Hybrid operative thrombectomy is non-inferior to percutaneous techniques for acute iliofemoral deep vein thrombosis treatment

Limael Rodriguez

Hybrid operative thrombectomy achieves complete thrombus resolution in one operating room trip which results in reduced length of stay, bleeding complications and transfusions when compared with percutaneous treatments that use thrombolytic therapy. This can be achieved without sacrificing successful clinical or duplex results, according to data presented at the American Venous Forum (AVF; 24–26 February, Orlando, USA).

Hybrid operative thrombectomy is a novel technique for the treatment of acute iliofemoral deep vein thrombosis. All components of the technique are employed through a single femoral venotomy (single incision), with retrograde manipulation to the distal vein segments and avoidance of arteriovenous fistula as the major distinguishing factors from contemporary operative approaches. The technique was developed by Jorge Martinez-Trabal, who is the senior author in the study.

Limael Rodriguez, St. Luke’s Memorial Hospital, Ponce, Puerto Rico, USA, told AVF delegates that “Although the best treatment for thrombus removal remains unclear, hybrid operative thrombectomy definitely has fewer major bleeding events when compared with thrombolytic infusion.”

“Techniques for deep vein thrombus removal have gained favour over the past 10–15 years,” Rodriguez said, “which is directly related to better techniques, better technology, and overall better skills, as well as a better understanding of the pathophysiology of the disease.”

There are two treatment methods that can be employed. The first are percutaneous techniques which in general encompass the use of thrombolytic infusion. This is most commonly achieved with catheter-directed thrombolysis, with or without (±) the addition of pharmaco-mechanical thrombectomy via a device. The second option is a mechanical thrombectomy via an operative approach, which avoids thrombolytic infusion.

Rodriguez and colleagues’ cross-sectional study enrolled 71 patients with acute/subacute iliofemoral deep vein thrombosis in a single limb. Patients were treated with either the hybrid operative thrombectomy ± balloon angioplasty and/or stent (n=40) or catheter-directed thrombolysis ± pharmacomechanical thrombectomy (n=31). The demographics of the two groups were similar in terms of gender, body mass index and deep vein thrombosis site, although they differed in age (hybrid operative thrombectomy group 56.5±16.1 years, percutaneous group 49.5±16.5 years).

Perioperative outcomes, technical success (>50% thrombus resolution), and thrombus resolution (partial vs. complete) were analysed between the two treatment groups. CEAP classification, Villalta score and venous duplex at intermediate follow-up were also analysed.

Rodriguez et al found that the left limb was the most common site of the deep vein thrombosis in both groups. Technical success was 100% in both groups, and at least 80% thrombus resolution in all patients treated with the hybrid operative technique. There was a trend towards a greater postoperative percentage drop in haemoglobin in the percutaneous treatment group (17% vs. 23%, p=0.07) which almost reached statistical significance. Percutaneous treatment patients were transfused more PRBC units postoperatively than the hybrid operative patients (p=0.07) and had a significantly longer length of stay (10 vs. 13.3 days, p=0.05) when compared to the hybrid operative group. Major bleeding complications (3 vs 8 events, p=0.04) where more common in the percutaneous group. At intermediate follow-up there was no difference between the two groups in mean reflux times (1.56 vs. 1.51 seconds, p=0.81) at the femoral-popliteal segment. At a mean follow-up time of 1.5 years the clinical CEAP classification at the surgical limb was 3 or less in the majority of patients in both groups.

“In our experience, percutaneous technique and the hybrid operative technique have demonstrated very good outcomes in the perioperative and intermediate periods,” Rodriguez explained. “The hybrid operative approach is non-inferior to a percutaneous approach as a technique for early thrombus removal, and has the advantage that thrombolytic therapy is not required, thrombus resolution is established in one operation, and length of stay is significantly decreased.” Rodriguez was awarded the 2016 Servier Traveling Fellowship for best study by a resident or fellow at the AVF, and will present the study at the European Venous Forum (7–9 July, London, UK).