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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 16  |  Issue : 4  |  Page : 447-450

Pharmacomechanical aspiration thrombectomy of iliofemoral deep venous thrombosis to salvage the transplanted kidney - A case report


1 Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission01-Feb-2022
Date of Acceptance05-Sep-2022
Date of Web Publication30-Dec-2022

Correspondence Address:
Dr. Sarbpreet Singh
Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research, Nehru Building, Sector-12, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_16_22

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  Abstract 


Ipsilateral acute iliofemoral deep venous thrombosis (DVT) after a renal transplantation, although rare, has a high morbidity, causing complications such as allograft failure, rupture, or death. Treatment modalities are limited due to the risk of bleeding and impaired renal function. We report successful treatment of a case of iliofemoral DVT in a 58-year-old male recipient of a living donor renal transplantation. The immediate postoperative course of the patient was uneventful, and he was discharged on 6th postoperative day (POD) with serum creatinine of 0.8 mg/dl. On POD 26, the patient was admitted with diarrhea, dehydration, and decreased urine output. His serum creatinine rose from 0.8 mg/dl to 2.6 mg/dl and he developed pain and swelling of the right lower extremity. Duplex ultrasonography was suggestive of acute DVT with noncompressible right distal external iliac vein, common femoral, superficial femoral and popliteal veins, absence of color flow from the right femoral vein to the common iliac vein, dilatation of allograft renal vein and an increased renal graft resistive index of 0.97. After inferior vena cava filter insertion, initial treatment with percutaneous balloon angioplasty and catheter-directed thrombolysis could not restore blood flow. Subsequently, percutaneous transluminal pharmacomechanical aspiration was performed with complete removal of the thrombus leading to restored renal allograft vein patency and normalization of allograft function and Duplex findings.

Keywords: DVT, percutaneous aspiration thrombectomy (pharmacomechanical aspiration thrombectomy-angiojet®), renal vein thrombosis


How to cite this article:
Patil SS, Sharma A, Kenwar DB, Vijayvergiya R, Singh S. Pharmacomechanical aspiration thrombectomy of iliofemoral deep venous thrombosis to salvage the transplanted kidney - A case report. Indian J Transplant 2022;16:447-50

How to cite this URL:
Patil SS, Sharma A, Kenwar DB, Vijayvergiya R, Singh S. Pharmacomechanical aspiration thrombectomy of iliofemoral deep venous thrombosis to salvage the transplanted kidney - A case report. Indian J Transplant [serial online] 2022 [cited 2023 Feb 3];16:447-50. Available from: https://www.ijtonline.in/text.asp?2022/16/4/447/364613




  Introduction Top


Deep venous thrombosis (DVT) is a major medical problem with an estimated incidence of approximately 1 per 1000 persons each year. Major complications of DVT include pulmonary embolism (PE), pulmonary hypertension, and long-term sequelae of chronic venous insufficiency of the lower extremities. Ipsilateral DVT in a kidney transplantation recipient, in addition to these complications, can cause devastating results such as allograft loss, rupture, and mortality.[1] Renal vein thrombosis (RVT) is a rare but serious complication of renal transplantation, which often causes graft loss. Sudden onset anuria with tenderness over the graft site is the clinical manifestations.[2] RVT is confirmed with a Doppler ultrasound. Recently, many reports showed successful results with percutaneous thrombectomy in combination with anticoagulant or thrombolytic therapy. Success is variable and is improved with early diagnosis and institution of treatment.[3]

Right ventricular thrombosis can be categorized as early, which is defined as occurring within the first 2 weeks with an incidence of approximately 0.4%–6%, or late, occurring after 2 weeks' posttransplant with an incidence of 0.5%–4%.[4] The most common causes of RVT include technical errors, kinking of the renal vein, stenosis at the site of anastomosis, hypovolemia causing diminished flow or intrinsic renal allograft vasculopathy, and postoperative hypercoagulability. The modalities of diagnosis and treatment of this serious complication are limited due to the risk of bleeding and impaired renal function.[5] In this article, we are reporting a case of ipsilateral acute iliofemoral DVT extending into renal vein that developed after severe diarrhea with dehydration and was successfully treated with percutaneous transluminal thrombus aspiration using an Angiojet, 8 French (F) mechanical thrombectomy catheter (AngioJet Zelante peripheral thrombectomy system, Boston Scientific, Natick, MA) under fluoroscopic guidance following a failed percutaneous angioplasty and catheter-directed thrombolysis (CDT). Pharmacomechanical aspiration thrombectomy (PMAT) using AngioJet endoluminal device restored venous patency and, normalization of the allograft function.


  Case Report Top


A 58-year-old male, with diabetic end-stage renal disease of 5 years' duration, underwent living donor kidney transplantation from his brother. Complement-dependent cytotoxicity crossmatch and flow cytometry crossmatch were all negative. The left kidney was transplanted into the right iliac fossa. The donor renal artery was anastomosed end to end to the recipient's internal iliac artery, and the renal vein was anastomosed end to side to the external iliac vein. On declamping, kidney reperfusion and urinary output were good. The patient was on triple immunosuppressive therapy with tacrolimus, mycophenolate mofetil, and prednisolone. The early postoperative course was uneventful with good graft function, and the patient was discharged on 6th postoperative day (POD) with serum creatinine of 0.8 mg/dl. Duplex ultrasonography of the allograft at the time of discharge showed good global vascularity and resistive index of 0.7. On the 26th POD, the patient presented with severe diarrhea, dehydration, and decreased urine output. On admission, his creatinine was 0.8 mg/dl. Two days after admission, the patient complained of swelling and pain in his right lower limb and his creatinine rose to 2.6 mg/dl along with decreasing urine output. Duplex ultrasonography showed noncompressibility of right distal external iliac vein, common femoral, superficial femoral, and popliteal veins suggestive of acute DVT with associated dilatation of renal allograft vein and absence of flow on Doppler ultrasound.

A venogram through right transpopliteal venous access showed thrombotic occlusion of the right iliofemoral venous system [Figure 1]a. An inferior vena cava (IVC) filter was placed through left femoral vein access. Following balloon angioplasty [Figure 1]b, there was partial resolution in thrombus occlusion [Figure 1]c. CDT with streptokinase (100,000 U/h) was started through right popliteal vein access. Following 36 h of thrombolysis there was a partial improvement in thrombus load [Figure 2]a; however, flow across the thrombosed segment could not be achieved. Pharmacomechanical thrombectomy of iliac vein and IVC thrombus was performed using 8 Fr AngioJet catheter (AngioJet Zelante system, Boston Scientific, Natick, MA). Following thrombectomy, the flow was restored and thrombus load reduced in the venous system [Figure 2]b and [Figure 2]c. Warfarin was started postthrombectomy targeting an INR of 2.5. Subsequently, serum creatinine reduced to 1.4 mg/dl after 1 week. A check angiogram at 6 weeks [Figure 3] showed normal flow across the right iliac vein [Figure 3]a and IVC, without any residual thrombus, and absence of any trapped thrombus at the IVC filter [Figure 3]b. The allograft renal artery was normal [Figure 3]c.
Figure 1: A venogram through right trans-popliteal venous access showed thrombotic occlusion of the right iliofemoral venous system. (a) An inferior vena cava filter was placed via left femoral vein access. Following balloon angioplasty. (b) There was partial resolution in thrombus occlusion (c)

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Figure 2: Following 36 h of thrombolysis there was partial improvement in thrombus load. (a) Following thrombectomy, the flow was restored and thrombus load reduced in the venous system (b and c)

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Figure 3: Showed normal flow across the right iliac vein. (a) And inferior vena cava, (b) without any residual thrombus, and absence of any trapped thrombus at the IVC filter. (b) The allograft renal artery was normal (c). IVC: Inferior vena cava

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After 18 months of follow-up, the serum creatinine is 0.8 mg/dL and there are no complications of DVT. Renal graft Doppler showed good transplant kidney blood flow [Figure 4]a. Duplex USG showed patent allograft renal vein [Figure 4]b, and femoral vein [Figure 4]c.
Figure 4: Renal graft doppler showed good transplant kidney blood flow. (a) Duplex USG showed patent allograft renal vein, (b) and femoral vein (c). USG: Ultrasonography

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  Discussion Top


Acute deep venous thrombosis (DVT) is a major cause of morbidity and mortality, affecting about 1 in 1000 adults every year. The lower extremities are most commonly involved, affecting the iliac veins, femoral veins, and rarely the vena cava. The Iliofemoral and central DVTs pose a higher risk of life-threatening PE, which is seen in up to 10%–25% of patients with DVT. Such complications and clinical deterioration can be avoided by early diagnosis and treatment of iliofemoral and central DVT.[1]

DVT in a kidney transplant recipient is rare but can be a devastating complication as it can cause allograft loss, rupture, and death in addition to the risk of pulmonary thromboembolism. The incidence of RVT ranges from 0.5% to 4% and this complication usually results in graft loss. Early detection and treatment are paramount to prevent graft loss.[2] The classical presentation of renal venous thrombosis is a swollen tender graft with hematuria, whereas the arterial thrombosis presents with a sudden drop in urine output. Severe rejections may cause intrarenal vessel thrombosis. More commonly, the thrombotic event occurs in the first 10 days after transplant, and in 93% of the cases, it occurs within 7 days. Although arterial thrombosis occurs later than venous thrombosis occasionally venous thrombosis presents as a late complication. The common causes of RVT include technical errors, kinking of the renal vein, hypovolemia causing diminished flow, or postoperative hypercoagulability. In the present case, the DVT developed after severe diarrhea and dehydration.[6]

When there is a clinical suspicion of transplant RVT, timely imaging must be performed. Duplex ultrasonography has proven to be an excellent modality for imaging in such cases due to its portability, wide availability, relative ease of use, and decades of validated experience.[7]

Venous thrombosis of the renal allograft can be treated by any of the two strategies available: thrombolytic therapy and surgical thrombectomy. The surgical management of vascular complications must include emergency surgical exploration of the allograft.[8] Successful emergency surgical thrombectomy has been reported in the early posttransplant period. There are a few case reports of early surgical thrombectomy within 2 h of thrombosis, which can result in reversal of the renal allograft function. The rationale is that emergency surgical intervention helps in the rapid removal of the thrombus and prevent bleeding complications seen in thrombolytic therapy.[9] Surgical interventions can facilitate better evaluation of the cause of thrombosis. This allows the correction of technical complicatio ared to surgical interventions, the angiographic percutaneous techniques are preferred as surgical thrombectomy has risks associated with anesthesia and postoperative infection in an immunosuppressed state.[8]

The treatment of iliofemoral DVT depends on the clot burden and clinical condition of the patient. The percutaneous interventions such as PMAT and percutaneous transluminal angioplasty are preferred for patients in whom there is concern that anticoagulation alone may not resolve the DVT.[10] However, there are risks of bleeding and hemolysis in CDT and PMAT, respectively. While CDT is highly effective in the treatment of acute iliofemoral or central DVT and commonly used, bleeding complications have been reported.[11] Thrombus aspiration by PMAT devices obviates thrombolysis thereby reducing the risk of bleeding. Our patient was initially treated with balloon angioplasty following which there was a partial reduction in thrombus load but flow could not be established even after 36 h of CDT. Subsequently, PMAT was done using AngioJet under C-arm guidance. Postprocedure, there were complete resolution of thrombus and reestablishment of blood flow across the affected segment. Serum creatinine decreased from 2.6 mg/dl to 1.4 mg/dl. The patient remained under follow-up and at 18 months' postprocedure, has a stable serum creatinine of 1 mg/dl with normal renal graft Doppler parameters and venous patency.

PMAT (Angiojet)® a rheological mechanical thrombectomy device, creates a low-pressure zone around the catheter using the luminal high-speed flow of liquids. The negative suction created, draws the targeted thrombus into the catheter and is impinged on by a high-speed flow of water and hence removed from the body. The thrombus burden is quickly reduced by this device relieving the clinical symptoms and thereby reducing the risk of bleeding, duration of hospital stay, and overall cost of treatment. AngioJet has been widely employed for the treatment of peripheral venous thrombosis and its reliability and safety have been clinically approved. Bush et al. used AngioJet to treat 23 patients with acute DVT and reported complete clearance in 65% of patients with no serious complications.[12]


  Conclusion Top


The use of PMAT (Angiojet)® helps in complete removal of the thrombus load in when conventional or CDT prove to be inadequate. In the postrenal transplant, the patient with acute iliofemoral DVT, PMAT has proved to be a useful tool in the restoration of blood flow in the affected veins helping to maintain renal allograft vein patency and normalization of allograft function.

Declaration of patient consent

The authors certify that patient consent has been taken for participation in the study and for publication of clinical details and images. The patient understands that the names, initials would not be published, and all standard protocols will be followed to conceal their identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Thomas M, Hollingsworth A, Mofidi R. Endovascular management of acute lower limb deep vein thrombosis: A systematic review and meta-analysis. Ann Vasc Surg 2019;58:363-70.  Back to cited text no. 1
    
2.
Pillot P, Bardonnaud N, Lillaz J, Delorme G, Chabannes E, Bernardini S, et al. Risk factors for surgical complications after renal transplantation and impact on patient and graft survival. Transplant Proc 2012;44:2803-8.  Back to cited text no. 2
    
3.
Rerolle JP, Antoine C, Raynaud A, Beyssen B, Julia P, Duboust A, et al. Successful endoluminal thrombo-aspiration of renal graft venous thrombosis. Transpl Int 2000;13:82-6.  Back to cited text no. 3
    
4.
Ripert T, Menard J, Schoepen Y, Nguyen P, Rieu P, Staerman F. Preventing graft thrombosis after renal transplantation: A multicenter survey of clinical practice. Transplant Proc 2009;41:4193-6.  Back to cited text no. 4
    
5.
Sadej P, Feld RI, Frank A. Transplant renal vein thrombosis: Role of preoperative and intraoperative doppler sonography. Am J Kidney Dis 2009;54:1167-70.  Back to cited text no. 5
    
6.
Penny MJ, Nankivell BJ, Disney AP, Byth K, Chapman JR. Renal graft thrombosis. A survey of 134 consecutive cases. Transplantation 1994;58:565-9.  Back to cited text no. 6
    
7.
Reuther G, Wanjura D, Bauer H. Acute renal vein thrombosis in renal allografts: Detection with duplex doppler US. Radiology 1989;170:557-8.  Back to cited text no. 7
    
8.
Harraz AM, Shokeir AA, Soliman SA, Osman Y, El-Hefnawy AS, Zahran MH, et al. Salvage of grafts with vascular thrombosis during live donor renal allotransplantation: A critical analysis of successful outcome. Int J Urol 2014;21:999-1004.  Back to cited text no. 8
    
9.
Renoult E, Cormier L, Claudon M, Cao-Huu T, Frimat L, Gaucher O, et al. Successful surgical thrombectomy of renal allograft vein thrombosis in the early postoperative period. Am J Kidney Dis 2000;35:E21.  Back to cited text no. 9
    
10.
Garcia MJ, Lookstein R, Malhotra R, Amin A, Blitz LR, Leung DA, et al. Endovascular management of deep vein thrombosis with rheolytic thrombectomy: Final report of the prospective multicenter PEARL (Peripheral use of angiojet rheolytic thrombectomy with a variety of catheter lengths) registry. J Vasc Interv Radiol 2015;26:777-85.  Back to cited text no. 10
    
11.
Kohi MP, Kohlbrenner R, Kolli KP, Lehrman E, Taylor AG, Fidelman N. Catheter directed interventions for acute deep vein thrombosis. Cardiovasc Diagn Ther 2016;6:599-611.  Back to cited text no. 11
    
12.
Bush RL, Lin PH, Bates JT, Mureebe L, Zhou W, Lumsden AB. Pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis: Safety and feasibility study. J Vasc Surg 2004;40:965-70.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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