Catheter-directed thrombolysis for the management of postpartum deep venous thrombosis

Catheter-directed thrombolysis that removes the thrombus and restores patency of the veins appears to be a safe and effective management of acute deep venous thrombosis (DVT). It has been shown to reduce long-term postthrombotic morbidity and improve the quality of life. Pregnancy and the postpartum period are generally considered as contraindications for thrombolysis. However, catheter-directed thrombolytic therapy of DVT may reduce long-term sequelae in these young patients by restoring the patency of veins. The purpose of this pilot study was to evaluate the efficacy of catheter-directed thrombolysis in treating acute symptomatic postpartum DVT.

Patients enrolled had symptomatic acute DVT (<3 weeks duration) within 42 days of childbirth. Thrombolysis was performed using a recombinant human tissue plasminogen activator, alteplase 5 mg i.v. bolus, followed by an infusion at 0.01 mg/kg/h for the next 20-24 hr. Unfractionated heparin 5000 IU bolus followed by 300 IU/kg/24 hr was infused concomitantly into an arm vein. Fibrinogen and cephotest were obtained every 6 hr and maintained at >1 g/l and between 50 and 70 s, respectively, by adjusting heparin and alteplase infusion. Venography was repeated after 20-24 hr and angioplasty (+/- stenting) was performed if stenosis was present. In case of partial thrombolysis infusion was continued for a maximum of 96 hr. Lysis was considered complete if there was less than 5% residual luminal area narrowing. The treatment was considered successful if there was complete or partial resolution of lower extremity pain and edema, and recanalization of vein with less than 30% residual luminal area narrowing. Following thrombolytic therapy, patients were fitted with graduated compression stockings, and anticoagulated with oral warfarin for 1 year (or lifelong in case of stent implantation).

Five women with postpartum DVT (four iliofemoral DVTs, and one renal and ovarian vein thrombosis on the left side) had catheter-directed thrombolysis. The treatment was successful in all four cases of iliofemoral DVT and symptom relief was achieved in all five cases. However, despite partial thrombolysis and restoration of some flow in the patient with renal and ovarian vein thrombosis, the renography performed 1 month later showed absent left kidney function.

Where expertise exists, endovascular therapy consisting of catheter-directed thrombolysis with angioplasty and stenting in selected cases could be considered as a primary therapeutic procedure in patients with acute postpartum DVT.