A Brief Review of Thrombolytics for Venous Interventions

Abstract

Anticoagulation continues to be the mainstay of therapy for the management of venous thromboembolism. However, anticoagulation does not lead to the breakdown or dissolving of the thrombus. In an acute pulmonary embolism, extensive thrombus burden can be associated with a high risk for early decompensation, and in acute deep venous thrombosis, it can be associated with an increased risk for phlegmasia. In addition, residual thrombosis can be associated with chronic thromboembolic pulmonary hypertension and postthrombotic syndrome in a chronic setting. Thrombolytic therapy is a crucial therapeutic choice in treating venous thromboembolism for thrombus resolution. Historically, it was administered systemically and was associated with high bleeding rates, particularly major bleeding, including intracranial bleeding. In the last two decades, there has been a significant increase in catheter-based therapies with and without ultrasound, where lower doses of thrombolytic agents are utilized, potentially reducing the risk for major bleeding events and improving the odds of reducing the thrombus burden. In this article, we provide an overview of several thrombolytic therapies, including delivery methods, doses, and outcomes.

Keywords: alteplase; interventional radiology; thrombolysis; venous thromboembolic disease; venous thromboembolism.

Fig. 1

A 22-year-old woman on oral contraception developed acute onset left lower extremity pain and swelling. ( a ) Gray-scale ultrasound image demonstrating echogenic thrombus within the common femoral vein (arrow). ( b ) Longitudinal Doppler ultrasound image highlighting thrombus and lack of flow in left external iliac vein (arrow). ( c ) Axial image from computed tomographic venography (CTV) redemonstrating occlusive thrombus in left external iliac vein (arrowhead). ( d ) Venogram highlighting tram-track appearance of thrombus within the popliteal vein (arrowhead). ( e ) Fluoroscopic image showing extent of infusion catheter within the iliofemoral veins (arrowheads). ( f ) Completion venogram with widely patent femoral vein. ( g ) Completion venogram with widely patent iliac veins containing stents (between arrowheads). ( h ) Photographs in prone position before (left) and after (right) thrombolysis and stenting.

Fig. 2

A 31-year-old man with acute deep venous thrombosis involving the inferior vena cava (IVC) and left lower extremity veins treated with percutaneous catheter-directed thrombolysis using Tenecteplase. ( a ) Coronal computed tomographic venography (CTV) image revealing IVC thrombus extending to the suprarenal IVC (white arrows). ( b ) Axial CTV image showing expanded left external iliac vein with hypodense filling defect (black arrow), consistent with acute thrombus. ( c ) Initial venogram from popliteal access demonstrates occlusion of the left common femoral and iliac veins (white arrowhead). ( d ) Contrast injection of the IVC demonstrates nonocclusive thrombus extending to the suprarenal IVC (between white arrowheads). ( e ) IVUS image demonstrating compression of the left common iliac vein (LCIV) by the right common iliac artery and thrombus in LCIV (asterisk). ( f ) Completion venography after 48 hours showing patent proximal left femoral and common femoral veins. ( g ) Completion venography highlighting patent common left iliac vein stent (arrowhead).