis; Catheter-directed thrombolysis; Stent placement; Bleeding complication; Post-thrombotic syndrome

MeSH Terms

Adult
Aged
Angioplasty, Balloon
*Catheterization, Peripheral
Combined Modality Therapy
Female
Fibrinolytic Agents/*administration & dosage
Humans
*Infusion Pumps
Infusions, Intravenous
Leg/*blood supply
Male
Middle Aged
Phlebography
*Thrombolytic Therapy/methods
Ultrasonography, Doppler
Urokinase-Type Plasminogen Activator/*administration & dosage
Vascular Patency
Venous Thrombosis/*drug therapy/radiography/ultrasonography

Figure

• 

  Fig. 1 Complete lysis in 33-year-old woman with 3-week history of swelling of left leg after cesarean section (venograms with patient in prone position). A-D. Venograms obtained before catheter-directed thrombolysis show part or complete absence of contrast material in superficial femoral vein, common femoral vein, external iliac vein and common iliac vein. E-I. Venograms obtained after 240 hours of catheter-directed thrombolysis show deep veins (from superficial femoral vein to external iliac vein) with restored patency; (G) complete occlusion in proximal segment of common iliac vein; (H) common iliac vein received percutaneous angioplasty and (I) common iliac vein has restored patency after percutaneous angioplasty.

• 

  Fig. 2 Complete lysis in 26-year-old man with 16 days history of pain and swelling of both legs. A-C. Venograms were obtained with patient in prone position, and these are the images shown. Venogram obtained before catheter-directed thrombolysis shows complete occlusion of dual iliac veins (A). Venograms obtained after 192 hours of catheter-directed thrombolysis show complete lysis (B) in right iliac vein and (C) in left iliac vein.

• 

  Fig. 3 Iliac vein's restored patency after catheter-directed thrombolysis and percutaneous angioplasty with stenting in 53-year-old man who presented with edema of left lower extremity for 35 days. A-C. Images were taken with patient prone on angiography table and these are images shown. Before catheter-directed thrombolysis, note severe left common iliac vein stenosis (arrow), complete absence of contrast material in external iliac vein (curved arrows) and thrombosis in inferior vena cava (open arrows) (A). After 196 hours of catheter-directed thrombolysis, thrombus in inferior vena cava was completely dissolved and external iliac vein obtained complete patency (B), and common iliac vein stenosis was treated with stent placement (arrow) and then common iliac vein achieved complete patency (C).

• 

  Fig. 4 Well-developed venous collaterals around recanalized femoral vein in 68-year-old man who presented with swelling of left leg for 30 days. A. Before catheter-directed thrombolysis, common femoral vein was completely occluded and there was small number of venous collaterals around it. B. After 216 hours of catheter-directed thrombolysis, common femoral vein's patency was restored and large number of venous collaterals opened around it.

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