Abstract
Deep venous thrombosis (DVT) is a common disorder with a significant mortality rate. Successful endovascular treatment of acute DVT is most likely to be achieved in patients with recently formed thrombus, (<10–14 days) with acute iliofemoral DVT. Endovascular treatment options include: Catheter-directed thrombolysis (CDT), pharmacomechanical catheter-directed thrombolysis (PCDT), percutaneous aspiration thrombectomy (PAT), vena cava filter protection, venous balloon dilatation and venous stent implantation. Current practice shows strong clinical tendency for the use of PCDT with or without other endovascular methods and an individualized approach for each DVT patient. PMT has not received general acceptance because of the associated risk of PE and damage to venous valves caused by thrombectomy devices. PAT is most commonly used as an adjunctive endovascular technique like balloon maceration to fragment thrombus, balloon angioplasty, stent implantation and vena cava filter placement. Interventional endovascular therapies for DVT have the potential to provide PE protection and prevention of PTS. Patient centered individualized approach for endovascular DVT treatment is recommended to optimize the ideal clinical result.
Acute stroke is the leading cause of death for people above the age of 60 and the fifth leading cause in people aged 15–59. Mortality during the first 30 days of ischemic stroke is 20 % and 30 % of survivors will remain permanently disabled. Acute stroke patients within the therapeutic window must receive IVrtPA unless there is a contraindication. In case of contraindication to IVrtPA or for patients out of the therapeutic window for thrombolytics, standart of care is the intraarterial treatment. Patients have to be transferred to a comprehensive stroke center with capacity of dedicated neurovascular imaging and interventional neuroradiology. Noncontrast head CT that is used to rule out hemorrhage is followed by imaging studies dedicated to show if there is reasonable penumbra to save. Intraarterial thrombolysis has the main advantage of extended therapy window, earlier and more efficient recanalization and less risk of hemorrhage due to lower doses of thrombolytics. Mechanical thrombectomy has several advantages over IV/IA fibrinolysis including faster recanalization and less risk of hemorrhage especially in large artery occlusions. ASA guidelines recommend choosing stent retrievers over other devices for mechanical thrombectomy. Better recanalization rates and less infarct volume after mechanical thrombectomy result in higher numbers of functionally independent patients compared with other treatments. Two landmark studies that were published recently, SWIFT PRIME and MR CLEAN, showed that IA treatment especially with the new stent retrievers lead to a significant increase in functional recovery and independence in daily life after an acute stroke.
Cerebral venous and sinus thrombosis (CVST) comprises nearly 0.5–1 % of all stroke cases. CVST causes different neurological deficits depending on the sinus/cortical vein involved. CVST may cause death and dependency in 13.4 % of patients. CT/CT venography and MR/MR venography can be effectively used to diagnose and to follow up CVT cases. Anticoagulation with heparin is the most widely accepted therapy to prevent the expansion of the thrombus. Patients deteriorating despite heparinization and patients presenting with very severe neurological deficits must receive endovascular treatment. Endovascular methods include intrasinus infusion of thrombolytics or heparin, balloon angioplasty, mechanical thrombectomy or a combination of different techniques. There is a higher rate or recanalization with endovascular methods compared to other medical therapies.
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Keywords
- Endovascular
- Deep venous thrombosis
- Catheter
- Thrombolysis
- Thrombectomy
- Stroke
- Stent retrievers
- Cerebral venous thrombosis
1 Endovascular Treatment of Deep Venous Thrombosis
Deep venous thrombosis (DVT) is a common life-threatening disorder with a significant mortality rate. Even after appropriate medical therapy, DVT recurs frequently and may cause serious complications such as pulmonary embolism (PE) and postthrombotic syndrome [1–3]. Despite these risks of major complications and potentially permanent sequelae, no single effective treatment modality for DVT yet exists. There has been growing experience in the treatment of deep vein thrombosis, but major clinical challenges and a wide variation in practice still remain [4, 5].
The main purpose of any DVT treatment is to improve symptoms and to prevent the development of PE and postthrombotic syndrome (PTS) by eliminating the thrombus material. Conventionally, there have been three acceptable basic treatment options for DVT and the rationale, risks, benefits, and uncertainties associated with these methods are summarized below.
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Anticoagulant Therapy: The main objectives of anticoagulant therapy are to prevent progression of existing thrombi and to lower the incidence of PE by preventing development of recurrent thrombosis. Anticoagulants do not exert a recanalization activity. Recanalization occurs by natural thrombus resorption over time. Many studies have reported that anticoagulation therapy prevented progression of popliteal and tibial vein thrombosis and allowed development of near-complete recanalization in 95 % of patients in the long term. However, recanalization rates are poor (20 %) in patients with iliofemoral vein thrombosis [6].
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2.
Systemic Thrombolytic Therapy: Systemic thrombolytic therapy is markedly superior to anticoagulation therapy (heparin) in terms of reestablishment of venous blood flow [7]. Thrombolytic agents only resolve thrombi with which they come into contact. Thus, if venous occlusion is complete, such agents sometimes do not penetrate blood clots, and treatment failure may result. The most significant concern of thrombolytic therapy is the increased risk of bleeding. Although the efficacy of systemic thrombolytic therapy used to treat DVT is widely acknowledged, the risk of bleeding, the potential development of serious related complications, uncertainties in terms of dosage and route of administration, the requirement for admission to the intensive care unit, a prolonged hospitalization period, and the need to conduct numerous laboratory tests to monitor health status, all indicate that this therapeutic modality is associated with limited indications [6, 7].
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3.
Surgical Thrombectomy: As another therapeutic alternative, surgical thrombectomy, can be used to treat a limited number of patients and is especially preferred in patients with phlegmasia caerulea dolens [8]. However, even in patients with this rare pathological abnormality, it is not possible to achieve adequate venous patency with preservation of venous valvular function using surgical techniques [9].
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4.
Endovascular treatment: Endovascular interventional treatments have been used in the management of DVT for many years, and recently endovascular options increased in number with many different technical advances and new devices. The limitations of conventional treatment options encouraged the progress in endovascular treatment of DVT, and advances in endovascular therapies have delivered a wide range of new treatment options. Acceptable recanalization rates have been reported using endovascular therapeutic methods such as: catheter-directed thrombolysis (CDT), pharmacomechanical catheter-directed thrombolysis (PCDT), percutaneous aspiration thrombectomy (PAT), vena cava filter protection, venous balloon dilatation and venous stent implantation [4, 5, 10]. In recent years, endovascular techniques are also undergoing evaluation in many multicenter randomized controlled trials to determine their clinical benefit [4, 5].
Patient Selection for Endovascular Acute DVT Therapy
All patients, in whom endovascular DVT therapy is planned, should undergo a detailed evaluation with clinical assessment that covers information from past medical history, physical examination and imaging findings. Patients should be evaluated for the thromboembolic risk factors and previous treatments, and preexisting comorbidities. Successful endovascular treatment of acute DVT is most likely to be achieved in patients with recently formed thrombus, (<10–14 days) with acute iliofemoral DVT [10–12]. Patients with a left-sided iliofemoral DVT are likely to have May-Thurner Syndrome with left common iliac vein stenosis that can be eliminated with venous stent placement [4, 13].
According to the Society of Interventional Radiology (SIR) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE) guidelines, imaging proven symptomatic DVT in inferior vena cava or iliac, common femoral, and/or femoral veins in a recently ambulatory patient with DVT symptoms for less than 28 days and in whom there is strong clinical suspicion for recently formed DVT are the primary indications for endovascular interventions for lower-extremity DVT thrombus removal [10]. Contraindications for endovascular pharmacologic catheter-directed DVT thrombolysis are summarized in Table 1.
1.1 Endovascular Interventional Options for Deep Vein Thrombosis
1.1.1 Catheter-Directed Thrombolysis (CDT) for DVT
Image-guided, catheter-directed, intra-thrombus drug delivery has been developed for improving the safety and efficacy of thrombolytic therapy for thromboembolic disease. CDT has several advantages for DVT patients and can be used:
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To achieve high intra-thrombus thrombolytic agent concentrations.
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To avoid bypass of the drug via collaterals around the thrombosed vein.
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To reduce thrombolytic agent dose, treatment time, intensive care utilization and hospitalization time.
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To decrease bleeding complications.
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5.
To treat underlying venous abnormalities by other endovascular techniques.
Catheter-directed thrombolysis (CDT) means delivery of a thrombolytic drug (rtPa, Urokinase) directly into the thrombus using a catheter or catheter-like device that is embedded within the thrombus by using Doppler ultrasound and fluoroscopy guidance. Usually a standard multisidehole catheter might be used but recently a multisidehole catheter that simultaneously applies ultrasound energy (EkoSoniccatheter; EKOS) to improve drug delivery into the thrombus has also been developed and this device is expected to increase safety and efficacy [4, 5, 10] (Fig. 1).
Currently, the most commonly used fibrinolytic drug for DVT is the recombinant tissue plasminogen activator (rtPA). The drug is infused continuously and directly into the thrombus at a low dose (0.5–1.0 mg/h) with systemic intravenous infusion of unfractionated heparin at subtherapeutic levels. Mostly the patient is closely monitored in an intensive care unit. Infusion might be stopped in case of active bleeding or severely abnormal coagulation parameters. Patients are evaluated by venography 1–2 times a day until the patency is achieved. Venous balloon angioplasty with thrombolytic infusion may also be used after partial thrombolysis [4, 5]. Left iliac anatomical venous stenosis (May-Thurner Syndrome) is usually treated by venous stent implantation and other venous stenoses might also be treated by balloon angioplasty and/or stent placement [4, 13]. Venography is performed to confirm the patency of the venous system. Before the patient is discharged anticoagulant therapy is arranged and compression stockings are prescribed. CDT has been evaluated in many case series and prospective multicenter trials. Major bleeding was observed in 5–12 % of patients in some older studies. However, more recent series with RCT reported much lower major bleeding rates [4, 5, 11, 12]. Fatal PE after CDT has also been reported very rarely [4, 14]. Although CDT is effective, currently the technique is not used widely because of long infusion times with intensive monitoring that are associated with longer hospital stays, and the risk of systemic bleeding still exists.
1.1.2 Pharmacomechanical Catheter-Directed Thrombolysis
Pharmacomechanical catheter-directed thrombolysis (PCDT) includes intrathrombus thrombolytic agent infusion with mechanical thrombectomy devices to improve drug penetration into thrombus and macerate thrombus for aspiration or percutaneous thrombectomy [5, 11]. These devices enable faster penetration of thrombolytic agent within the thrombus, accelerating successful thrombolysis and improving safety by reducing drug dose and exposure time. Successful use of PCDT has been described in a number of published DVT studies [15–17]. Recently, new PCDT devices have been introduced that can enable endovascular DVT therapy to be completed in a single procedure session without the need for further drug infusions or intensive care monitoring. AngioJet Thrombectomy System (Boston Scientific) gives forceful pulse-spray bolus dose of the thrombolytic drug directly into the thrombus [18]. The drug is allowed to interact within the thrombus for a while and the device is used to aspirate the residual thrombus at the end. Isolated thrombolysis is another method performed by Trellis Peripheral Infusion System (Covidien) [5, 19]. With this device two catheter-mounted balloons are inflated to isolate a segment of vein and a bolus dose of a thrombolytic drug is injected directly into the thrombus. Activation of an oscillating wire for 10 min is then used to mechanically disperse the drug within the thrombus, and then the drug and liquefied debris are aspirated through a port on the device. Another similar device is Reya Thrombectomy catheter (Biolas Health) that is designed to use with the implantation of a temporary retrievable vena cava filter for protection before activation of an oscillating wire (Fig. 2). There are also many different endovascular venous thrombus aspiration systems such as Aspirex S Catheter (Straub Medical) and Angiovac Cannula and Circuit (AngioDynamics).
Although definitive multicenter RCTs comparing the most recent PCDT, CDT and combined methods have not been published yet, current practice shows strong clinical tendency for the use of PCDT with or without other endovascular methods and an individualized approach for each DVT patient [4, 5, 20].
1.1.3 Percutaneous Mechanical Thrombectomy
Stand-alone percutaneous mechanical thrombectomy (PMT) refers to the percutaneous use of catheter-based mechanical devices that contribute to thrombus removal via fragmentation, maceration, and/or aspiration, without administration of a thrombolytic drug. These methods are not always suitable for every patient and in most of the cases they are reserved for the patients with serious risk of bleeding and/or other contraindications for the thrombolytic therapy. PMT has not received general acceptance because of the associated risk of PE and damage to venous valves caused by thrombectomy devices [10, 13].
1.1.4 Percutaneous Aspiration Thrombectomy
Percutaneous aspiration thrombectomy (PAT) technique can be defined as using a syringe to aspirate thrombus from the vein via a catheter, device, or sheath. PAT has been routinely used to effectively eliminate thrombi located in hemodialysis fistulae with a patency rate of 86 % at 6 months after PAT [21]. PAT also has been accepted as a rapid, safe, and effective method of management of iliofemoral vein thrombosis and provides higher recanalization rates than alternative treatments [13]. However, few clinical studies have been performed. Previous studies reported a recanalization rate of 88.9 % with PAT for the lower extremity DVT. Mechanical thrombectomy devices are not required during PAT and, therefore, the risk of trauma to the vascular wall and valves is thought to be low. Thrombolytic agents are not given to PAT patients, and the bleeding complications associated with systemic therapy are therefore absent [13, 22]. However there is no standardized PAT aspiration method and the technique is not widely accepted. PAT is most commonly used as an adjunctive endovascular technique like balloon maceration to fragment thrombus, balloon angioplasty, stent implantation and vena cava filter placement (Fig. 3).
Interventional endovascular therapies for DVT have the potential to provide PE protection and prevention of PTS. There is increasing number of scientific evidence in support of endovascular treatments. However, patient centered individualized approach for endovascular DVT treatment is recommended to optimize the ideal clinical result.
2 Endovascular Treatment of Acute Stroke
According to the World Health Organization (WHO), stroke is the leading cause of death for people above the age of 60 and the fifth leading cause in people aged 15–59 [23]. Stroke is the most common cause of disability worldwide [23, 24]. Every 6 s someone in the world will either be permanently disabled or will die due to stroke. More than 80 % of stroke cases are acute ischemic stroke cases due to cessation or diminution of blood supply to a certain part of the brain after arterial occlusion or hypoperfusion. Acute ischemia occurs mostly due to thromboembolism or local occlusion. Less frequently global hypoperfusion may cause acute cerebral ischemia. Immediate and prompt treatment of acute stroke is very important because of the heavy burden of this disease on a person and the society. Mortality during the first 30 days of ischemic stroke is 20 % and 30 % of survivors will remain permanently disabled [25].
2.1 Primary Management of Acute Stroke Patients
An acute stroke patient first seen in a hospital with the capability of intravenous (IV) fibrinolysis must have a nonenhanced computerized tomography (NECT) of the head to rule out cerebral hemorrhage. Patients without significant improvement after IV fibrinolysis can be immediately transferred to higher-level stroke centers. Patients that are seen by the emergency medical services in the field will benefit more if they can be sent to the nearest stroke center with the capability of both intravenous and intraarterial therapy and dedicated neurovascular imaging capabilities. IV recombinant tissue plasminogen activator (alteplase, rtPA) was the first approved treatment for acute ischemic stroke within 3 h of stroke onset after the NINDS (National Institute of Neurological Disorder and Stroke) trial. There are several exclusion criteria for the IV fibrinolytic therapy (Table 2).
The American Stroke Association (ASA, 2013) published guidelines for the early management of patients with acute ischemic stroke [26] (Tables 3, 4 and 5).
Recommendations with the highest level of evidence and that are directly related with the endovascular management of acute stroke are included. Recommendations regarding the intensive care management of acute stroke patients are not within the scope of this article. According to these guidelines an algorithm for management of acute stroke patients can be formed (Table 6).
2.2 Endovascular Therapy
Recanalization rates after IV rtPA in internal carotid artery terminus and MCA M1 segment occlusions range between 10 and 50 % and less than 40 % of patients regain functional independence [27]. Endovascular therapy has the main advantage of extended therapy window, earlier and more efficient recanalization and less risk of hemorrhage due to lower doses of thrombolytics. Endovascular therapies include either application of local intraarterial thrombolytics in the occluded intracranial segment or mechanical removal of the clot with a thrombectomy device or another endovascular device like a balloon or stent. According to most recent guidelines safe therapy window for endovascular treatment is the first 6 hours after the stroke onset [26]. After the development of dedicated mechanical thrombectomy devices, including stent retrievers, the balloon angioplasty has been put aside. Major disadvantages of endovascular therapies include low availability due to requirement of high level of expertise of specialists and complex neurointerventional infrastructure, delay in therapy initiation and invasive nature of the endovascular methods. Potential complications of endovascular stroke treatment are reperfusion hemorrhage, distal emboli, intracranial dissections, hematomas and subarachnoid hemorrhage [28, 29].
2.2.1 Intraarterial Fibrinolysis
The first positive randomized trial [28] to evaluate the efficiency of intraarterial fibrinolysis was PROACT 2 (Prolyse in Acute Cerebral Thromboembolism). In this study IA fibrinolysis with recombinant prourokinase (r-pro-UK) yielded higher middle cerebral artery recanalization rates than the control group (66 % vs % 18, p < 0.001). Fibrinolytics used in acute stroke treatment work as plasminogen activators. Prourokinase did not achieve FDA approval and it is not available any more and today the most frequently used IA fibrinolytic is Alteplase (rtPA). Alteplase is applied directly within the thrombus through a microcatheter. Most neurointerventional specialists would use a maximum dose of 22 mg of IA rtPA [30, 31]. Adjunct mechanical disruption of the clot can be used with microwire maneuvers to increase the interaction surface area of the clot and the medicine. Recanalization rates in large artery occlusion including internal carotid artery, basilar artery or MCA M1 segment is not as high as distal and smaller arteries [32, 33]. Due to this reason in most centers first line treatment for large artery occlusions causing stroke is the mechanical thrombectomy. However, IA fibrinolysis is still used very efficiently in distal small artery occlusions like MCA M2-M3 segments, ACA paricallosal/callosomarginal branches and posterior cerebral artery occlusions. Bridging therapies as combination of IV rtPA and IA rtPA can further increase recanalization rates. Three consecutive trials, interventional management of stroke (IMS) 1, 2 and 3, showed better outcomes with comparable rates of symptomatic intracranial hematoma and mortality compared with NINDS rtPA trial [30, 34, 35].
2.2.2 Mechanical Thrombectomy
Mechanical thrombectomy has several advantages over IV/IA fibrinolysis. First of all, recanalization with mechanical techniques is faster. There is less risk of hemorrhage due to lower dose of fibrinolytics. Atherosclerotic emboli rich of calcium or cholesterol causing stroke are more resistant to pharmacological lysis and this brings the potential benefit of better recanalization by mechanical thrombectomy in these cases. Patients with contraindication to IV/IA fibrinolysis due to recent surgery and abnormal coagulation parameters can be treated only by means of mechanical thrombectomy [36]. Although there are several commercially available mechanical thrombectomy devices, only devices that are most frequently used, and that have been thoroughly studied in the literature, will be mentioned in this chapter. All mechanical thrombectomy devices are deployed in the intracranial arteries through microcatheters. Depending on the device they are either deployed within or distal to the clot and engage with the thrombus when deployed. Then the whole system, device, microcatheter and proposedly engaged clot are retrieved (Fig. 4). For documenting the recanalization/reperfusion rates after IA intervention a scale was proposed by Higashida et al. [37]. TICI (Thrombolysis in Cerebral Infraction) scale is commonly used in stroke centers to document the results of their therapies [38]. First FDA approved (2004) device MERCI (Concentric Medical, Mountain View, California) is a flexible nitinol wire with coil loops [39, 40]. Penumbra (Penumbra, Alameda, California) is another device that works by thromboaspiration by a microcatheter connected to an aspiration pump after mechanical disruption of the clot with a separator [41]. After the Penumbra Pivotal Stroke Trial [42], the Penumbra device was approved by FDA (2008). Newest and most frequently used devices are stent retrievers including Solitaire (Covidien, Irvine, CA), Trevo (Stryker Neurovascular, Fremont, California), Catch (Balt Extrusion, Montmerency, France) and Preset (Phenox, Bochum, Germany). ASA guidelines recommend choosing stent retrievers over other devices for mechanical thrombectomy in addition to other recommendations (Table 7). These devices are self-expandable and retrievable stents that are deployed within the thrombus, jail the thrombus in between the stent struts and the artery wall and remove the thrombus by retrieving (Fig. 5). Both pivotal studies for Solitaire and Trevo showed superiority in recanalization rates compared with Merci [43, 44]. FDA approved both devices in 2012. The main advantage of stent retrievers is that once they are deployed temporary restoration of the blood flow to the deprived brain parenchyma occurs. By technological improvements, smaller microcatheter systems are used to navigate these stent retrievers in distal cerebral vasculature. Two landmark studies that were published recently, SWIFT PRIME and MR CLEAN, will potentially revolutionize the management of acute stroke [44–47]. MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) [47] assessed whether intraarterial treatment plus usual care would be more effective than usual care alone in patients with a proximal arterial occlusion in the anterior cerebral circulation that could be treated intraarterially within 6 h after symptom onset. 195 patients (81.5 %) out of 233 patients treated with IA treatment had mechanical thrombectomy with stent retrievers. Only one patient (0.4 %) had IA thrombolytic agents as monotherapy. This represents the paradigm shift toward a more frequent use of mechanical thrombectomy devices as the first line therapy for IA treatment of acute stroke [48]. There were better recanalization (75.4 % vs 32.9 %), less infarct volume and more functionally independent patients (32.6 % vs 19.1 %) in the IA treatment group than the IV fibrinolysis group. SWIFT PRIME (Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment) trial evaluated the efficacy and safety of mechanical thrombectomy with the stent retriever in conjunction with intravenous t-PA versus intravenous t-PA alone in patients with acute ischemic stroke. Successful reperfusion rates were significantly higher (83 % vs 40 %) in the stent retriever group. Both studies showed that IA treatment especially with the new stent retrievers lead to a significant increase in functional recovery and independence in daily life after an acute stroke.
3 Endovascular Treatment Cerebral Venous and Sinus Thrombosis
Cerebral venous and sinus thrombosis (CVST) comprises nearly 0.5–1 % of all stroke cases. Incidence of CVST is 3–4 cases per million in adults and incidence in pediatric population is 0.67 per 100.000 children [49]. In adult population it is more common in women and female predominance is most likely related with oral contraceptive use and hormonal disturbances during pregnancy. Other causes of CVST are infection, dehydration, hypercoagulable states, cardiac disease, surgery and trauma [50–53]. Most commonly affected intracranial venous structure is the superior sagittal sinus (SSS) followed by the transverse sinus. Other dural sinuses and cortical veins may also be involved. Clinical presentation is highly variable from completely asymptomatic cases to severe intracranial hypertension, cerebral hematoma and herniation. Most common symptoms are headache, nausea, seizures, visual disturbances, decreased consciousness level and focal neurological deficits like hemiparesis, aphasia. Different neurological deficits are seen depending on the location of the thrombosis in the cerebral venous system and the affected cerebral lobe drained by that specific vein. For example, whereas thrombosis of the middle 1/3 of the SSS may cause hemiparesis, occlusion of the posterior 1/3 of the SSS may lead to cortical blindness due to occipital lobe involvement. Occlusion of the anterior 1/3 of the SSS may be asymptomatic. Occlusion of the dural sinus accompanied by the thrombosis of a cortical vein may potentially cause a higher risk of hemorrhagic infarct. Ferro et al. in the largest prospective multicenter international study found out 13.4 % death and dependency in 624 CVST patients [54]. Risk factors for an unfavorable outcome were male sex, age >37 years, coma, mental status disorder, intracranial hemorrhage on admission, thrombosis of the deep cerebral venous system, central nervous system (CNS) infection, and cancer [54, 55].
3.1 Radiological Work-up
Computerized tomography of the head is the most frequently used noninvasive radiological exam in patients presenting with headache or focal neurologic deficits. Cerebral infarct with or without hemorrhage can be seen in head CT of severe cases (Fig. 6). Cerebral infarct in venous thrombosis will not follow the arterial territories and will have a more atypical appearance and location than the arterial thromboembolism. The “empty delta sign” can be seen in enhanced head CT as enhancement of dura around the nonenhanced thrombosed sinus segment (Fig. 7). The “cord sign” defined as a homogeneous, hyperattenuated appearance of thrombosed venous sinuses on nonenhanced CT scans is highly specific and sensitive for deep venous system thrombosis [56].
CT or Magnetic resonance (MR) angiography of the cerebral veins will depict the thrombus and its expansion within the venous system (Fig. 8). “Cord sign”, cerebral edema, infarct, subdural hematoma and subarachnoid hemorrhage due to cerebral venous thrombosis can be seen in CT or MR imaging. Both modalities CT/CT venography and MR/MR venography can be effectively used to diagnose and to follow up CVT cases [57–59].
3.2 Medical Management
Stabilization of the general status of the patient with hydration, treatment for intracranial hypertension and management of symptoms like seizures and headaches are first line measures. Anticoagulation with heparin is the most widely accepted therapy to prevent the expansion of the thrombus. Several studies showed better outcomes in CVST patients treated with heparin [60, 61].
Effective systemic anticoagulation targets activated partial thromboplastin times (aPTT) between 60 and 80 s. Cerebral hemorrhage is not a contraindication for heparin use in CVST and a substudy from ISCVT (International Study on Cerebral Vein and Dural Sinus Thrombosis) study group suggested a better efficacy and safety of low–molecular weight heparin over unfractionated heparin [62].
3.3 Endovascular Treatment
Despite heparinization, some CSVT patients with negative prognostic factors will fail to recover and mortality rate can be as high as 10 % in these patients [63]. Patients with rapid decompensation despite medical therapies will need more aggressive treatments. Rahman et al. [64], based on their literature review for endovascular treatment of CSVT, proposed a treatment algorithm for CSVT patients. Patients who present with severe neurological deficits (Glasgow coma scale score ≤ 8) are strongly considered for direct thrombolysis/thrombectomy immediately. Patients with Glasgow coma scale score (GCS) scores between 9 and 12 may be considered for immediate endovascular treatment. For other patients (GCS score > 12), direct thrombolysis/thrombectomy would be considered only after a trial of systemic anticoagulation. Endovascular methods include intrasinus infusion of thrombolytics or heparin, balloon angioplasty, mechanical thrombectomy or a combination of different techniques [65–70]. For pharmacological lysis of the clot, intrasinus heparin or thrombolytic infusion can be performed. Either urokinase or tissue plasminogen activators can be used as thrombolytics [71–75]. Infusion of local thrombolytics may increase the size of the hemorrhagic infarct in addition to complications including pulmonary embolism and hemorrhage. Mechanical thrombectomy can be achieved with rheolytic catheters, balloon angioplasty, Fogarty catheter or dedicated mechanic thrombectomy devices including stent retrievers. There is a higher rate of recanalization with endovascular methods compared to other medical therapies. Even with partial recanalization of the sinus significant clinical recovery may happen. Until today there is no controlled randomized trial to compare the efficacy of intrasinus infusion of thrombolytics/heparin with mechanical thrombectomy for the treatment of CSVT.
References
Fowkes FJ, Price JF, Fowkes FG (2003) Incidence of diagnosed deep vein thrombosis in the general population: systematic review. Eur J Vasc Endovasc Surg 25(1):1–5
Scarvelis D, Wells PS (2006) Diagnosis and treatment of deep vein thrombosis. CMAJ 175(9):1087–1092
Geerts W, Ray JG, Colwell CW, Bergqvist D, Pineo G, Lassen MR et al (2005) Prevention of venous thromboembolism. Chest 128(5):3775–3776
Vedantham S (2012) Interventional approaches to deep vein thrombosis. Am J Hematol 87(Suppl 1):S113–S118
Pernes JM, Auguste M, Kovarski S, Borie H, Renaudin JM, Coppe G (2012) Diagn Interv Imaging 93(10):725–733
Elsharawy M, Elzayat E (2002) Early results of thrombolysis vs anticoagulation in iliofemoral venous thrombosis. A randomized clinical trial. Eur J Vasc Endovasc Surg 24(3):209–214
Rogers LQ, Lutcher CL (1990) Streptokinase therapy for deep vein thrombosis: a comprehensive review of the English literature. Am J Med 88(4):389–395
Plate G, Eklof B, Norgren L, Ohlin P, Dahlstrom JA (1997) Venous thrombectomy for iliofemoral vein thrombosis 10 year results of a prospective randomized study. Eur J Vasc Endovasc Surg 14(5):367–374
Plate G, Einarsson E, Ohlin P, Jensen R, Qvarfordt P, Eklof B (1984) Thrombectomy with temporary arteriovenous fistula: the treatment of choice in acute iliofemoral venous thrombosis. J Vasc Surg 1(6):867–876
Vedantham S, Sista AK, Klein SJ, Nayak L, Razavi MK, Kalva SP, et al. Society of Interventional Radiology and Cardiovascular and Interventional Radiological Society of Europe Standards of Practice Committees (2014) Quality improvement guidelines for the treatment of lower-extremity deep vein thrombosis with use of endovascular thrombus removal. J Vasc Interv Radiol 25(9):1317–1325
Semba CP, Dake MD (1994) Iliofemoral deep venous thrombosis: aggressive therapy with catheter-directed thrombolysis. Radiology 191:487–494
Mewissen WM, Seabrook GR, Meissner MH, Cynamon J, Labropoulos N, Haughton SH (1999) Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a National Multicenter Registry. Radiology 211:39–49
Cakir V, Gulcu A, Akay E, Capar AE, Gencpinar T, Kucuk B et al (2014) Use of percutaneous aspiration thrombectomy vs. anticoagulation therapy to treat acute iliofemoral venous thrombosis: 1-year follow-up results of a randomized clinical trial. Cardiovasc Intervent Radiol 37:969–976
Sugimoto K, Hoffman LV, Razavi MK et al (2003) The safety, efficacy, and pharmacoeconomics of low-dose alteplase compared with urokinase for catheter directed thrombolysis of arterial and venous occlusions. J Vasc Surg 37:512–517
Vedantham S, Vesely TM, Sicard GA et al (2004) Pharmacomechanical thrombolysis and early stent placement for iliofemoral deep vein thrombosis. J Vasc Interv Radiol 15:565–574
Bush RL, Lin PH, Bates JT et al (2004) Pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis: safety and feasibility study. J Vasc Surg 40:965–970
Lin PH, Zhou W, Dardik A et al (2006) Catheter-direct thrombolysis versus pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis. Am J Surg 192:782–788
Cynamon J, Stein EG, Dym J et al (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
O’Sullivan G, 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 18:715–724
Jaff MR, McMurtry MS, Archer SL et al (2011) Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 123:1788–1830
Turmel-Rodrigues L, Raynaud A, Louail B, Beyssen B, Sapoval M (2001) Manual catheter-directed aspiration and other thrombectomy techniques for declotting native fistulas for hemodialysis. J Vasc Interv Radiol 12(12):1365–1371
Oguzkurt L, Ozkan U, Gulcan O, Koca N, Gur S (2012) Endovascular treatment of acute and subacute iliofemoral deep venous thrombosis by using manual aspiration thrombectomy: long-term results of 139 patients in a single center. Diagn Interv Radiol 18(4):410–416
Mackay J, Mensah G, Mendis S, Greenlund K (2004) Atlas of heart disease and stroke. World Health Organization, Geneva
Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M et al. on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee (2015) Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation 27;131(4):e29–322. doi:10.1161/CIR.0000000000000152
Rosamond W, Flegal K, Furie K et al (2008) Heart disease and stroke statistics: 2008 update—a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 117:e25–e146
Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM et al. American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, Council on Clinical Cardiology (2013) Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 44(3):870–947
Christou I, Burgin WS, Alexandrov AV, Grotta JC (2001) Arterial status after intravenous TPA therapy for ischaemic stroke: a need for further interventions. Int Angiol 20:208–213
Furlan A, Higashida R, Wechsler L et al (1999) Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 282(21):2003–2011
Lisboa RC, Jovanovic BD, Alberts MJ (2002) Analysis of the safety and efficacy of intra-arterial thrombolytic therapy in ischemic stroke. Stroke 33(12):2866–2871
IMS Study Investigators (2004) Combined intravenous and intra-arterial recanalization for acute ischemic stroke: the Interventional Management of Stroke Study. Stroke 35:904–911
Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Interventional Management of Stroke (IMS) III Investigators (2013) Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 368(10):893–903. doi:10.1056/NEJMoa1214300
Wolpert SM, Bruckmann H, Greenlee R et al (1993) Neuroradiologic evaluation of patients with acute stroke treated with recombinant tissue plasminogen activator: the rtPA Acute Stroke Study Group. AJNR Am J Neuroradiol 14:3–13
Nogueira RG, Schwamm LH, Hirsch JA (2009) Endovascular approaches to acute stroke, Part 1: Drugs, devices, and data. AJNR Am J Neuroradiol 30:649–661
IMS II Trial Investigators (2007) The Interventional Management of Stroke (IMS) II study. Stroke 38:2127–2135
Marler JR, Tilley BC, Lu M, Brott TG, Lyden PC, Grotta JC et al (2000) Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study. Neurology 55:1649–1655
Nogueira RG, Smith WS (2009) Safety and efficacy of endovascular thrombectomy in patients with abnormal hemostasis: pooled analysis of the MERCI and Multi MERCI trials. Stroke 40:516–522
Higashida RT, Furlan AJ, Roberts H et al (2003) Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke 34:e109–e137
Kallmes DF (2012) TICI: if you are not confused, then you are not paying attention. AJNR Am J Neuroradiol 33:975–976
Smith WS, Sung G, Starkman S et al (2005) Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 36:1432–1438
Smith WS, Sung G, Saver J et al (2008) Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke 39:1205–1212
Bose A, Henkes H, Alfke K et al (2008) The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism. AJNR Am J Neuroradiol 29:1409–1413
Penumbra Pivotal Stroke Trial Investigators (2009) The penumbra pivotal stroke trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke 40(8):2761–2768. doi:10.1161/STROKEAHA.108.544957
Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG et al. SWIFT Trialists (2012) Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 380:1241–1249
Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, et al. TREVO 2 Trialists (2012) Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomized trial. Lancet 380:1231–1240
Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM et al. SWIFT PRIME Investigators (2015) Solitaire™ with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial: protocol for a randomized, controlled, multicenter study comparing the Solitaire revascularization device with IV tpa with IV tpa alone in acute ischemic stroke. Int J Stroke 10(3):439–448. doi: 10.1111/ijs.12459
Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM et al. SWIFT PRIME Investigators (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 372(24):2285–95. doi:10.1056/NEJMoa1415061
Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ et al. MR CLEAN Investigators (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372(1):11–20. doi:10.1056/NEJMoa1411587
Mehta B, Leslie-Mazwi TM, Chandra RV et al (2013) Assessing variability in neurointerventional practice patterns for acute ischemic stroke. J Neurointerv Surg 5(Suppl 1):i52–i57
Stam J (2005) Thrombosis of the cerebral veins and sinuses. N Engl J Med 352:1791–1798
Martinelli I, Sacchi E, Landi G, Taioli E, Duca F, Mannucci PM (1998) High risk of cerebral-vein thrombosis in carriers of a prothrombin-gene mutation and in users of oral contraceptives. N Engl J Med 338(25):1793–1797
Cantú C, Barinagarrementeria F (1993) Cerebral venous thrombosis associated with pregnancy and puerperium. Review of 67 cases. Stroke 24(12):1880–1884
Rahmanian R, Wan Fook Cheung V, Chadha NK (2015) Non-fatal extensive cerebral venous thrombosis as a complication of adenotonsillectomy. Int J Pediatr Otorhinolaryngol 79(2):254–258. doi:10.1016/j.ijporl.2014.11.016
Emir M, Ozisik K, Cagli K, Bakuy V, Ozisik P, Sener E (2004) Dural sinus thrombosis after cardiopulmonary bypass. Perfusion 19(2):133–135
Ferro JM, Canhao P, Stam J, Bousser MG, Barinagarrementeria F (2004) Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke 35(3):664–670
Girot M, Ferro JM, Canhão P, Stam J, Bousser MG, Barinagarrementeria F et al. ISCVT Investigators (2007) Predictors of outcome in patients with cerebral venous thrombosis and intracerebral hemorrhage. Stroke 38(2):337–342. Epub 2007 Jan 4
Linn J, Pfefferkorn T, Ivanicova K, Müller-Schunk S, Hartz S, Wiesmann M et al (2009) Noncontrast CT in deep cerebral venous thrombosis and sinus thrombosis: comparison of its diagnostic value for both entities. AJNR Am J Neuroradiol 30(4):728–735. doi:10.3174/ajnr.A1451
Bonneville F (2014) Imaging of cerebral venous thrombosis. Diagn Interv Imaging 95(12):1145–1150. doi:10.1016/j.diii.2014.10.006
Bracken J, Barnacle A, Ditchfield M (2013) Potential pitfalls in imaging of paediatric cerebral sinovenous thrombosis. Pediatr Radiol 43(2):219–231. doi:10.1007/s00247-012-2402-6
Linn J, Brückmann H (2010) Cerebral venous and dural sinus thrombosis: state-of-the-art imaging. Clin Neuroradiol 20(1):25–37. doi:10.1007/s00062-010-9035-7
Einhaupl K, Bousser MG, de Bruijn SF, Ferro JM, Martinelli I, Masuhr F et al (2006) EFNS guideline on the treatment of cerebral venous and sinus thrombosis. Eur J Neurol 13:553–559
Bousser MG, Ferro JM (2007) Cerebral venous thrombosis: an update. Lancet Neurol 6:162–170
Coutinho JM, Ferro JM, Canhaõ P, Barinagarrementeria F, Bousser MG, Stam J, for the ISCVT investigators (2010) Unfractionated or low–molecular weight heparin for the treatment of cerebral venous thrombosis. Stroke 41:2575–2580
Masuhr F, Mehraein S (2004) Cerebral venous and sinus thrombosis: patients with a fatal outcome during intravenous dose-adjusted heparin treatment. Neurocrit Care 1(3):355–361
Rahman M, Velat GJ, Hoh BL, Mocco J (2009) Direct thrombolysis for cerebral venous sinus thrombosis. Neurosurg Focus 27(5):E7. doi:10.3171/2009.7.FOCUS09146
Rael JR, Orrison WW Jr, Baldwin N, Sell J (1997) Direct thrombolysis of superior sagittal sinus thrombosis with coexisting intracranial hemorrhage. AJNR Am J Neuroradiol 18:1238–1242
Philips MF, Bagley LJ, Sinson GP, Raps EC, Galetta SL, Zager EL et al (1999) Endovascular thrombolysis for symptomatic cerebral venous thrombosis. J Neurosurg 90:65–71
Chaloupka JC, Mangla S, Huddle DC (1999) Use of mechanical thrombolysis via microballoon percutaneous transluminal angioplasty for the treatment of acute dural sinus thrombosis: case presentation and technical report. Neurosurgery 45:650–657
Chow K, Gobin YP, Saver J, Kidwell C, Dong P, Vinuela F (2000) Endovascular treatment of dural sinus thrombosis with rheolytic thrombectomy and intra-arterial thrombolysis. Stroke 31:1420–1425
Curtin KR, Shaibani A, Resnick SA, Russell EJ, Simuni T (2004) Rheolytic catheter thrombectomy, balloon angioplasty, and direct recombinant tissue plasminogen activator thrombolysis of dural sinus thrombosis with preexisting hemorrhagic infarctions. AJNR Am J Neuroradiol 25:1807–1811
Newman CB, Pakbaz R, Nguyen A, Kerber C (2009) Endovascular treatment of extensive cerebral sinus thrombosis. J Neurosurg 110:442–445
Frey JL, Muro GJ, McDougall CG, Dean BL, Jahnke HK (1999) Cerebral venous thrombosis: combined intrathrombus rtPA and intravenous heparin. Stroke 30:489–494
Wasay M, Bakshi R, Kojan S, Bobustuc G, Dubey N, Unwin DH (2001) Nonrandomized comparison of local urokinase thrombolysis versus systemic heparin anticoagulation for superior sagittal sinus thrombosis. Stroke 32:2310–2317
Soleau SW, Schmidt R, Stevens S, Osborn A, Macdonald J (2003) Extensive experience with dural sinus thrombosis. Neurosurgery 52:534–544
Stam J, Majoie CB, van Delden OM, van Lienden KP, Reekers JA (2008) Endovascular thrombectomy and thrombolysis for severe cerebral sinus thrombosis: a prospective study. Stroke 39:1487–1490
La Barge DV 3rd, Bishop FS, Stevens EA, Eskandari R, Schmidt RH, Skalabrin EJ et al (2009) Intrasinus catheter-directed heparin infusion in the treatment of dural venous sinus thrombosis. AJNR Am J Neuroradiol 30(9):1672–1678. doi:10.3174/ajnr.A1677
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Goktay, A.Y., Senturk, C. (2016). Endovascular Treatment of Thrombosis and Embolism. In: Islam, M. (eds) Thrombosis and Embolism: from Research to Clinical Practice. Advances in Experimental Medicine and Biology(), vol 906. Springer, Cham. https://doi.org/10.1007/5584_2016_116
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