RESUMO
BACKGROUND: Extensive deep venous thrombosis (DVT) during pregnancy is usually treated with anticoagulation alone, risking significant post-thrombotic syndrome (PTS) in young patients. Catheter-directed thrombolysis (CDT) and operative venous thrombectomy have been safely and effectively used in nonpregnant patients, demonstrating significant reduction in post-thrombotic morbidity. This report reviews short- and long-term outcomes of 13 patients with extensive DVT of pregnancy treated with a strategy of thrombus removal. METHODS: From 1999 to 2013, 13 patients with iliofemoral DVT during pregnancy were offered CDT, pharmacomechanical thrombolysis (PMT), and/or venous thrombectomy. Gestational age ranged from 8 to 34 weeks. Fetal monitoring was performed throughout hospitalization. Radiation exposure was minimized with pelvic lead shields, focal fluoroscopy, and limited angiographic runs. Follow-up included objective vein evaluation using venous duplex and PTS assessment using the Villalta scale. RESULTS: CDT and/or PMT were used in 11 patients. Two patients underwent venous thrombectomy alone, and one patient had operative thrombectomy as an adjunct to CDT and PMT. Each patient had complete or near-complete thrombus resolution and rapid improvement in clinical symptoms. Eight of 11 having CDT or PMT underwent venoplasty and stenting of the involved iliac veins. Twelve of the 13 delivered healthy infants at term. One patient opted for termination of her pregnancy. Mean patient and gestational ages were 26 years and 26 weeks, respectively. Mean follow-up was 1.3 years, with only one recurrence. Duplex ultrasonography demonstrated patent veins in all but one patient and normal valve function in 10 patients. Eleven patients had Villalta scores <5 (considered normal), with a mean score of 0.7. CONCLUSIONS: Extensive DVT of pregnancy can be effectively and safely treated with a strategy of thrombus removal, resulting in a patent venous system, normal valve function in many, prevention of PTS, and reduction in recurrence.
Assuntos
Veia Femoral/cirurgia , Veia Ilíaca/cirurgia , Complicações Cardiovasculares na Gravidez/terapia , Trombectomia , Terapia Trombolítica , Trombose Venosa/terapia , Adulto , Feminino , Veia Femoral/diagnóstico por imagem , Veia Femoral/fisiopatologia , Idade Gestacional , Humanos , Veia Ilíaca/diagnóstico por imagem , Veia Ilíaca/fisiopatologia , Flebografia , Síndrome Pós-Trombótica/prevenção & controle , Gravidez , Complicações Cardiovasculares na Gravidez/diagnóstico , Complicações Cardiovasculares na Gravidez/fisiopatologia , Estudos Retrospectivos , Prevenção Secundária , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Dupla , Grau de Desobstrução Vascular , Trombose Venosa/diagnóstico , Trombose Venosa/fisiopatologiaRESUMO
OBJECTIVE: To evaluate the usefulness of a published clinical decision support tool to predict the likelihood of a retrievable inferior vena cava (IVC) filter being maintained as a permanent device. METHODS: This multicenter retrospective cohort study included 1498 consecutive patients (852 men and 646 women; median age, 60 years; range, 18-98 years) who underwent retrievable IVC filter insertion between January 2012 and December 2019. The indications for IVC filtration, baseline neurologic disease, history of venous thromboembolism (VTE), and underlying malignancy were recorded. Accuracy, sensitivity, and specificity of a published clinical support tool were calculated to determine the usefulness of the tool. RESULTS: The majority of filters (1271/1498 [85%]) were placed for VTE with a contraindication to anticoagulation. A history of VTE was present in 811 of 1498 patients (54%) patients; underlying malignancy in 531 of 1498 patients (35%), and neurological disease in 258 of 1498 patients (17%). Of the 1498 filters, 456 (30%) were retrieved, 276 (18%) were maintained as permanent devices on follow-up, and 766 (51%) filters were not retrieved. The accuracy of the clinical prediction model was 61%, sensitivity was 60%, and specificity was 62%. CONCLUSIONS: A previously published clinical decision support tool to predict permanence of IVC filters had modest usefulness in the examined population; this factor should be taken into account when using this clinical decision support tool outside of the original study population. Future studies are required to refine the predictive capability of IVC filter decision support tools for broader use across different patient populations.
Assuntos
Sistemas de Apoio a Decisões Clínicas , Neoplasias , Embolia Pulmonar , Filtros de Veia Cava , Tromboembolia Venosa , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Remoção de Dispositivo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Prognóstico , Estudos Retrospectivos , Resultado do Tratamento , Veia Cava Inferior , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle , Adulto JovemRESUMO
BACKGROUND: Early thrombus removal in patients with iliofemoral deep venous thrombosis (IFDVT) reduces postthrombotic morbidity. Preserving valve function and relieving venous obstruction prevents deterioration of quality of life and loss of economic potential. The preferred method for treating IFDVT is catheter-directed thrombolysis (CDT). Recently, isolated segmental pharmacomechanical thrombolysis (ISPMT) has emerged as a treatment option for patients with extensive IFDVT. The purpose of our study is to determine whether there are advantages to using ISPMT as the primary treatment for patients with iliofemoral IFDVT and, if so, to quantify those advantages relative to CDT. METHODS: Forty-three patients with IFDVT were treated with percutaneous CDT between May 2003 and June 2007. Twenty-one patients (27 limbs) were treated with CDT and 22 patients (25 limbs) were treated with ISPMT +/- CDT. Demographics, extent of thrombus, procedural details, and thrombus resolution were recorded. RESULTS: Treatment time (55.4 vs 23.4 hours; P < .0001) and dose of rt-PA (59.3 vs 33.4 mg; P = .0009) were decreased and overall lytic success (60% vs 80%; P = .0016) increased with ISPMT. Adjunctive venoplasty and stenting, complications, hospital length-of-stay (LOS), and intensive care unit LOS were similar between groups. CONCLUSION: ISPMT offers more effective thrombus removal in less time and with a reduced dose of thrombolytic agent. However, decreased treatment time did not translate into decreased hospital or ICU stay. Longer-term follow-up is required to determine whether improved thrombus resolution translates to better functional outcome and reduced postthrombotic morbidity.