venous thrombolysis, dissolving depe vein thrombosis

VENOUS THROMBOLYSIS

Venous thrombolysis is a newer option in the treatment of deep vein thrombosis (DVT) or pulmonary Embolism (PE). The decision to proceed with this type of intervention depends on the extent and symptoms present, as well as the clinical situation of the patient.

WHAT IS VENOUS OR PULMONARY THROMBOLYSIS?

Venous thrombolysis involves trying to remove or dissolve the clots. In the past, the clot dissolving medication was given into the veins, with the hope that the clot at the site of the DVT or PE would be broken down by circulating clot dissolving medicines. The newer technology now employs catheter directed treatments.

WHAT IS INVOLVED IN VENOUS THROMBOLYSIS?

Essentially, a thin catheter is placed at the site of the blood clot through a small puncture wound through the skin into a main vein. Mechanical and well as chemical removal of the blood clot is then performed. Venous thrombolysis can be performed under local or general anesthesia, as dictated by the situation. An angiogram through the catheter confirms the extent of the clot. There are several mechanical catheters that can be used to essentially agitate the clot and suction it out. These catheters include the "Bacchus device" or the "Angiojet." This mechanical debridement of the clot is performed often in conjunction with clot dissolving medications that are infused directly into the clot, such as TPA.

The rationale for such an approach is that by debulking the amount of clot, the normal vein flow patterns can be re-established. Thus, in the legs, the valve structures that play an essential function is normal vein pressures are preserved, and the chance of chronic venous stasis changes are reduced. In the case of dissolving a PE, by removing the clot burden, the blood heading back to the lungs to be loaded with oxygen can now reach the lung successfully, and then be transported to the tissues.

An angiojet device in a vessel. This is an over the wire catheter that is placed into the clot. It breaks up the clot via the Bernoulli principle, with the help of clot dissolving medication

WHO IS A GOOD CANDIDATE FOR DVT OR PE THROMBOLYSIS?

Removing clots mechanically in conjunction with thrombolysis has to be used judiciously. In a younger patient with an extensive DVT and leg swelling, removing the majority of the clot using this technique can have profund life-long implications. By avoiding the long term vein problems associated with some DVT's, the possiblity of skin breakdown, swelling and pain is significantly reduced using this technology. Similarly, in cases of massive PE when the patient is in serious distress, mechanical and chemical thrombolysis can rapidly change a dire situation into one that is much more favorable prognostically.

However, these great results must be put into the context of evaluating the patient clinically. If the patient is older, or they have minimal clot loads, or are clinically stable without evidence of heart failure with a PE, then perhaps just placing them on blood thinning medications and letting the body do its healing work might be a better decision. There are complications to the aggressive approach, such as bleeding into the tissues or intestinal tract, kidney failure, and even fatal bleeding into the brain that suggest careful selection of patients for this type of intervention is of paramount importance.