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Venous thromboembolism (VTE) is a major public health issue; deep vein thrombosis (DVT) affects about 1/1000 patients. Each year, VTE kills more patients in Western Europe than breast cancer, prostate cancer, acquired immune deficiency syndrome (AIDS) and road traffic accidents combined and is responsible for the deaths of approximately 370,000 European citizens (Cohen et al. in Thromb Haemost 98:756-764, 2007; Bĕlohlávek et al. in Exp Clin Cardiol 18(2):129-138, 2013). The recently published ATTRACT trial (Acute Venous Thrombosis Thrombus Removal with Adjunctive Catheter-directed Thrombolysis) (Vedantham et al. in N Engl J Med 377:2240-2252, 2017) concluded that the addition of catheter-directed thrombolysis to standard therapy with anticoagulation and compression stockings offers no significant clinical benefit over standard therapy in terms of reduction in the rate of post-thrombotic syndrome (PTS) at 2 years. It is the largest, prospective, multi-centre, randomised controlled trial (RCT) and represents the culmination over a decade of planning, execution and analysis. In this opinion article, we analyse why it was needed, what it demonstrated, some limitations, and the directions in which this important publication will take us.

Purpose: The purpose of this work was to describe the results of a technique of simultaneous antegrade and retrograde vascular access ("criss-cross") to the popliteal vein to achieve venous recanalization in patients with acute, extensive, iliofemoral DVT with concomitant popliteal and calf vein thrombosis., Materials and Methods: Seven patients were treated using this technique, in three patients as a bailout option after failed posterior tibial vein puncture and in four as a first option. Antegrade popliteal venous access was performed according to the usual technique using duplex ultrasound (DUS) guidance and thrombolysis (CDT), or thrombectomy (PMT) was performed. Following this, the retrograde sheath was placed under DUS guidance, a tibial vein was selectively catheterized and CDT, and/or a PMT was performed., Results: Three patients underwent isolated CDT, another three had associated PMT, and one patient underwent iliofemoral PMT and catheter thromboaspiration of the popliteal and calf veins. Median thrombolysis duration was 72 h (24-72 h). SIR grade III thrombolysis was achieved in six patients and grade II in one patient. All patients underwent subsequent stenting of their iliac vein lesions. Minor complications were observed in two patients (ecchymosis), while one patient developed a hematoma on the popliteal fossa., Conclusion: This "criss-cross" technique represents a safe alternative to the distal (anterior or posterior tibial) vein access both as a bailout option after failed distal venous access as well as a primary approach due to its potential advantage of clearing larger thrombus volume. Experience in ultrasound-guided popliteal vein puncture is crucial to avoid complications., Level of Evidence: Case series, Level IV.

Purpose: To assess the effects of iliofemoral vein stent placement on symptomatic lower extremity swelling (LES), presumed to be lymphedema, in patients with cancer., Materials and Methods: During the period 2005-2013, 62 patients (38 female; age, 60.4 y ± 15.4) with histology-proven metastatic disease and LES resistant to standard therapies were evaluated and found to have venous outflow obstruction. Stents were placed in the iliofemoral veins or inferior vena cava, or both, and evaluated by color Doppler ultrasound or contrast-enhanced computed tomography during the follow-up period. Patient symptoms were assessed using the Venous Disability Score (VDS) and the Galway Limb Swelling score, a patient-directed, 5-question symptom scoring system., Results: Stents were successfully placed in all patients. During the follow-up period, in-stent thrombosis occurred in 13 patients, and additional stents were placed in 3 patients to treat luminal narrowing. The mean VDS improved significantly (P < .05): from 3.0 ± 0 on the day of the procedure to 2.95 ± 0.22 on day 3, 2.0 ± 0.33 on day 7, and 1.87 ± 0.34 on day 30. The mean Galway Limb Swelling score also improved significantly (P < 0.001): from 3.6 ± 0.74 on the day of the procedure to 1.96 ± 0.91 on day 3, 1.06 ± 0.78 on day 7, and 0.6 ± 0.66 on day 30. During the follow-up period, 60 patients died as a result of their underlying malignancy (mean, 230 d; range, 5-1,080 d)., Conclusions: Iliofemoral or iliocaval venous stent placement may have a valuable role in patients with metastatic disease and symptomatic LES associated with venous obstruction., (Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To report a combined procedure that opens the acutely thrombosed superior vena cava (SVC) to rapidly alleviate symptoms in seriously ill patients with SVC syndrome., Case Reports: Four patients aged 54 to 63 years old with underlying malignancies were referred for treatment of SVC syndrome. All received isolated pharmacomechanical thrombolysis (IPMT) with tissue plasminogen activator delivered in a Trellis Peripheral Infusion System that removed obstructive clot in minutes versus the 24 to 48 hours required for traditional catheter-directed thrombolysis. In each case, stents were inserted immediately following IPMT in a combined procedure lasting <1 hour. Patients exhibited near-immediate relief of debilitating symptoms; completion venography demonstrated patent vessels with excellent blood flow., Conclusion: Combining IPMT with immediate stenting during the same session is an effective method for managing acute thrombotic SVC syndrome and limiting the exposure time and number of interventions performed on seriously ill patients.

Purpose: To evaluate the performance of the Trellis-8 isolated thrombolysis catheter during single-session pharmacomechanical thrombectomy (PMT) combined with low-dose thrombolysis with tissue plasminogen activator (TPA) in the treatment of patients with acute deep vein thrombosis (DVT) and multiple comorbidities., Materials and Methods: Retrospective analysis was performed of 19 consecutive patients with acute above-knee DVT treated by PMT with the Trellis device followed by venous angioplasty and stent placement. Isolated thrombolysis with low-dose TPA was used with all patients. Concurrent therapies included retrievable inferior vena cava filter insertion (n = 4). The primary endpoint was restoration of rapid inline venous flow; the secondary endpoint was thrombus clearance., Results: Restoration of rapid inline venous flow was achieved in all cases; thrombus removal was less than 50% in one case (4%), 50%-95% in 18 cases (82%), and at least 95% in three cases (14%). The median administered dose of TPA was 13.4 mg per patient. The mean treatment time was 91 minutes per limb (range, 61-129 min), with a mean of 21 minutes per thrombosed segment (range, 8-31 min). There were no major complications. Primary patency rate of the treated venous segments at 2 days was 86% (n = 19) and the primary assisted patency rate was 100% at 30 days. Two patients died of advanced malignancy at 17 and 24 days., Conclusions: The Trellis system was an effective method for the treatment of acute DVT. Based on the present data, the Trellis system could prove to be a safe and feasible single-session PMT method for the treatment of acute DVT in a broader patient population and warrants further investigation in a large-scale study.