Single-Session Thrombectomy without Thrombolysis for Iliofemoral Deep Vein Thrombosis: A Single-Center Experience of ClotTriever with Evaluation of Predictors for Reocclusion

Abstract

Objective The aim of this study was to determine the effectiveness of a mechanical thrombectomy device in treating iliofemoral deep vein thrombosis (DVT) without thrombolysis and factors associated with post-thrombectomy occlusion.

Methods A single-institution retrospective study of consecutive patients who underwent mechanical thrombectomy for iliofemoral DVT using the Inari ClotTriever device was performed from August 2019 to July 2022 without thrombolysis or aspiration. Pre- and post-thrombectomy modified Marder score, symptomatic relief, and other baseline characteristics were evaluated. Occlusion rate was evaluated by clinical symptoms and imaging studies during follow-up. Occlusion-free survival (OFS) was calculated. Factors associated with OFS were evaluated with log-rank tests and cox-proportional hazard ratio model. Procedure-related complications were reported.

Results Among 32 included patients and 45 limbs, the mean Marder score decreased from 17.5 ± 8.1 to 0.13 ± 0.89 after thrombectomy. Stenting was needed in 13 patients (40.6%). No procedure-related major complication was observed postprocedurally. At initial follow-up, symptomatic improvement and occlusion-free patency were achieved in 80.0 and 72.2%, respectively. Poor venous inflow on post-thrombectomy venogram (p < 0.05) was associated with early occlusion. Suboptimal use of post-thrombectomy anticoagulation (n = 7) was the only independent predictor of clinical and radiological OFS (p = 0.042).

Conclusion Mechanical thrombectomy with ClotTriever is safe and effective in the treatment of acute and/or subacute iliofemoral DVT and can mitigate the need for thrombolytic therapy. Poor venous inflow on post-thrombectomy venogram and suboptimal use of anticoagulation were associated with early reocclusion.

Keywords

deep vein thrombosis - thrombectomy - venous

• References

• 1 Lichtenberg MKW, Stahlhoff S, Młyńczak K. et al. Endovascular mechanical thrombectomy versus thrombolysis in patients with iliofemoral deep vein thrombosis - a systematic review and meta-analysis. Vasa 2021; 50 (01) 59-67
• 2 Murphy KD. Mechanical thrombectomy for DVT. Tech Vasc Interv Radiol 2004; 7 (02) 79-85
• 3 Comerota AJ. The ATTRACT trial: rationale for early intervention for iliofemoral DVT. Perspect Vasc Surg 2009; 21 (04) 221-224 , quiz 224–225
• 4 Winokur RS, Sista AK. DVT intervention in the post-ATTRACT era. Curr Treat Options Cardiovasc Med 2018; 20 (09) 70
• 5 Robertson B, Neville E, Muck A. et al. Technical success and short-term results from mechanical thrombectomy for lower extremity iliofemoral deep vein thrombosis using a computer aided mechanical aspiration thrombectomy device. J Vasc Surg Venous Lymphat Disord 2022; 10 (03) 594-601
• 6 Abramowitz S. Effective removal of chronic thrombus with the ClotTriever System: results from the CLOUT Registry. J Vasc Surg Venous Lymphat Disord 2021; 9 (02) 544-545
• 7 Jolly MA, Lockhart MM, Shah D. et al. Outcomes from a tertiary care center using a catheter thrombectomy system for managing acute iliofemoral deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2022; 10 (05) 1044-1050
• 8 Wadhwa V, Malhotra A, Kesselman A. Single-session mechanical thrombectomy of lower extremity deep venous thrombosis using the ClotTriever system: a single-institution experience. Arab J Intervent Radiol 2021; 5 (02) 071-075
• 9 Dexter D. Thrombus chronicity subanalysis of mechanical thrombectomy for deep vein thrombosis in real-world patients: six-month outcomes from the CLOUT registry. J Vasc Surg Venous Lymphat Disord 2022; 10 (04) 832-840
• 10 Vedantham S, Salter A, Lancia S, Lewis L, Thukral S, Kahn SR. Clinical outcomes of a pharmacomechanical catheter-directed venous thrombolysis strategy that included rheolytic thrombectomy in a multicenter randomized trial. J Vascular Intervent Radiol 2021; 32 (09) 1296-1309. e7
• 11 Khalilzadeh O, Baerlocher MO, Shyn PB. et al. Proposal of a new adverse event classification by the Society of Interventional Radiology Standards of Practice Committee. J Vascular Intervent Radiol 2017; 28 (10) 1432-1437. e3
• 12 Dexter DJ, Kado H, Schor J. et al; CLOUT Investigators. Interim outcomes of mechanical thrombectomy for deep vein thrombosis from the All-Comer CLOUT Registry. J Vasc Surg Venous Lymphat Disord 2022; 10 (04) 832-840.e2
• 13 Benarroch-Gampel J, Pujari A, Aizpuru M, Rajani RR, Jordan WD, Crawford R. Technical success and short-term outcomes after treatment of lower extremity deep vein thrombosis with the ClotTriever system: a preliminary experience. J Vasc Surg Venous Lymphat Disord 2020; 8 (02) 174-181
• 14 Jeyabalan G, Marone L, Rhee R. et al. Inflow thrombosis does not adversely affect thrombolysis outcomes of symptomatic iliofemoral deep vein thrombosis. J Vasc Surg 2011; 54 (02) 448-453
• 15 Abraham NS, Singh S, Alexander GC. et al. Comparative risk of gastrointestinal bleeding with dabigatran, rivaroxaban, and warfarin: population based cohort study. BMJ 2015;350;
• 16 Holster IL, Valkhoff VE, Kuipers EJ, Tjwa ET. New oral anticoagulants increase risk for gastrointestinal bleeding: a systematic review and meta-analysis. Gastroenterology 2013; 145 (01) 105-112. e15
• 17 Ruff CT, Giugliano RP, Braunwald E. et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 2014; 383 (9921): 955-962
• 18 Abraham NS, Noseworthy PA, Yao X, Sangaralingham LR, Shah ND. Gastrointestinal safety of direct oral anticoagulants: a large population-based study. Gastroenterology 2017; 152 (05) 1014-1022. e1
• 19 Fralick M, Colacci M, Schneeweiss S, Huybrechts KF, Lin KJ, Gagne JJ. Effectiveness and safety of apixaban compared with rivaroxaban for patients with atrial fibrillation in routine practice: a cohort study. Ann Intern Med 2020; 172 (07) 463-473
• 20 Lip GYH, Keshishian A, Li X. et al. Effectiveness and safety of oral anticoagulants among nonvalvular atrial fibrillation patients. Stroke 2018; 49 (12) 2933-2944
• 21 Noseworthy PA, Yao X, Abraham NS, Sangaralingham LR, McBane RD, Shah ND. Direct comparison of dabigatran, rivaroxaban, and apixaban for effectiveness and safety in nonvalvular atrial fibrillation. Chest 2016; 150 (06) 1302-1312
• 22 Raskob GE, van Es N, Verhamme P. et al; Hokusai VTE Cancer Investigators. Edoxaban for the treatment of cancer-associated venous thromboembolism. N Engl J Med 2018; 378 (07) 615-624
• 23 Young AM, Marshall A, Thirlwall J. et al. Comparison of an oral factor Xa inhibitor with low molecular weight heparin in patients with cancer with venous thromboembolism: results of a randomized trial (SELECT-D). J Clin Oncol 2018; 36 (20) 2017-2023
• 24 Agnelli G, Becattini C, Meyer G. et al; Caravaggio Investigators. Apixaban for the treatment of venous thromboembolism associated with cancer. N Engl J Med 2020; 382 (17) 1599-1607
• 25 McBane II RD, Wysokinski WE, Le-Rademacher JG. et al. Apixaban and dalteparin in active malignancy-associated venous thromboembolism: the ADAM VTE trial. J Thromb Haemost 2020; 18 (02) 411-421
• 26 Shah NG, Wible BC, Paulisin JA. et al. Management of inferior vena cava thrombosis with the FlowTriever and ClotTriever systems. J Vasc Surg Venous Lymphat Disord 2021; 9 (03) 615-620