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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 6, November/December 2020
286
AFRICA
Cardiovascular Topics
The safety and efficacy of pharmaco-mechanical
thrombolysis in lower-extremity deep venous thrombosis
Emced Khalil, Sedat Ozcan
Abstract
Objective:
The aim of this study was to investigate the impact
of accelerated pharmaco-mechanical thrombolysis (PMT)
with low-dose second-generation urokinase for the manage-
ment of cases with lower-extremity deep venous thrombosis
(DVT), and to compare its efficacy in subjects with acute and
subacute DVT.
Methods:
Thirty-five patients with acute (
<
15 days) or suba-
cute (15–30 days) DVT who underwent PMT in a tertiary
centre were enrolled in this single-arm, prospective study.
Following the placement of a temporary vena cava filter,
urokinase (200 000 IU) was administered into the occlusion
through a multi-hole catheter for 15 to 20 minutes. Control
venography was performed to assess venous flow and the rate
of acute recanalisation. Percutaneous balloon dilatation and
stent placement were carried out in case of a residual iliac
vein stenosis of
>
50%. Any residual thrombi were suctioned
with an aspiration catheter.
The primary outcome measures
of this study were the percentages of vessel patency and
PTS in the third month after PMT.
Results:
Complete recanalisation was noted in 23 (66%)
patients, while two (6%) had poor recanalisation. The rate of
minor complications was 14%. None of the subjects experi-
enced major complications, such as intracranial haemorrhage
or pulmonary embolism. No mortality was recorded during
the three months of follow up. Control duplex ultrasonogra-
phy in the third month revealed that the target vein was patent
in all subjects. None of the subjects experienced PTS during
follow up. In addition, the percentage of acute complete
recanalisation was significantly higher in subjects with acute
DVT compared to those with subacute DVT (95 vs 27%,
p
<
0.001).
Conclusion:
PMT with an accelerated regimen of low-dose
urokinase provided excellent efficacy in the resolution of
thrombus and prevented the development of PTS in the mid-
term when used for the management of lower-extremity DVT.
Keywords:
deep venous thrombosis, catheter-directed thromboly-
sis, urokinase, outcomes
Submitted 24/12/19, accepted 28/5/20
Published online 19/6/20
Cardiovasc J Afr
2020;
31
: 286–290
www.cvja.co.zaDOI: 10.5830/CVJA-2020-020
Pulmonary embolism and deep-vein thrombosis (DVT) are
the most common presentations of venous thromboembolism.
DVT, which is common in the lower limbs, is characterised by
the formation of thrombus in a deep calf vein. The popliteal
vein and those proximal to the popliteal vein are affected in
more than 80% of subjects with lower-extremity DVT.
1
Further
propagation of thrombus is common and leads to several
complications through the embolisation of the thrombus or
complete occlusion of the relevant vein. The reported incidence
of DVT is about 1.6 per 1 000 individuals per year.
2,3
While pulmonary embolism is the most common cause
of early mortality associated with venous thromboembolism,
chronic thrombotic pulmonary hypertension subsequent to
pulmonary embolism may result in long-term morbidity and
mortality. On the other hand, post-thrombotic syndrome
(PTS), a condition characterised by pain, oedema, swelling
and pigmentation has been shown to develop in 25 to 38% of
patients with DVT, and results in severe morbidity due to the
deterioration in skin integrity.
4
Inflammatory destruction of the venous valves due to venous
incompetence caused by venous obstruction has been proposed
as the most probable theory for the development of PTS.
5
Early removal of the thrombus and restoration of venous flow
through systemic use of thrombolytic agents has been shown
to prevent venous dysfunction and subsequent PTS.
6
However,
the possibility of major bleeding, especially intracranial
haemorrhage, restricts widespread use of systemic thrombolysis
in the management of DVT.
It has been shown that three to 6% of subjects treated
with intravenous tissue plasminogen activator (TPA) have
complications with intracranial haemorrhage.
7
In contrast to
systemic thrombolysis, pharmaco-mechanical thrombolysis
(PMT) enables administration of the thrombolytic agent directly
into the thrombus with a reduced total dose,
8
thereby reducing
the possibility of systemic complications.
9
Moreover, systemic
thrombolytic agents are delivered to the surface of the thrombus
only, whereas PMT enables deep penetration of the thrombolytic
agent with relatively low doses.
Our aim was to investigate the impact of accelerated PMT
with low-dose, second-generation urokinase for the management
School of Medicine, Ordu University, Ordu, Turkey
Emced Khalil, MD,
emjedkhalil@gmail.comÇanakkale Onsekiz Mart University, Çanakkale, Turkey
Sedat Ozcan, MD