Clinical outcomes of AngioJet pharmacomechanical thrombectomy versus catheter-directed thrombolysis for the treatment of filter-related caval thrombosis

Abstract

Background: The inferior vena cava filter is utilized worldwide to intercept thrombi and to reduce the risk of fatal pulmonary embolism (PE). However, filter-related thrombosis is a complication of filter implantation. Endovascular methods such as AngioJet rheolytic thrombectomy (ART) and catheter-directed thrombolysis (CDT) can treat filter-related caval thrombosis, but the clinical outcomes of both treatment modalities have not been determined.

Aim: To compare the treatment outcomes of AngioJet rheolytic thrombectomy vs catheter-directed thrombolysis in patients with filter-related caval thrombosis.

Methods: In this single-center retrospective study, 65 patients (34 males and 31 females; mean age: 59.0 ± 13.43 years) with intrafilter and inferior vena cava thrombosis were enrolled between January 2021 and August 2022. These patients were assigned to either the AngioJet group (n = 44) or the CDT group (n = 21). Clinical data and imaging information were collected. Evaluation measures included thrombus clearance rate, periprocedural complications, urokinase dosage, incidence of PE, limb circumference difference, length of stay, and filter removal rate.

Results: Technical success rates were 100% in the AngioJet and CDT groups. In the AngioJet group, grade II and grade III thrombus clearance was achieved in 26 (59.09%) and 14 (31.82%) patients, respectively. In the CDT group, grade II and grade III thrombus clearance was accomplished in 11 (52.38%) patients and 8 (38.10%) patients, respectively (P > 0.05).The peridiameter difference of the thigh was significantly reduced in patients from both groups after treatment (P < 0.05). The median dosage of urokinase was 0.08 (0.02, 0.25) million U in the AngioJet group and 1.50 (1.17, 1.83) million U in the CDT group (P < 0.05). Minor bleeding was shown in 4 (19.05%) patients in the CDT group, and when it was compared with that in the AngioJet group, the difference was statistically significant (P < 0.05). No major bleeding occurred. Seven (15.91%) patients in the AngioJet group had hemoglobinuria and 1 (4.76%) patient in the CDT group had bacteremia. There were 8 (18.18%) patients with PE in the AngioJet group and 4 (19.05%) patients in the CDT group before the intervention (P > 0.05). Computed tomography angiopulmonography (CTA) showed that PE was resolved after the intervention. New PE occurred in 4 (9.09%) patients in the AngioJet group and in 2 (9.52%) patients in the CDT group after theintervention (P > 0.05). These cases of PE were asymptomatic. The mean length of stay was longer in the CDT group (11.67 ± 5.34 d) than in the AngioJet group (10.64 ± 3.52 d) (P < 0.05). The filter was successfully retrieved in the first phase in 10 (47.62%) patients in the CDT group and in 15 (34.09%) patients in the AngioJet group (P > 0.05).Cumulative removal was accomplished in 17 (80.95%) out of 21 patients in the CDT group and in 42 (95.45%) out of 44 patients in the ART group (P > 0.05). The median indwelling time for patients with successful retrieval was 16 (13139) d in the CDT group and 59 (12231) d in the ART group (P > 0.05).

Conclusion: Compared with catheter-directed thrombolysis, AngioJet rheolytic thrombectomy can achieve similar thrombus clearance effects, improve the filter retrieval rate, reduce the urokinase dosage and lower the risk of bleeding events in patients with filter-related caval thrombosis.

Keywords: AngioJet rheolytic thrombectomy; Catheter-directed thrombolysis; Clinical outcome; Inferior vena cava filter; Thrombosis.

Figure 1

Study profile. IVC: Inferior vena cava; CDT: Catheter-directed thrombolysis.

Figure 2

Angiography was performed to evaluate the thrombus clearance of AngioJet. A: A 31-year-old male patient with acute traumatic lower-limb fracture and simultaneous deep venous thrombosis received an inferior vena cava (IVC) filter before surgical fixation; B and C: Filter removal was attempted within 2 weeks after fracture surgery, and angiography showed filter-related IVC-iliac vein thrombosis (white arrow); D and E: A 6-Fr AngioJet thrombectomy catheter was placed for thrombus clearance; F: The 10F guiding catheter was placed and withdrawn, and the thrombus was aspirated under negative pressure until it exited the body, which could be repeated 2-3 times; G and H: The venography showed the complete clearance thrombus of filter-related IVC-iliac vein thrombosis; I: The venography showed that the IVC vein was unobstructed after filter retrieval; J: Computed tomography angiopulmonography did not show pulmonary embolism after intervention.

Figure 3

Angiography was implemented to assess the thrombus clearance of catheter-directed thrombolysis. A: A 36-year-old male patient with acute traumatic lower-limb fracture and simultaneous deep venous thrombosis received an inferior vena cava (IVC) filter before surgical fixation. Filter removal was attempted within 2 wk after fracture surgery, and venography showed IVC-related caval thrombosis; B: A thrombolytic catheter was placed in the thrombosed segment via the right femoral vein, and urokinase was continuously injected; C: The venography showed that the most clearance thrombus of filter-related thrombosis; D: The patient was given anticoagulation therapy with rivaroxaban 20 mg daily after catheter-directed thrombolysis. The venography showed that the complete thrombus clearance of filter-related thrombosis 7 wk later; E: The venography showed that the IVC vein was unobstructed after the filter removal; F: Computed tomography angiopulmonography did not show pulmonary embolism after intervention.