Optimizing catheter-directed thrombolysis access and predicting post-thrombotic syndrome in acute entire-limb DVT: a retrospective cohort study and nomogram development

Background Selecting the optimal catheter-directed thrombolysis (CDT) access for acute entire-limb deep vein thrombosis (DVT) remains controversial. This study aimed to compare the technical and clinical outcomes of three CDT access approaches and to develop a prognostic nomogram for predicting post-thrombotic syndrome (PTS) based on hemodynamic and procedural variables. Methods We retrospectively analyzed 172 patients with acute entire-limb DVT who underwent CDT via contralateral femoral vein access (CFVA, n = 87), ipsilateral popliteal vein access (IPVA, n = 34), or ipsilateral calf venous access (ICVA, n = 51). Procedural metrics, angiographic patency, and 2-year PTS incidence were evaluated. A LASSO-Cox regression model was utilized to address multicollinearity, identify independent PTS predictors, and construct a prognostic nomogram. Results Although CFVA afforded the shortest sheath insertion time (1.74 ± 1.02 min), it required significantly longer access establishment (17.07 ± 6.81 min) than IPVA and ICVA ( P 0.001). Antegrade approaches (IPVA and ICVA) yielded superior femoropopliteal thrombus clearance and enhanced inflow patency compared to CFVA ( P 0.001). The 2-year PTS incidence was significantly higher in the CFVA group (59.8%) versus the IPVA (38.2%) and ICVA (41.2%) cohorts ( P = 0.033). LASSO-Cox analysis identified poor inflow patency (HR 3.19), poor outflow patency (HR 2.17), and deep femoral vein axial transformation (HR 2.44) as independent risk factors for PTS. Prolonged thrombolysis duration and subsequent endovascular interventions were protective. The developed nomogram demonstrated excellent discriminative ability (C-index = 0.82). Conclusion For acute entire-limb DVT, antegrade CDT access optimizes early femoropopliteal thrombus resolution. However, long-term PTS prevention is fundamentally driven by comprehensive hemodynamic restoration rather than the initial access site alone. Our proposed nomogram serves as a robust, evidence-based tool for individualized risk stratification and clinical decision-making.