Tibial Venous Access is Safe and Effective in Treating DVT

A new technique for treatment of deep vein thrombosis (DVT) is feasible and has significant advantages over conventional popliteal and common femoral vein access.

Editor's note: A video featuring Dr. Fadi Saab accompanies this article.

For the past two years, we have increasingly used tibial venous access to deliver catheter-directed thrombolysis to patients with deep vein thrombosis (DVT). We now treat more than 70% of our patients with DVTs using this approach. As long-time champions of arterial tibial access to treat arterial disease and critical limb ischemia with great success, it was natural to apply this novel technique to venous problems. Tibial veins are actually much larger than the tibial arteries accessed to treat arterial disease. Therefore, there is no anatomic reason to not utilize tibial veins to advance wires and catheters to reach occlusions in the lower extremity veins, especially using a low-profile sheath, such as the Slender Sheath (Terumo). 

The initial use of tibial access to treat DVT was born of clinical necessity. For patients who had a large DVT that extended from the iliac vein to the tibial veins, traversing the occluded vein with a wire and catheter from the conventional popliteal segment was often very difficult. In many cases, the only treatment option for these patients was oral anticoagulation, which fails in a significant number of patients.  Post-thrombotic syndrome (PTS), which has been reported in up to 50% of cases of DVT treated with oral anticoagulation, causes significant pain, redness, discomfort, and possibly ulcers.

Tibial venous access can be approached in two different ways. The first approach is to cross the thrombotic venous occlusion extending from the tibial veins all the way to the iliac veins. Then the physician may choose to perform thrombectomy, or, most importantly, catheter-based directed therapy (CDT). Ultrasound-mediated lytic therapy can be delivered via tibial venous access.

The second option to deliver therapy would be to cross the thrombotic venous occlusion via tibial venous access. At this point, the physician may choose to obtain a contralateral common femoral vein for additional access. The operator may decide to snare over the wire that was advanced from the tibial venous access. Once that wire is snared, the physician has secured straight-line therapy through the thrombotic venous system in the contralateral limb. From the contralateral side, large catheters can be used to deliver thrombolytic therapy. With this technique, it is much easier and more successful to cross the occlusion in a retrograde fashion from the ankle upwards. 

Tibial venous access also allows treatment of occluded tibial veins with pharmaco- mechanical therapy, which was impossible using conventional popliteal and common femoral vein access. The recent results of the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) study, presented at the Society of Interventional Radiology in March, highlight the need for better case selection. Until the study is published and full details are available, however, the value of catheter-based therapy in DVT patients should not be overlooked.

Greater patient comfort and minimal complications

Immediately, we recognized that tibial access was much more comfortable for our patients. Patients’ mobility can be significantly limited by having a sheath inserted behind the knee from popliteal access or from the groin from common femoral vein access. The much less intrusive tibial venous access allows patients to lie comfortably while the sheath is inserted in the ankle area and to sit up immediately afterwards. With tibial access, patients can also be mobile within 30 minutes after catheter-directed therapy is completed, compared with the 4 to 6 hours of bed rest required after popliteal or common femoral vein access. 

Tibial access complication rates are minimal and are limited to local pain at the site, with potential bruising after the sheath has been removed from the tibial vein. This superficial location of the tibial vein is responsible for less risk of bleeding and hematoma formation than with access to the larger and deeper popliteal and common femoral vein structures. Bleeding in the popliteal fossa in particular can lead to significant complications. 

In treating DVT, there is no limitation in using tibial venous access to deliver catheter-based lytics therapy. The tibial access approach actually provides an advantage because a much larger area can be targeted — tibial veins, popliteal veins, superficial femoral veins — than can be targeted with other traditional access points like the common femoral vein or popliteal vein. The natural valves within the venous system are more favorable toward crossing in a retrograde fashion from the tibial direction. 

The EkoSonic Endovascular System (EKOS) catheter can be used to deliver lytic therapy for 12 or 24 hours. Ultrasound accelerates the penetration of lytic drug into the thrombus by thinning and opening up the fibrin mesh of the clot. In this way, the clot can be completely dissolved, with no distal embolization. After the procedure, the patient is typically brought back to the endovascular suite to assess the remaining clot burden with a venogram. If a case arises in which less than 50% of the thrombus is resolved, we use pharmacomechanical options to remove the thrombotic material. These devices are adequate to clear thrombus from the distal superficial femoral, popliteal and tibial veins, but tibial venous access currently is limited to 6 French-compatible devices.  

Tibial venous access also cannot be used to deliver stents to the iliac venous system for patients with iliac stenosis or May-Thurner Syndrome; a larger French size is necessary to introduce the stent. If a larger device is required, the physician may choose to obtain popliteal or superficial femoral vein access to clear the thrombus from a much larger iliac venous system. 

Operator comfort with ultrasound-guided technique is required to successfully obtain tibial venous access. Physicians who already use ultrasound visualization to obtain access to the common femoral vein and the popliteal vein can easily learn the tibial venous access technique.   

Although we have had excellent success with tibial venous access to treat DVT, a head-to-head comparison with traditional venous access in a clinical trial that evaluates safety among multiple operators, patient comfort and complication rates is recommended. 
The treatment of DVT is evolving; we have just scratched the surface of what can be achieved. Physicians should be open to pushing the envelope and providing better treatment for our patients with DVT. 

Disclosures: Dr. Saab reports consulting agreements with Boston Scientific, Penumbra and Terumo. Dr. Mustapha reports consulting agreements with Boston Scientific and Terumo.

The authors can be contacted via Fadi Saab, MD, at fadi.saab@metrogr.org.