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Endovascular thrombolysis safe, viable for pediatric population
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Pediatric patients with iliofemoral thrombosis can be treated with endovascular thrombolysis at a high technical success rate with few major complications, according to results from a retrospective review.
However, attempts to measure postthrombotic syndrome in this population according to two different scales yielded widely varying results, indicating a need for a standardized method of assessing treatment outcomes for pediatric patients, the researchers wrote.
The analysis included data from 57 children (mean age, 14.5 years; 26 boys, 31 girls) with iliofemoral thrombosis who underwent venous thrombolysis in 64 limbs between March 2003 and June 2013. Patients were treated via catheter-directed thrombolysis (CDT); percutaneous mechanical thrombectomy (PMT); and pharmacomechanical catheter-directed thrombolysis (PCDT) with angioplasty or stenting. Technical success was defined as thrombolysis of 50% or greater, with grade III indicating 100% thrombolysis and grade II 50% to 99%.
Follow-up was conducted every 3 months after treatment for 1 year, then annually. At each follow-up visit, patients were assessed for symptoms of postthrombotic syndrome according to the Villalta scale, a validated tool that assesses numerous symptoms and signs of the syndrome, and a modified version of the Villalta scale developed to account for the potential difficulty for pediatric patients to accurately describe their symptoms.
Patients underwent CDT alone in 17 limbs, CDT with PMT in 23 limbs and CDT with PCDT in 21 limbs, for a mean of 36.5 hours. PMT was performed alone in three limbs. Four limbs required stents, and adjunctive angioplasty was performed in 35 limbs.
Technical success occurred in 93.7% of treated limbs (grade III, 29.7%; grade II, 59.7% of limbs). One patient experienced major gastrointestinal bleeding during CDT that required transfusion, whereas seven experienced minor bleeding. Patients underwent inferior vena cava filter placement in 21 cases, including two permanent filters and two placed at other facilities before treatment. Filter retrieval was successful in 17 cases. No patients with filters developed pulmonary embolism.
During a median follow-up of 1.5 years, repeat thrombolysis to treat recurrent thrombosis occurred in seven patients. Among 52 patients with evaluable follow-up data, Villalta scores were available for 43 limbs and modified Villalta scores were available for 54. The researchers identified a postthrombotic syndrome rate of 2.1% on the Villalta scale, including one severe case, during a median of 1.8 years. However, the rate according to the modified scale was 59.3%, with 87.5% of cases considered mild, 9.4% moderate and 3.1% severe, during a median follow-up of 1.5 years.
The researchers attributed the disparity to the particular sensitivity of the modified to mild signs of postthrombotic syndrome, including swelling or collateral vessels, which are typically asymptomatic. Also, they noted, the presence of postthrombotic syndrome is identified with a score of 5 points or greater on the standard scale vs. a score of 1 on the modified scale.
“Based on our experience in a large pediatric population, endovascular thrombosis is a technically feasible and safe therapy for proximal lower-extremity [deep vein thrombosis] in children and shows an acceptable complication rate,” the researchers concluded, adding that the varied results from the postthrombotic syndrome scales “[suggest] an acute need for standardization of outcome measurement in children for future studies.” – by Adam Taliercio
Disclosure: The researchers report no relevant financial disclosures.
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