Deep Vein Thrombosis, treated with Angiojet Percutaneous Mechanical Thrombectomy (PMT): A Case Report
Parimala
Clinical Instructor, Kauvery Hospital, Chennai, Tamilnadu, India
Abstract
Deep vein thrombosis (DVT) is an obstructive disease hindering venous flow dynamics. It usually involves the venous systems of the lower limbs resulting in clots formation, originating in deep calf veins. Venous thrombosis occurs in areas of the legs with decreased or mechanically altered blood flow in the deep veins that are potential locations for venous stasis and hypoxia.
The mechanisms underlying deep venous thrombosis is interaction between inflammation and hemostasis. It has been described that the alteration of venous blood flow produces endothelial activation, adhesion of platelets and contribute to the activation of coagulation.
Virchow’s Triad, was established in 1856, and implicates three contributing factors in the formation of thrombosis: venous stasis, vascular injury, and hypercoagulability.
The deep venous thrombosis is commonly triggered by the interaction between acquired risk factors, such as hip fracture, surgery or trauma, malignancy, pregnancy, immobility, obesity, advancing age and hereditary conditions. The cardinal signs and symptoms of DVT include asymmetrical swelling, warmth, and pain in an extremity and venous ulcers.
Background
Deep vein thrombosis (DVT), with a subset of venous thromboembolism (VTE), is a major preventable cause of morbidity and mortality worldwide. The prevalence of VTE is estimated to be 1 per 1,000 people affecting with DVT annually.
National center for biotechnology information, 2022 stated that DVT affects more than 200,000 people in the United States in which 50,000 cases are complicated by pulmonary embolism.
The prospective study to assess the prevalence of risk factors for venous thromboembolism among pregnant women in Hyderabad, Telangana, India included 200 antenatal and postnatal women, and used a pragmatic approach. The study concluded that 20% of pregnant women had intermediate risk factors- immobility, ovarian hyperstimulation syndrome( OHSS), medical comorbidities, and surgical procedures- and 20% had low-risk factors. In the study, approximately 80 women (40%) had significant risk factors for the development of VTE during pregnancy and postpartum period.
Case Presentation
A female patient, 30 years of age, was admitted with the complaints of left lower limb swelling and pain for 2 days. She had undergone LSCS one month earlier. On physical examination there was oedema and redness from the groin region to left lower limb and in addition there was
tenderness of calf muscle. D-dimer was elevated, and so was fibrinogen levels.
In CT venogram, hypoechoic thrombus was found in the common femoral vein and it was extending into the external iliac and common iliac veins, up to the infrarenal IVC, with no flow. Hence the patient was diagnosed with Post-Partum DVT (Left iliofemoral DVT with IVC extension and right CIV extension).
A surgical procedure, IVC filter deployment and Angiojet Percutaneous Mechanical Thrombectomy (PMT) was planned and done. Post operatively she was under treatment of heparin and Altepase infusion and during discharge she was advised with Low Molecular Weight Heparins (LMWH) and other supportive measures. Patient’s condition was improved symptomatically and clinically stable.
On clinical assessment
| Temperature | Pulse | Respiration | Blood pressure | SPO2 |
| 98.6 F | 112/min | 20/min | 110/60 mmHg | 98% |
Lower Limb Examination
| Right leg |
|
| Left leg |
|
Investigation Reports
| Date | Investigation | Report |
| 11/02/23 | CBC | HB-9.1 g/dl |
| WBC-14300 Cells/cumm | ||
| Platelet count – 360000 Cells/cumm | ||
| ESR – 30 | ||
| RFT | Urea – 13.2 mg/dl | |
| Creatinine- 0.62 mg/dl | ||
| Sodium – 141 mmol/L | ||
| Potassium – 4.64 mmol/L | ||
| Chloride – 107.5 mmol/L | ||
| Bicarbonate – 18.1 mmol/L | ||
| LFT | All the parameters in normal range | |
| Homocysteine | 7.4 mmol/L | |
| D-Dimer | 2690 ng/ml | |
| Fibrinogen | 366 mg/dl |
Drug Chart
| Empirical treatment | ||
| S.No | Drug name | Dose/Frequency |
| 1 | Inj.Supacef | 1.5gm/BD |
| 2 | Inj.Para | 1gm/BD |
| 3 | Inj.Clexane | 0.6ml/BD |
| Surgical treatment | ||
| 1 | Inj.Heparin | 600 units/hr |
| 2 | Inj.Alteplase | 7ml/hr |
| Follow up treatment | ||
| 1 | Inj.Fondared | 7.5mg/OD |
| 2 | Tab.Acitrom | 4mg /OD |
| 3 | Tab.Livogen | One/OD |
| 4 | Tb.Homochek | One /OD |
Nursing Care
- Advised the patient to avoid green leafy vegetables and extra salt in the food items.
- Advised the patient to take medications regularly
- Educated the patient to avoid putting constant pressure on the posterior region of knee.
- Advised that, while sitting in a car or bus, wiggle the toes, tighten and relax the calf muscles, and shift position often.
- Educated about personal care and hygienic measures
Discussion
The risk of pregnancy-related VTE increases due to a prothrombotic state in pregnancy, blood flow stagnation, and vascular traumas during delivery, particularly with assistive devices and cesarean section.
To prevent of VTE in peripartum patients with the above-mentioned risk factors they should be treated with anticoagulation therapy and it is an important standard treatment for DVT. This prevents new clot formation and reduces the risk of recurrent venous thromboembolism.
Conclusion
The risk of VTE increases during peripartum period and the best course of treatment for DVT patients is thrombectomy. This procedure has multiple benefits like, it can restore venous patency, recurrence of DVT, alleviate post-traumatic stress, and prevents pulmonary embolism.
The prevalence of DVT among pregnant women is low (<3%) but thromboembolic complications can occur. LMWH is frequently used as a thromboprophylaxis agent.
References
- Stone J., et al. Deep vein thrombosis: pathogenesis, diagnosis, and medical management. Cardiovasc Diagn Ther. 2017;7(Suppl 3):S276-S284.
- Navarrete S., et al. Pathophysiology of deep vein thrombosis. Clin Exp Med. 2022.
- Lu ZX., et al. Safety and Efficacy of Endovascular Treatment on Pregnancy-Related Iliofemoral Deep Vein Thrombosis. Clin Appl Thromb Hemost. 2022;28.
- Waheed SM, et al. Deep Vein Thrombosis. [Updated 2022 Nov 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK507708/
- Varre H., et al. Prevalence of venous thromboembolism risk factors in pregnant women. Indian J Vasc Endovasc Surg. 2020;7(3):225.