CardioVascular and Interventional Radiology

, Volume 34, Issue 1, pp 25–36

Catheter-Directed Thrombolysis of Lower Limb Thrombosis

Review/State of the Art


Late complications of thrombosis of the deep veins in the region between the popliteal vein termination and the confluence of the common iliac veins and inferior vena cava (suprapopliteal deep-vein thrombosis) are common and often unrecognized by those responsible for the initial management. Pharmacomechanical-assisted clearance of the thrombus at the time of first presentation provides the best opportunity for complete recovery with preservation of normal venous valve function and avoidance of recurrent deep-vein thrombosis and postthrombotic syndrome. Recent interventional radiology methods provide for rapid and complete thrombolysis even in some patients in whom thrombolysis was previously considered contraindicated. This review describes the methods, safety, and efficacy of acute interventional treatment of suprapopliteal deep-vein thrombosis.


Deep-vein thrombosis (DVT) Thrombus removal Mechanical thrombolysis Thrombolysis Contraindications to thrombolysis Intervention Endovascular Venous valves Postphlebitic syndrome Pulmonary embolus Complications of DVT Treatment of DVT 


  1. 1.
    Butani D, Waldman DL (2008) Catheter directed thrombolysis for iliofemoral deep vein thrombosis. Oper Tech Gen Surg 10:143–148CrossRefGoogle Scholar
  2. 2.
    Qaseem A, Snow V, Barry P et al (2007) Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Fam Med 5:57–62CrossRefPubMedGoogle Scholar
  3. 3.
    Segal JB, Eng J, Jenckes MW et al (2003) Diagnosis and treatment of deep venous thrombosis and pulmonary embolism. Evid Rep Technol Assess (summer):1–6Google Scholar
  4. 4.
    Decousus H, Leizorovicz A, Parent F et al (1998) A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d’Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med 338:409–415CrossRefPubMedGoogle Scholar
  5. 5.
    White RH, Zhou H, Kim J et al (2000) A population-based study of the effectiveness of inferior vena cava filter use among patients with venous thromboembolism. Arch Intern Med 160:2033–2041CrossRefPubMedGoogle Scholar
  6. 6.
    Levine MN, Hirsh J, Gent M et al (1995) Optimal duration of oral anti-coagulant therapy: a randomized trial comparing four weeks with three months of warfarin in patients with proximal deep vein thrombosis. Thromb Haemost 74:606–611PubMedGoogle Scholar
  7. 7.
    Schulman S, Granqvist S, Holmström M et al (1997) The duration of oral anticoagulant therapy after a second episode of venous thrombo-embolism. The Duration of Anticoagulation Trial Study Group. N Engl J Med 336:393–398CrossRefPubMedGoogle Scholar
  8. 8.
    Kearon C, Gent M, Hirsh J et al (1999) A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism. N Engl J Med 340:901–907CrossRefPubMedGoogle Scholar
  9. 9.
    Prandoni P, Lensing AW, Prins MH et al (2004) Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial. Ann Intern Med 141:249–256PubMedGoogle Scholar
  10. 10.
    Snow V, Qaseem A, Barry P et al (2007) Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Fam Med 5:74–80CrossRefPubMedGoogle Scholar
  11. 11.
    Hood DB, Alexander JQ (2004) Endovascular management of iliofemoral venous occlusive disease. Surg Clin N Am 84:1381–1396CrossRefPubMedGoogle Scholar
  12. 12.
    Kwon SH, Oh JH, Seo TS et al (2009) Percutaneous aspiration thrombectomy for the treatment of acute lower extremity deep vein thrombosis: is thrombolysis needed? Clin Rad 64:484–490CrossRefGoogle Scholar
  13. 13.
    Vedantham S, Millward SF, Cardella JF et al (2006) Society of Interventional Radiology position statement: treatment of acute iliofemoral deep vein thrombosis with use of adjunctive catheter-directed intrathrombus thrombolysis. J Vasc Interv Radiol 17:613–616CrossRefPubMedGoogle Scholar
  14. 14.
    National Health and Medical Research Council of Australia (2009) NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. Stage 2 pilot. Available at: Accessed April 25, 2010
  15. 15.
    Goldhaber SZ, Buring JE, Lipnick RJ, Hennekens CH (1984) Pooled analyses of randomized trials of streptokinase and heparin in phlebographically documented acute deep venous thrombosis. Am J Med 76:393–397CrossRefPubMedGoogle Scholar
  16. 16.
    Plate G, Akesson H, Einarsson E et al (1990) Long-term results of venous thrombectomy combined with a temporary arterio-venous fistula. Eur J Vasc Surg 4:483–489CrossRefPubMedGoogle Scholar
  17. 17.
    Plate G, Einarsson E, Ohlin P et al (1984) Thrombectomy with temporary arteriovenous fistula: the treatment of choice in acute iliofemoral venous thrombosis. J Vasc Surg 1:867–876CrossRefPubMedGoogle Scholar
  18. 18.
    Merli GJ (2008) Treatment of venous thromboembolism. Am J Med 121(11A):S2–S9CrossRefGoogle Scholar
  19. 19.
    AbuRahma AF, Perkins SE, Wulu JT (2001) Iliofemoral deep vein thrombosis: conventional therapy versus lysis and percutaneous transluminal angioplasty and stenting. Ann Surg 233:752–760CrossRefPubMedGoogle Scholar
  20. 20.
    Sherry S (1985) Thrombolytic therapy for deep venous thrombosis. Semin Intervent Radiol 4:331–337Google Scholar
  21. 21.
    Comerota AJ, Gravett MH (2007) Iliofemoral venous thrombosis. J Vasc Surg 46:1065–1076CrossRefPubMedGoogle Scholar
  22. 22.
    Rhodes JM, Cho JS, Gloviczki P (2000) Thrombolysis for experimental deep venous thrombosis maintains valvular competence and vasoreactivity. J Vasc Surg 31:205–1193CrossRefGoogle Scholar
  23. 23.
    Hutten BA, Prins MH (2006) Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism. Cochrane Database Syst Rev (1):CD001367Google Scholar
  24. 24.
    Ng CM, Rivera JO (1998) Meta-analysis of streptokinase and heparin in deep vein thrombosis. Am J Health Syst Pharm 55:1995–2001PubMedGoogle Scholar
  25. 25.
    Watson L, Armon MP (2004) Thrombolysis for acute deep vein thrombosis. Cochrane Database Syst Rev (3):CD002783Google Scholar
  26. 26.
    Segal JB, Streiff MB, Hofmann LV et al (2007) Management of venous thromboembolism: a systematic review for a practice guideline. Ann Intern Med 146:211–222PubMedGoogle Scholar
  27. 27.
    Greenfield LJ, Alexander EL (1985) Current status of surgical therapy for deep vein thrombosis. Am J Surg 150(4A):64–70PubMedGoogle Scholar
  28. 28.
    Tillett WS, Garner RL (1933) The fibrinolytic activity of haemolytic streptococci. J Exp Med 58:485–502CrossRefPubMedGoogle Scholar
  29. 29.
    Roychoudhury PK, Khaparde SS, Mattiasson B, Kumar A (2006) Synthesis, regulation and production of urokinase using mammalian cell culture: a comprehensive review. Biotechnol Adv 24:514–528CrossRefPubMedGoogle Scholar
  30. 30.
    Comerota AJ, Paolini D (2007) Treatment of acute iliofemoral deep venous thrombosis: a strategy of thrombus removal. Eur J Vasc Endovasc Surg 33:351–360CrossRefPubMedGoogle Scholar
  31. 31.
    Alonso A, Dempfle C, Martina A et al (2009) In vivo clot lysis of human thrombus with intravenous abciximab immunobubbles and ultrasound. Thromb Res 124:70–74CrossRefPubMedGoogle Scholar
  32. 32.
    Kim BJ, Chung HH, Lee SH (2010) Single-session endovascular treatment for symptomatic lower extremity deep vein thrombosis: a feasibility study. Acta Radiol 51:248–255CrossRefPubMedGoogle Scholar
  33. 33.
    Chang R, Chen CC, Kam A et al (2008) Deep vein thrombosis of lower extremity: direct intraclot injection of alteplase once daily with systemic anticoagulation—results of pilot study. Radiology 246:619–629CrossRefPubMedGoogle Scholar
  34. 34.
    Shi HJ, Huang YH, Shen T et al (2009) Percutaneous mechanical thrombectomy combined with catheter-directed thrombolysis in the treatment of symptomatic lower extremity deep venous thrombosis. Eur J Radiol 71:350–355CrossRefPubMedGoogle Scholar
  35. 35.
    Cynamon J, Stein EG, Dym RJ, Jagust MB, Binkert CA, Baum RA (2006) A new method for aggressive management of deep vein thrombosis: retrospective study of the power pulse technique. J Vasc Interv Radiol 17:1043–1049.CrossRefPubMedGoogle Scholar
  36. 36.
    O’Sullivan GJ, Lohan DG, Gough N et al (2007) Pharmacomechanical thrombectomy of acute deep vein thrombosis with the trellis-8 isolated thrombolysis catheter. J Vasc Interv Radiol 18:715–724CrossRefPubMedGoogle Scholar
  37. 37.
    Martinez Trabal J, Comerota A, LaPorte F et al (2008) The quantitative benefit of isolated, segmental, pharmacomechanical thrombolysis (ISPMT) for iliofemoral venous thrombosis. J Vasc Surg 48:1532–1537CrossRefPubMedGoogle Scholar
  38. 38.
    Hilleman DE, Razavi MK (2008) Clinical and economic evaluation of the Trellis-8 infusion catheter for deep vein thrombosis. J Vasc Interv Radiol 19:377–383CrossRefPubMedGoogle Scholar
  39. 39.
    Delomez M, Beregi JP, Willoteaux S, Bauchart JJ, Janne d’Othée B, Asseman P, Perez N, Théry C (2001) Mechanical thrombectomy in patients with deep venous thrombosis. Cardiovasc Intervent Radiol 24:42–48CrossRefPubMedGoogle Scholar
  40. 40.
    Lang EV, Kulis AM, Villani M et al (2008) Hemolysis comparison between the OmniSonics OmniWave Endovascular System and the Possis AngioJet in a porcine model. J Vasc Interv Radiol 19:1215–1221CrossRefPubMedGoogle Scholar
  41. 41.
    Neglén P, Raju S (2004) In-stent recurrent stenosis in stents placed in the lower extremity venous outflow tract. J Vasc Surg 39:181–188CrossRefPubMedGoogle Scholar
  42. 42.
    Neglén P, Tackett TP Jr, Raju S (2008) Venous stenting across the inguinal ligament. J Vasc Surg 48:1255–1261CrossRefPubMedGoogle Scholar
  43. 43.
    Oguzkurt L, Ozkan U, Ulusan S et al (2008) Compression of the left common iliac vein in asymptomatic subjects and patients with left iliofemoral deep vein thrombosis. J Vasc Interv Radiol 19:366–371CrossRefPubMedGoogle Scholar
  44. 44.
    Brightwell RE, Osman IS (2006) Iliofemoral deep vein thrombosis in childhood: developing a management protocol. Eur J Vasc Endovasc Surg 31:667–677CrossRefPubMedGoogle Scholar
  45. 45.
    Lindqvist P, Dahlback B, Marsal K (1999) Thrombotic risk during pregnancy: a population study. Obstet Gynecol 94:595–599CrossRefPubMedGoogle Scholar
  46. 46.
    Toglia MR, Weg JG (1996) Venous thromboembolism during pregnancy. N Engl J Med 335:108–114CrossRefPubMedGoogle Scholar
  47. 47.
    Greer IA, Nelson-Piercy C (2005) Low-molecular-weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy. Blood 106:401–407CrossRefPubMedGoogle Scholar
  48. 48.
    Clark P, Bates SM (2009) North American and British guidelines for anti-thrombotic therapy: are we reaching consensus? Thromb Res 123:S111–S123CrossRefPubMedGoogle Scholar
  49. 49.
    Doreen te Raa G, Ribbert L, Snijder R et al (2009) Treatment options in massive pulmonary embolism during pregnancy: a case-report and review of literature. Thromb Res 124:1–5CrossRefPubMedGoogle Scholar
  50. 50.
    Tsivgoulis G, Culp WC, Alexandrov AV (2008) Ultrasound enhanced thrombolysis in acute arterial ischemia. Ultrasonics 48:303–311CrossRefPubMedGoogle Scholar
  51. 51.
    Gurbel PA, Bliden KP, Hiatt BL, O’Connor CM (2003) Clopidogrel for coronary stenting: response variability, drug resistance, and the effect of pretreatment platelet reactivity. Circulation 107:2908–2913CrossRefPubMedGoogle Scholar
  52. 52.
    Ginsberg JS, Hirsh J, Julian J et al (2001) Prevention and treatment of postphlebitic syndrome: results of a 3-part study. Arch Intern Med 161:2105–2109CrossRefPubMedGoogle Scholar
  53. 53.
    Schulman S, Rhedin AS, Lindmarker P et al (1995) A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism. Duration of Anticoagulation Trial Study Group. N Engl J Med 332:1661–1665CrossRefPubMedGoogle Scholar
  54. 54.
    Hann CL, Streiff MB (2005) The role of vena caval filters in the management of venous thromboembolism. Blood Rev 19:179–202CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2010

Authors and Affiliations

  1. 1.Department of Radiology, Faculty of Medicine, The Alfred HospitalMonash UniversityMelbourneAustralia

Personalised recommendations