Natural History and Role of Anticoagulation in the Management of Endovenous Glue Induced Thrombus

Introduction, Objectives, and/or Purpose: The natural history of endovenous glue induced thrombus (EGIT) resolution and the role of anticoagulation in their management is currently ill-defined. The goal of this investigation is to determine the biologic behavior of EGITs and whether or not anticoagulation (AC) affects treatment outcomes.

Methods: We performed a retrospective review of all endovenous ablations utilizing cyano-acrylate glue (CAG) from January 2020 to December 2021 at the Center for Vein Restoration. Demographics, medical/surgical histories, rVCSS, CIVIQ 20, CEAP, EGIT category, type of anticoagulation, resolution time and location of any deep vein thrombosis (DVT) was analyzed. EGITs were categorized as follows: EGIT 1- Thrombus extension into the deep vein covering less than 25% of the luminal area, EGIT 2- Thrombus between 25% and 49%, EGIT 3- Thrombus between 50% and74%, EGIT 4- Total occlusion.

Results: During the study period, 4,321 CAC procedures were performed and 133 EGITS (3.1%) identified: EGIT 1 (n=57), EGIT 2 (n=35), EGIT 3 (n=19), EGIT 4 (n=22). The most common presenting symptoms were the following: Swelling (n=108), pain (n=101), cramping (n=72), limb fatigue (n=67) and heaviness (n=66). The average age, rVCSS and CIVIQ 20 of the entire cohort was 65.3±14.2, 8.2±2.8, 48±18.3 respectively with 89 females and 44 males. For EGIT 1s, 56/57 (98%) resolved at 4.2±5.1 weeks, with one patient lost to follow up. AC regimen included two Aspirin (ASA), one Eliquis, 5 Xarelto and nothing in 49 (86%). For EGIT 2s, 27/35 (77%) resolved at 4.4±3.4 weeks, one unresolved, six regressions to EGIT 1s and one remained an EGIT 2. AC regimen included 7 ASA, three Eliquis, three Xarelto, one Coumadin and nothing in 21 (60%). For EGIT 3s, 9/19 (47%) resolved at 6±5.9 weeks, 4 regressions, 1 migrated to the proximal common femoral vein, 3 chronic, and 2 unknown. AC regimen included 3 ASA, three Eliquis, seven Xarelto, and nothing in six (32%). AC compared to no AC had no effect on clot resolution (p=0.3). Of the 22 EGIT 4s, one was in the common femoral vein (CFV), two were in the popliteal vein (POPV) and 18 (82%) were remote calf vein DVTs (15 Gastrocnemius, one peroneal (PV) and three posterior tibial veins (PTV)). The CFV EGIT became chronic, one POPV resolved and one was lost to follow-up. For the Gastrocnemius clots, five became chronic, 8 resolved and two were lost to follow-up. For the PTV clots, one resolved, one became chronic and one was lost to follow-up. The PV clot became chronic. AC regimen included four ASA, five Eliquis, six Xarelto, and nothing in seven. AC compared to no AC had no effect on clot resolution (p=0.9). The average proximal thigh diameter, vein length treated and catheter distance from the junction were the following: EGIT 1 (5.9±2.4/37.5±17.6/5.2±1), EGIT 2 (5.9±1.7/38±16.9/4.79±0.71), EGIT 3 (5.1±2.6/27.9±16.6/5.26±1.4) and EGIT 4 (5±1.7/29.9±15.8/5.39±2.18) respectively (p=0.5).

Conclusion(s): Regardless of EGIT class or severity, the majority of EGITs are not associated with clot extension or migration and tend to resolve or regress. For EGIT class 1 and 2 patients, anticoagulation or anti-platelet therapy is not necessary as 86% and 60% respectively, resolved with observation alone by four weeks. For EGIT 3s, 68% resolved or regressed regardless of anticoagulant or anti-platelet use. The majority of EGIT 4s were remote calf vein DVTs. DVTs associated with the saphenofemoral/popliteal junction are rare. Finally, there was no association between catheter distance from a junction and EGIT type.