Catheter-Directed Thrombolysis of Iliocaval Thrombosis in Patients With COVID-19
Catheter-Directed Thrombolysis of Iliocaval Thrombosis in Patients With COVID-19
Catheter-Directed Thrombolysis of Iliocaval Thrombosis in Patients With COVID-19
Mohamad Al-Otaibi, MD, Omer Iftikhar, MD, Yevgeniy Brailovsky, DO MSc, Parth
Rali, MD, Sabrina Islam, MD MPH, Erin Narewski, DO, Eric Choi, MD, Gary Cohen,
MD, Riyaz Bashir, MD, Vladimir Lakhter, DO, for the Temple University COVID-19
research group
PII: S2666-0849(20)31005-6
DOI: https://doi.org/10.1016/j.jaccas.2020.07.057
Reference: JACCAS 737
Please cite this article as: Al-Otaibi M, Iftikhar O, Brailovsky Y, Rali P, Islam S, Narewski E, Choi E,
Cohen G, Bashir R, Lakhter V, for the Temple University COVID-19 research group, Catheter-Directed
Thrombolysis of Iliocaval Thrombosis in Patients with COVID-19, JACC Case Reports (2020), doi:
https://doi.org/10.1016/j.jaccas.2020.07.057.
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of
record. This version will undergo additional copyediting, typesetting and review before it is published
in its final form, but we are providing this version to give early visibility of the article. Please note that,
during the production process, errors may be discovered which could affect the content, and all legal
disclaimers that apply to the journal pertain.
Mohamad Al-Otaibia MD, Omer Iftikharb MD, Yevgeniy Brailovskyd DO MSc, Parth Ralie MD,
Sabrina Islamc MD MPH, Erin Narewskie DO, Eric Choif MD, Gary Cohenj MD, Riyaz Bashirb
MD, Vladimir Lakhterb DO, for the Temple University COVID-19 research group
a
Department of Internal Medicine, Temple University Hospital, Philadelphia, PA
b
Department of Interventional Cardiology, Temple University Hospital, Philadelphia, PA
c
Department of Cardiology, Temple University Hospital, Philadelphia, PA
d
Division of Cardiology, Columbia University Irving Medical Center, New York, NY
e
Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA
f
Division of Vascular Surgery, Temple University Hospital, Philadelphia, PA
j
Department of Radiology, Temple University Hospital, Philadelphia, PA
of
Address for correspondence
ro
Vladimir Lakhter, DO
Temple University Hospital
Division of Cardiovascular Diseases
3401 N. Broad Street (9PP)
-p
re
Philadelphia, PA 19140
Tel: 215 707 5800
lP
Disclosures: Dr. Bashir, has equity interest in Thrombolex Inc. The other authors have no
conflict of interest to disclose.
Funding: There are no funding sources to disclose.
ur
Keywords: Deep vein thrombosis – femoral vein thrombosis - clot burden - COVID-19 infection
– COVID-19 infection complication
Abbreviations:
BEC = Bashir™ Endovascular Catheter
CDT = catheter-directed thrombolysis
CFV = common femoral vein
CIV = common iliac vein
CT = computed tomography
DVT = deep vein thrombosis
EIV = external iliac vein
FV = femoral vein
IVC = inferior vena cava
PV = popliteal vein
rtPA = recombinant tissue plasminogen activator
1
Abstract
We present the characteristics and outcomes of the first two cases of catheter-directed
thrombolysis performed in patients presenting with COVID-19 related iliocaval thrombosis
of
ro
-p
re
lP
na
ur
Jo
2
Introduction
patients each year in the United States (1), is frequently complicated by a debilitating post-
thrombotic syndrome (2). SARS-CoV-2 virus is associated with a hypercoagulable state and a 16
to 27% incidence of DVT and pulmonary embolism (3,4). As of June 1st 2020, the US Centers
for Disease Control and Prevention had reported over 1.8 million cases of COVID-19 in the
United States, over 75% of them are <65 years of age (5), and a high proportion presenting with,
of
or destined to develop thrombosis of large veins, including iliocaval thrombosis. In these
ro
patients, anticoagulation alone is often insufficient and, in absence of COVID-19, they would be
-p
considered candidates for catheter-directed thrombolysis (CDT) to alleviate symptoms and
re
improve quality of life (6).
lP
patients with Low molecular weight heparin (LMWH), they however did not address the use of
advanced therapies like CDT (7). Our cases illustrate the potential role of CDT in selected low
ur
bleeding risk young patients. To the best of our knowledge, CDT of symptomatic iliocaval
Jo
thrombosis in COVID-19 patients has not been reported, which is likely because of the potential
risks of bleeding complications and viral transmission to the catheterization laboratory staff. We
report 2 cases of COVID-19 patients presenting with severely symptomatic iliofemoral and
Case reports
Case 1: A 34-year-old man with COVID-19 positive nasopharyngeal swab presented with 1
week of increasing left lower extremity swelling and pain. On physical examination prominent
3
edema was present from the foot to the proximal thigh. Initial labs were notable for a D-Dimer
of 11,864 ng/ml, PTT of 36.4 seconds, platelet count of 277 K/mm3, hemoglobin of 14.1 g/dL,
fibrinogen of 488 mg/dL, LDH of 230 U/L, and ferritin of 411 ng/ml. A left venous Duplex
showed acute occlusive DVT extending from the common femoral (CFV) to the popliteal (PV)
veins (figure 1 A-B). A thoracic computed tomography (CT) scan revealed the presence of
small, bilateral, lower lobe thrombi and multiple, diffuse, bilateral ground glass opacities,
consistent with viral pneumonia. The venous phase of the CT scan revealed acute thrombotic
of
occlusion of the left external iliac vein (EIV), CFV and PV. The patient was anticoagulated
ro
using IV UFH at a rate of 2540 units/hr for 72 h with serial therapeutic PTTs without any
-p
improvement in swelling or pain. The risks and benefits of CDT including the conflict of interest
re
associated with the use of Bashir Endovascular Catheter were explained to the patient after
lP
which a written consent was obtained. The patient was taken to the catheterization laboratory
na
where under ultrasound guidance PV access was obtained. After baseline venography, a
Bashir™ Endovascular Catheter (BEC)+30 (Thrombolex, Inc.; New Britain, PA) was introduced
ur
delivered from the PV to the EIV by repeatedly expanding and collapsing the infusion basket
(Figure 1 E-F). The latter was repositioned across the left EIV and CFV and a 30-cm infusion
shaft was placed across the CFV and PV for continuous infusion of rtPA. The patient was
monitored overnight in the COVID unit. Follow-up venography performed the following day
after administration of 16mgs of rtPA showed >90% lysis of the thrombus, with brisk flow
across the left EIV, CFV, FV and PV (Figure 1 G-H), associated with marked decrease in
swelling and pain. He was discharged home on the same day on therapeutic dose of enoxaparin.
4
Case 2: A 64-year-old, COVID-positive woman and a history of morbid obesity (body mass
index = 62), chronic left lower extremity DVT, prior IVC filter placement presented with a 5-day
history of swelling extending from the right foot to the inguinal region. Initial labs were notable
for a D-Dimer of 7,069 ng/ml, PTT of 33.6 seconds, platelet count of 203 K/mm3, Hemoglobin
of 13.1 g/dL, fibrinogen of 499 mg/dL, LDH of 856 U/L, and ferritin of 1,711 ng/ml. Duplex
ultrasound revealed an occlusive DVT from right CFV to PV. CT venography showed acute
occlusive thrombosis from the IVC filter, at the renal veins confluence, to the right FV (Fig 2A).
of
There was also evidence of chronic DVT in the left lower extremity with atretic left common
ro
iliac vein (CIV) and EIV. The patient was anticoagulated using IV UFH at a rate of 2,100
-p
units/hr for 72 h with serial therapeutic PTTs without any change in the swelling or pain. The
re
risks and benefits of CDT including the conflict of interest associated with the use of Bashir
lP
Endovascular Catheter were explained to the patient after which a written consent was obtained.
na
After obtaining successful ultrasound-guided right popliteal venous access, venography revealed
the presence of a thrombus extending from the IVC filter to the right popliteal vein (Figure 2B).
ur
BEC+40 catheter, CDT was performed by delivering a 6-mg pulse of rtPA via the infusion
basket, which was sequentially expanded along the infra-renal IVC, right CIV, EIV, CFV and
FV. The rtPA infusion was continued overnight via the basket (placed at the level of IVC filter)
(Figure 2C) and the 40 cm shaft, infusing across the infrarenal IVC, and the iliac and femoral
veins. Follow-up venography after a total of 24mgs of rtPA infusion, revealed >80% clot lysis,
with brisk flow between the PV and the suprarenal IVC (Figure 2 D-F). Residual thrombus was
Scientific; Marlborough, MA). Intravenous ultrasound imaging showed severe stenosis of the
5
right CIV, which was stented using an 18 x 90 mm WALLSTENT™ Endoprosthesis (Boston
Scientific). The patient remained on intravenous heparin, with resolution of the right lower
extremity swelling and pain, and supplemental oxygen for management of viral pneumonia.
Conclusion
These cases illustrate the successful implementation of CDT with a novel pharmaco-
mechanical device, for the management of COVID-19-related proximal iliofemoral and iliocaval
of
DVT. A single case of acute pulmonary embolism successfully treated with CDT has been
ro
reported (8), though this is the first report of CDT for DVT in COVID-19 patients. Both patients
-p
benefited from nearly complete resolution of the clot burden and marked clinical improvement. It
re
is particularly noteworthy that the first patient could be discharged from the hospital within hours
lP
following the CDT. At a time when hospital resources are being used to their limit by COVID-19
na
cases (9), safely reducing the length of hospital stay by CDT represents a major benefit,
6
LEARNING OBJECTIVES
2. Propose CDT’s potential in reducing hospital stays in young, low bleeding risk COVID-
19 patients.
of
ro
-p
re
lP
na
ur
Jo
7
References
1. Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public
2. Kahn SR, Ginsberg JS. Relationship between deep venous thrombosis and the
of
2020;18:844-847.
ro
4. Middeldorp S, Coppens M, van Haaps TF, et al. Incidence of venous thromboembolism
-p
in hospitalized patients with COVID-19. Thromb Haemost 2020. doi: 10.1111/jth.14888.
re
5. Centers for Disease Control and Prevention. Cases in the U.S.
lP
https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Last
na
6. Comerota AJ, Kearon C, Gu CS, et al. Endovascular thrombus removal for acute
ur
iliofemoral deep vein thrombosis: analysis from a stratified multicenter randomized trial.
Jo
Circulation 2019;139:1162-73.
19 pneumonia with acute PE: Thinking beyond the guidelines. Thromb Res 2020;192:9-
11.
8
9. Bartsch SM, Ferguson MC, McKinnell JA, et al. The Potential Health Care Costs And
Resource Use Associated With COVID-19 In The United States. Health Aff (Millwood)
2020;39:927-935.
of
ro
-p
re
lP
na
ur
Jo
9
Figure legends
Figure 1:
A-B) Doppler ultrasound with and without compression showing non-compressible left common
femoral vein
C-D) Venogram showing extensive thrombus in the left common femoral and femoral vein
E-F) BEC+ with expanded shaft in the left common femoral vein and femoral vein for tPA
infusion
of
G-H) Venogram showing resolution of thrombus in the left common femoral and femoral vein
ro
post infusion
Figure 2:
-p
re
A) CT venogram showing thrombus in the IVC Filter with arrow pointing towards clot above the
lP
D-F) Venogram showing Resolution of thrombus in the IVC, Right CIV, EIV, CFV and femoral
Jo
vein
10
Jo
ur
na
lP
re
-p
ro
of
Jo
ur
na
lP
re
-p
ro
of