Quality Improvement Guidelines for the Treatment of Lower-Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal

      The membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from the private and academic sectors of medicine. Generally, Standards of Practice Committee members dedicate the vast majority of their professional time to performing interventional procedures; as such, they represent a valid broad expert constituency of the subject matter under consideration for standards production.


      CDT (catheter-directed thrombolysis), DVT (deep vein thrombosis), ECS (elastic compression stocking), IVC (inferior vena cava), PCDT (pharmacomechanical catheter-directed thrombolysis), PE (pulmonary embolism), PMT (percutaneous mechanical thrombectomy), PTS (postthrombotic syndrome), PTT (partial thromboplastin time), VTE (venous thromboembolism)
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        • Semba C.P.
        • Dake M.D.
        Iliofemoral deep venous thrombosis: aggressive therapy with catheter-directed thrombolysis.
        Radiology. 1994; 191: 487-494
        • Vedantham S.
        • Thorpe P.E.
        • Cardella J.F.
        • et al.
        Quality improvement guidelines for the treatment of lower extremity deep venous thrombosis with use of endovascular thrombus removal.
        J Vasc Interv Radiol. 2006; 17: 435-448
        • Porter J.M.
        • Rutherford R.B.
        • Clagett G.P.
        • et al.
        Reporting standards in venous disease.
        J Vasc Surg. 1988; 8: 172-181
        • Bookstein J.J.
        • Fellmeth B.
        • Roberts A.
        • Valji K.
        • Davis G.
        • Machado T.
        Pulsed-spray pharmacomechanical thrombolysis: preliminary clinical results.
        AJR Am J Roentgenol. 1989; 152: 1097-1100
        • Patel N.
        • Sacks D.
        • Patel R.I.
        • et al.
        SIR reporting standards for the treatment of acute limb ischemia with use of transluminal removal of arterial thrombus.
        J Vasc Interv Radiol. 2003; 14: S453-S465
        • Kahn S.R.
        • Partsch H.
        • Vedantham S.
        • et al.
        Definition of post-thrombotic syndrome in the leg for use in clinical investigations: a recommendation for standardization.
        J Thromb Haemost. 2009; 7: 879-883
        • Patel N.H.
        • Plorde J.J.
        • Meissner M.
        Catheter-directed thrombolysis in the treatment of phlegmasia cerulea dolens.
        Ann Vasc Surg. 1998; 12: 471-475
        • Robinson D.L.
        • Teitelbaum G.P.
        Phlegmasia cerulea dolens: treatment by pulse-spray and infusion thrombolysis.
        AJR Am J Roentgenol. 1993; 160: 1288-1290
        • Weaver F.A.
        • Meacham P.W.
        • Adkins R.B.
        • Dean R.H.
        Phlegmasia cerulea dolens: therapeutic considerations.
        South Med J. 1988; 81: 306-312
        • Ginsberg J.S.
        • Hirsh J.
        • Julian J.
        • et al.
        Prevention and treatment of postphlebitic syndrome: results of a 3-part study.
        Arch Intern Med. 2001; 16: 2105-2109
        • Douketis J.D.
        • Crowther M.A.
        • Foster G.A.
        • Ginsberg J.S.
        Does the location of thrombosis determine the risk of disease recurrence in patients with proximal deep vein thrombosis?.
        Am J Med. 2001; 110: 515-519
        • Kahn S.R.
        • Shrier I.
        • Julian J.A.
        • et al.
        Determinants and time course of the postthrombotic syndrome after acute deep venous thrombosis.
        Ann Intern Med. 2008; 149: 698-707
        • Kahn S.R.
        • Shbaklo H.
        • Lamping D.L.
        • et al.
        Determinants of health-related quality of life during the 2 years following deep vein thrombosis.
        J Thromb Haemost. 2008; 6: 1105-1112
        • Delis K.T.
        • Bountouroglou D.
        • Mansfield A.O.
        Venous claudication in iliofemoral thrombosis: long-term effects on venous hemodynamics, clinical status, and quality of life.
        Ann Surg. 2004; 239: 118-126
        • Mewissen M.W.
        • Seabrook G.R.
        • Meissner M.H.
        • Cynamon J.
        • Labropoulos N.
        • Haughton S.H.
        Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry.
        Radiology. 1999; 211: 39-49
        • Vedantham S.
        • Millward S.F.
        • Cardella J.F.
        • et al.
        Society of Interventional Radiology Position Statement: Treatment of acute iliofemoral deep vein thrombosis with use of adjunctive catheter-directed intrathrombus thrombolysis.
        J Vasc Interv Radiol. 2006; 17: 613-616
        • Jaff M.R.
        • McMurtry M.S.
        • Archer S.L.
        • et al.
        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. 2011; 123: 1788-1830
        • Kuki S.
        • Taketani S.
        • Matsumura R.
        • et al.
        Acute Budd-Chiari syndrome due to inferior vena cava occlusion following blunt trauma.
        Thorac Cardiovasc Surg. 1995; 43: 227-229
        • Enden T.
        • Haig Y.
        • Klow N.
        • et al.
        Long-term outcomes after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial.
        Lancet. 2012; 379: 31-38
        • Haig Y.
        • Enden T.
        • Slagsvold C.
        • et al.
        Determinants of early and long-term efficacy of catheter-directed thrombolysis in proximal deep vein thrombosis.
        J Vasc Interv Radiol. 2013; 24: 17-24
        • Grewal N.K.
        • Martinez J.T.
        • Andrews L.
        • Comerota A.J.
        Quantity of clot lysed after catheter-directed thrombolysis for iliofemoral deep venous thrombosis correlates with postthrombotic morbidity.
        J Vasc Surg. 2010; 51: 1209-1214
        • Comerota A.J.
        • Grewal N.
        • Martinez J.T.
        • et al.
        Postthrombotic morbidity correlates with residual thrombus following catheter-directed thrombolysis for iliofemoral deep vein thrombosis.
        J Vasc Surg. 2012; 55: 768-773
        • Vedantham S.
        • Goldhaber S.Z.
        • Kahn S.R.
        • et al.
        Rationale and design of the ATTRACT Study: a multicenter randomized trial to evaluate pharmacomechanical catheter-directed thrombolysis for the prevention of postthrombotic syndrome in patients with proximal deep vein thrombosis.
        Am Heart J. 2013; 165: 523-553
        • Grunwald M.R.
        • Hofmann L.V.
        Comparison of urokinase, alteplase, and reteplase for catheter-directed thrombolysis of deep venous thrombosis.
        J Vasc Interv Radiol. 2004; 15: 347-352
        • Jackson L.
        • Wang X.
        • Dudrick S.J.
        • et al.
        Catheter-directed thrombolysis and/or thrombectomy with selective endovascular stenting as alternatives to systemic anticoagulation for treatment of acute deep vein thrombosis.
        Am J Surg. 2005; 190: 871-876
        • Sillesen H.
        • Just S.
        • Jorgensen M.
        • et al.
        Catheter directed thrombolysis for treatment of ilio-femoral deep venous thrombosis is durable, preserves venous valve function and may prevent chronic venous insufficiency.
        Eur J Vasc Endovasc Surg. 2005; 30: 556-562
        • Lin P.H.
        • Zhou W.
        • Dardik A.
        • et al.
        Catheter-direct thrombolysis versus pharmacomechanical thrombectomy of symptomatic lower extremity deep venous thrombosis.
        Am J Surg. 2006; 192: 782-788
        • Kim H.S.
        • Patra A.
        • Paxton B.E.
        • et al.
        Adjunctive percutaneous mechanical thrombectomy for lower-extremity deep vein thrombosis: clinical and economic outcomes.
        J Vasc Interv Radiol. 2006; 17: 1099-1104
        • Yamada N.
        • Ishikura S.
        • Ota A.
        • et al.
        Pulse-spray pharmacomechanical thrombolysis for proximal deep vein thrombosis.
        Eur J Vasc Endovasc Surg. 2006; 31: 204-211
        • Casella I.B.
        • Presti C.
        • Aun R.
        • et al.
        Late results of catheter-directed recombinant tissue plasminogen activator fibrinolytic therapy of iliofemoral deep venous thrombosis.
        Clinics (Sao Paulo). 2007; 62: 31-40
        • Protack C.D.
        • Bakken A.M.
        • Patel N.
        • et al.
        Long-term outcomes of catheter directed thrombolysis for lower extremity deep venous thrombosis without prophylactic inferior vena cava filter placement.
        J Vasc Surg. 2007; 45: 992-997
        • Park Y.J.
        • Choi J.Y.
        • Min S.K.
        • et al.
        Restoration of patency in iliofemoral deep vein thrombosis with catheter-directed thrombolysis does not always prevent post-thrombotic damage.
        Eur J Vasc Endovasc Surg. 2008; 36: 725-730
        • Kolbel T.
        • Alhadad A.
        • Acosta S.
        • et al.
        Thrombus embolization into IVC filters during catheter-directed thrombolysis for proximal deep venous thrombosis.
        J Endovasc Ther. 2008; 15: 605-613
        • Parikh S.
        • Motarjeme A.
        • McNamara T.
        • et al.
        Ultrasound-accelerated thrombolysis for the treatment of deep vein thrombosis: initial clinical experience.
        J Vasc Interv Radiol. 2008; 19: 521-528
        • Rao A.S.
        • Konig G.
        • Leers S.A.
        • et al.
        Pharmacomechanical thrombectomy for iliofemoral deep vein thrombosis: an alternative in patients with contraindications to thrombolysis.
        J Vasc Surg. 2009; 50: 1092-1098
        • Jeon Y.S.
        • Yoon Y.H.
        • Cho J.Y.
        • et al.
        Catheter-directed thrombolysis with conventional aspiration thrombectomy for lower extremity deep vein thrombosis.
        Yonsei Med J. 2010; 51: 197-201
        • Sharifi M.
        • Mehdipour M.
        • Bay C.
        • et al.
        Endovenous therapy for deep venous thrombosis: the TORPEDO trial.
        Cathet Cardiovasc Interv. 2010; 76: 316-325
        • Murphy E.H.
        • Broker H.S.
        • Johnson E.J.
        • et al.
        Device and imaging-specific volumetric analysis of clot lysis after percutaneous mechanical thrombectomy for iliofemoral DVT.
        J Endovasc Ther. 2010; 17: 423-433
        • Kim B.J.
        • Chung H.H.
        • Lee S.H.
        • et al.
        Single-session endovascular treatment for symptomatic lower extremity deep vein thrombosis: a feasibility study.
        Acta Radiol. 2010; 51: 248-255
        • Ghanima W.
        • Kleven W.
        • Enden T.
        • et al.
        Recurrent venous thrombosis, post-thrombotic syndrome and quality of life after catheter-directed thrombolysis in severe proximal deep venous thrombosis.
        J Thromb Haemost. 2011; 9: 1261-1263
        • Gao B.
        • Zhang J.
        • Wu X.
        • et al.
        Catheter-directed thrombolysis with a continuous infusion of low-dose urokinase for non-acute deep venous thrombosis of the lower extremity.
        Korean J Radiol. 2011; 12: 97-106
        • Jeyabalan G.
        • Marone L.
        • Rhee R.
        • et al.
        Inflow thrombosis does not adversely affect thrombolysis outcomes of symptomatic iliofemoral deep vein thrombosis.
        J Vasc Surg. 2011; 54: 448-453
        • Chang R.
        • Horne III, M.K.
        • Shawker T.H.
        • et al.
        Low-dose, once-daily, intraclot injections of alteplase for treatment of acute deep venous thrombosis.
        J Vasc Interv Radiol. 2011; 22: 1107-1116
        • Manninen H.
        • Juutilainen A.
        • Kaukanen E.
        • et al.
        Catheter-directed thrombolysis of proximal lower extremity deep vein thrombosis: a prospective trial with venographic and clinical follow-up.
        Eur J Radiol. 2012; 81: 1197-1202
        • Baker R.
        • Samuels S.
        • Benenati J.F.
        • et al.
        Ultrasound-accelerated vs standard catheter-directed thrombolysis—a comparative study in patients with iliofemoral deep vein thrombosis.
        J Vasc Interv Radiol. 2012; 23: 1460-1466
        • Aziz F.
        • Comerota A.J.
        Quantity of residual thrombus after successful catheter-directed thrombolysis for iliofemoral deep venous thrombosis correlates with recurrence.
        Eur J Vasc Endovasc Surg. 2012; 44: 210-213
        • Oguzkurt L.
        • Ozkan U.
        • Gulcan O.
        • et al.
        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. 2012; 18: 410-416
        • Baekgaard N.
        • Broholm R.
        • Just S.
        • et al.
        Long-term results using catheter-directed thrombolysis in 103 lower limbs with acute iliofemoral venous thrombosis.
        Eur J Vasc Endovasc Surg. 2010; 39: 112-117
        • Jorgensen M.
        • Broholm R.
        • Baekgaard N.
        Pregnancy after catheter-directed thrombolysis for acute iliofemoral deep venous thrombosis.
        Phlebology. 2013; 28: 34-38
        • Sharifi M.
        • Bay C.
        • Nowroozi S.
        • Bentz S.
        • Valeros G.
        • Memari S.
        Catheter-directed thrombolysis with argatroban and tPA for massive iliac and femoropopliteal vein thrombosis.
        Cardiovasc Intervent Radiol. 2013; 36: 1586-1590
        • Schwieder G.
        • Grimm W.
        • Siemens H.J.
        • et al.
        Intermittent regional therapy with rt-PA is not superior to systemic thrombolysis in deep vein thrombosis (DVT)—a German multicenter trial.
        Thromb Haemost. 1995; 74: 1240-1243
        • Mickley V.
        • Schwagierek R.
        • Rilinger N.
        • Gorich J.
        • Sunder-Plassman L.
        Left iliac venous thrombosis caused by venous spur: treatment with thrombectomy and stent implantation.
        J Vasc Surg. 1998; 28: 492-497
        • May R.
        • Thurner J.
        The cause of the predominantly sinistral occurrence of thrombus of the pelvic veins.
        Angiology. 1957; 8: 419-427
        • Kearon C.
        • Akl E.A.
        • Comerota A.J.
        • et al.
        Antithrombotic therapy for VTE disease. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
        Chest. 2012; 141: e419S-e494S
        • Brandjes D.P.
        • Buller H.R.
        • Heijboer H.
        • et al.
        Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis.
        Lancet. 1997; 349: 759-762
        • Prandoni P.
        • Lensing A.W.
        • Prins M.H.
        • et al.
        Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial.
        Ann Intern Med. 2004; 141: 249-256
        • Kahn S.R.
        • Shbaklo H.
        • Shapiro S.
        • et al.
        Effectiveness of compression stockings to prevent the post-thrombotic syndrome (the SOX Trial and Bio-SOX biomarker substudy): a randomized controlled trial.
        BMC Cardiovasc Disord. 2007; 7: 21
        • The STILE Investigators
        Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity. The STILE trial.
        Ann Surg. 1994; 220 (251–166)
        • Uflacker R.
        Mechanical thrombectomy in acute and subacute thrombosis with use of the Amplatz device: arterial and venous applications.
        J Vasc Interv Radiol. 1997; 8: 923-932
        • Delomez M.
        • Beregi J.
        • Willoteaux S.
        • et al.
        Mechanical thrombectomy in patients with deep venous thrombosis.
        Cardiovasc Intervent Radiol. 2001; 24: 42-48
        • Sharifi M.
        • Bay C.
        • Skrocki L.
        • et al.
        Role of IVC filters in endovenous therapy for deep venous thrombosis: the FILTER-PEVI (filter implantation to lower thromboembolic risk in percutaneous endovenous intervention) trial.
        Cardiovasc Intervent Radiol. 2012; 35: 1408-1413
        • Decousus H.
        • Leizorovicz A.
        • Parent F.
        • et al.
        A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis.
        N Engl J Med. 1998; 338: 409-416
        • Imanaka S.
        • Aihara S.
        • Yoshihara K.
        • Kato A.
        • Matsumoto K.
        • Kudo S.
        Use of a temporary caval filter in a young man with pulmonary embolism to prevent migration of massive caval thrombus during an attempt of caval thrombolysis.
        J Atheroscler Thromb. 2000; 6: 18-21