In Reply to: Case 0498_06 -- Thrombectomy and thrombolysis of iliac veins and inferior vena cava posted by Editor on March 31, 1998 at 14:51:35:
We've treated two similar cases of iliac/caval thromosis in the past year, both in relatively young men with no significant past medical history and no IVC filter. Both presented acutely with leg swelling progressing toward threatened limbs. In each case the patients were treated with a combination of Amplatz Thrombectomy Device (ATD) and high-dose Urokinase via bilateral sono-guided popliteal vein accesses. We "pre-treated" with the ATD to increase the overall surface area the UK would have to work on but stopped short of reestablishing direct flow back to the heart on the theory the UK would "hang around" longer in the region of the clot. We subsequently administered high-dose UK (150K/hr x 2caths = 300K/hr x 12hr = 3.6M units) resulting about 90% lysis of clot burden. Residual clot was addressed with ATD with limited success. Patients were heparinized during procedure and afterward until coumadinization to an INR of ~2.5 They were discharged with support stockings on coumadin. One patient is doing well 6 months out with mild residual venous insufficiency. The other, unfortunately, rethrombosed while fully anticoagulated. In our experience, the ATD follows the path of least resistence and does not work well for clots along the walls of large vessels. A "steerable" version is supposed to be forthcomming and may be helpfull in this regard. We do feel the ATD is effective in reducing the duratation of thrombolytic therapy and as such is usefull in the treatment of acute venous thrombosis. We have had very little success using the new 6 Fr device.