The Power-Pulse Spray Technique in Complex Venous Thrombotic Disease: A Multidisciplinary "Call to Action"

In this issue of Vascular Disease Management, Sharifi et al, obviously cardiologists, did a nice job treating their patient and identifying a great clinical need, an aggressive endovascular interventional mindset and treatment for venous thrombotic disease (VTD). They are to be congratulated for their “call to action” for more cardiologists becoming involved with treating VTD. This “call to action” has gone out before and must also be repeated to all surgical and radiology specialists and to all multidisciplinary healthcare providers who treat or manage vascular disease, including primary care physicians, emergency room physicians, hospitalists, podiatrists, orthopedists, wound care specialists, hematologists, oncologists, gynecologists, physiatrists, registered nurses, etc.

Safe and effective interventional techniques with supportive data are now available and noted in this article for the endovascular treatment of acute and chronic VTD. Several clinical issues regarding this patient’s initial care underscore the inconsistencies in all aspects of the clinical treatment of VTD. It seems appropriate that a temporary inferior vena cava (IVC) filter was placed during the patient’s initial injury and intensive care unit stay, but he may have benefited from earlier Coumadin therapy when the bleeding risks were lower, especially once discharged with a filter in place. There is no question there is a higher risk for deep vein thrombosis (DVT) after filter placement, especially if not anticoagulated. Obviously, the individual clinical risks and benefits must be closely weighed in each case. An earlier filter removal strategy may also have been a good clinical alternative in this patient once he became ambulatory, therefore, decreasing recurrent DVT and filter thrombosis. These are often difficult clinical decisions to make, as I suspect occurred in this case. Regardless, the authors appeared to have devised and executed a successful interventional strategy. The authors appeared to get remarkably good venous duplex ultrasound (DU) information on the patient. We have not been so lucky with DU, especially in these patients who are oftentimes obese and always edematous.

Recently, we have obtained excellent clinical information and images utilizing 64-slice computed tomographic venography (CTV). Contemporary imaging software and venous imaging protocols give detailed information on the entire limb venous system, iliac veins, IVC, and oftentimes, suprarenal IVC. This information is very important for the interventional treatment plan including vascular access, which is invariable, a difficult decision in these patients. CTV is also an excellent way to follow-up iliac vein stenting after May-Turner Syndrome. The authors did not apply the power-pulse spray (P-PS) technique in the IVC after popliteal-femoral mechanical thrombectomy and relied on more traditional continuous catheter-based iliocaval thrombolysis overnight with “clean up” AngioJet (Possis Medical, Minneapolis, Minnesota) the next day with good results.

Another alternative, especially in an older or higher-risk-for-bleeding patient could have been to begin with the P-PS into the IVC, and even into the thrombosed IVC filter at the same setting. This could have been accomplished via a popliteal, femoral, or jugular approach. We have successfully utilized the P-PS mode through thrombosed IVC filters. Additionally, a second “temporary” filter could also have been placed above the thrombosed IVC filter if the patient was at risk for PE or had compromised pulmonary function. We have employed this strategy on several cases in an effort to rapidly remove or debulk all, or as much as possible, thrombus under one setting to decrease the overall systemic lytic effect, ICU time, bleeding risks, clinical-economic costs, etc. These strategies are mentioned to illustrate the variety of endovascular strategies now available to offer patients with the most complex cases of VTD. I again congratulate the authors on their successful VTD interventional strategy.

A dramatic case of a patient with Phlegmasia Cerolia Dolens was recently transferred from out of state. The 53-year-old, 300-lb female had a 3–4 day history of worsening left leg pain, erythema, paralysis, and cyanosis. A prior DU revealed a left leg DVT. Multiple-organ system failure and sepsis were in their early stages. A CTV was not performed, and the patient was immediately taken to the cath lab with a clinical diagnosis of Phlegmasia Cerolia Dolens. A right common femoral vein (CFV) approach venogram revealed a flush occlusion of the left iliac vein at the IVC, with no limb venous filling. The left iliac vein could not be crossed and a temporary IVC filter was placed. The patient was immediately transferred to the operating room endosuite where general anesthetic was obtained and the thrombosed left CFV was surgically exposed. A retrograde proximal Fogarty catheter (Edwards Lifesciences, Irvine, California) thromboembolectomy was performed with fresh and chronic tissue and the clot removed. A glidewire crossed a chronic iliac stenosis from the retrograde CFV approach and a 14-mm self-expanding stent was placed, treating an iliac vein stenosis, very reminiscent of May-Turner Syndrome. The left CFV, SFV, popliteal, and infrapopliteal veins were then crossed in an antegrade fashion using an 0.035 mm glidewire, and an intraoperative “P-PS” technique was performed. The valves were easily crossed. This was followed by both aggressive manual calf and thigh message and Fogarty catheter embolectomy, completing the surgical venous thrombectomy facilitated by the P-PS technique. Venography and CFV back flow confirmed significant removal of thrombus. The CFV venotomy was closed and a 4-compartment fasciotomy performed. The patient had recent gynecological surgery, so thrombolysis was avoided and full anticoagulation with heparin/warfarin was later accomplished. The patient was transferred 72 hours later with significant clinical improvement in all aspects of medical care.

This case demonstrates the intraoperative use of the P-PS technique, which facilitated this patient’s good clinical outcome. Over the last 3–4 years, the P-PS technique has developed traction in treating patients with acute and chronic VTD. It is likely the treatment of choice in most practices interventionally treating VTD. In 2004, we were the first to report the P-PS technique, with our earliest experience being in the treatment of acute limb ischemia (ALI) in acute/subacute occlusions of the iliac artery, SFA and femoral–popliteal grafts between 2001–2004 in 49 patients.^1–3 This reflected our, and everyone else’s, emphasis on arterial disease at that time. It is good to see Possis Medical has developed a full and efficient product line dedicated to the P-PS technique in both the arterial and venous system, complete with a distal embolic protection strategy in treating arterial disease, with the guard dog system providing distal balloon occlusion and proximal rheolytic thrombectomy. We began our P-PS experience in VTD in 2003–2004, and it has steadily grown since then mirroring the rest of healthcare. PE remains an underestimated and understated major cause of death yearly. Likewise, chronic venous insufficiency continues to be understated, and is the source of huge healthcare costs and resource utilization.

Endovascular techniques and strategies should now be considered the “standard of care” to treat acute DVT. The safety, feasibility, and efficacy data are available to support an aggressive interventional treatment approach to the treatment of DVT. I strongly suspect that an aggressive treatment of acute DVT within the first 24–48 hours of diagnosis would decrease the incidence, mortality, and morbidity associated with PE. Data suggesting less morbidity with CVI with an early interventional treatment of acute DVT are certainly available. I agree with Sharifi et al in making their article a “call to action” for a “paradigm shift” in the treatment of acute and chronic VTD, not only for interventional cardiologists, but for all multidisciplinary healthcare providers.