Isolated pharmacomechanical thrombolysis using the Trellis system

Abstract

While anticoagulation remains the current gold standard for treating acute deep vein thrombosis,1 there is a growing body of evidence that rapid thrombus removal results in better short- and long-term outcomes.2–5 This is a practical guide to achieve rapid thrombus removal with isolated pharmacomechanical thrombolysis using the Trellis® peripheral infusion system. Although it may sound obvious, it is surprising how often a supposedly ‘acute’ deep vein thrombosis is, in fact, chronic or acute-on-chronic. This may sound like a trivial distinction, but it has wide-reaching implications for treatment. Primarily, and fundamentally, thrombus older than 14–21 days becomes fibrin-depleted,6 so techniques to achieve fibrinolysis, on their own, are likely to fail.7 Previous episodes of cellulitis, bruising, cramping, heaviness, spider-vein development, and so on are important clues to make the physician consider the possibility that this presentation is not purely the result of an acute deep vein thrombosis.8 Patients rarely connect seemingly distant events with the acute problem. They may consider long-term unilateral or bilateral leg swelling as their normal state without realizing this often implies an episode of prior deep vein thrombosis and the current acute deep vein thrombosis reflects thrombosis of the veins peripheral to a stenotic or obstructive underlying lesion. This is most obvious with iliac vein compression syndrome,9 but there are other pathologies that may cause a similar venous stenotic lesion.10 In patients who have experienced a recent onset of cough or shortness of breath, including more chronic symptoms such as those ascribed to asthma, a computed tomography (CT) pulmonary angiogram should be performed as the initial part of the CT venogram. General symptoms such as malaise or weight loss should prompt a search for a malignancy; in women, recurrent abortions together with a deep vein thrombosis would suggest a systemic pro-coagulant disorder.11