Acute deep vein thrombosis and endovascular techniques: It is time for a new aggiornamento!

Abstract

The stated aims of treating acute deep vein thrombosis (DVT) are to prevent a pulmonary embolism, stop the clot from spreading, reduce the risk of a recurrence; they are less concerned with the late morbidity associated with post-thrombotic syndrome (PTS). In accordance with the French (Afssaps, 2009) and North American (ACCP, 2008) recommendations, anticoagulants (LMWH, heparin, AVK) form the cornerstone for treating DVT. These treatments appear to be far less effective in preventing post-thrombotic syndrome (PTS), associated with venous hypertension, residual occlusion, and with reflux caused by valve incompetence. Given that, the new aim is to optimise the prevention of PTS, the ACCP guidelines, unlike those of Afssaps, "suggest" for selected patients suffering from acute iliofemoral DVT, the use of both classic anticoagulants, and in situ percutaneous administration of thrombolytic drugs (recommendation grade 2B) and simultaneous correction of any underlying anatomical anomalies using angioplasty and stenting (recommendation 2C). Contemporary endovascular methods, referred to collectively as "facilitated" thrombolysis, combine low doses of rtPa or Urokinase administered locally, and the removal of the clot using various mechanical, rotating, rheolytic systems, or using ultrasound. The results of non-randomised, heterogeneous studies objectivised a lysis rate of 80%, a 50% lower risk of haemorrhage complications compared with systemic thrombolysis (<4%), and a clear reduction in treatment time (one-shot methods possible for procedures lasting less than 2 hours). This data ties in with the modern "open vein" concept which underpins the hope of an improvement in the late prognosis of acute DVT, through the removal of a clot, thereby improving permeability and valve integrity; this hypothesis is supported by the results at 24 months of a randomised CaVent objectifying absolute risk reduction of 15% in the thrombolysis in situ. The current randomised study (ATTRACT trial) comparing the combination of "facilitated thrombolysis" in addition to the usual treatment with the traditional treatment alone for acute iliofemoral DVT, the statistical power of which has been established (600 patients) to authenticate a reduction by a third in the number of PTS (CaVent trial, showing a 15% reduction rate of 24 months PTS in the thrombolysed group results expected in 2016), might, if the results are positive, lead to a profound change in the paradigms for the treatment of acute iliofemoral DVT.

Endovascular management of the deep venous thrombosis: A new challenging role for the endovascular specialist in 2020

“…17,18 After a thrombotic episode, the risk of incomplete recanalization is as high as 40%, with a venous insufficiency rate of 50%, with poorer outcomes in proximal ilio-femoral DVT than for popliteal or distal thrombosis. 16,19 These two factors, both the persistent venous obstruction and the venous insufficiency, participate to the elevated risk of PTS after a proximal DVT and supported the rational of the early thrombus removal by the endovascular approach.…”

“…Concerning the first item, extreme scenarios of DVT such as the phlegmasia cerulea dolens remain a hard challenge for the physicians and a rapid restoration of the venous flow would be likely important to reduce morbidity and mortality, given the strong association of outcomes with severity at the time of presentation 17,18 . After a thrombotic episode, the risk of incomplete recanalization is as high as 40%, with a venous insufficiency rate of 50%, with poorer outcomes in proximal ilio‐femoral DVT than for popliteal or distal thrombosis 16,19 . These two factors, both the persistent venous obstruction and the venous insufficiency, participate to the elevated risk of PTS after a proximal DVT and supported the rational of the early thrombus removal by the endovascular approach.…”

“…4,14 Because of these clinical claims and the economical impact of the palliative management of the PTS on the national health care system, a national call action from the office of the surgeon general, that supervises in the United States the public health policy, addressed in 2008 a specific motion to industry, physicians and researchers to improve prevention and treatment resources for the management of the DVT. 15,16 This manuscript is aimed to present the recent developments in the management of the DVT with particular regards to the modern endovascular strategies in acute and chronic theaters and their clinical outcomes.…”

“…Because of these clinical claims and the economical impact of the palliative management of the PTS on the national health care system, a national call action from the office of the surgeon general, that supervises in the United States the public health policy, addressed in 2008 a specific motion to industry, physicians and researchers to improve prevention and treatment resources for the management of the DVT 15,16 …”

Design of a HIFU array for the treatment of deep venous thrombosis: a simulation study

“…Currently, catheter directed thrombolysis in combination with anticoagulants is the recommended treatment for DVT of the iliofemoral veins by the clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum (Meissner et al 2012). However, many patients are contraindicated for such treatment, both because of the risk of hemorrhaging involved with interventional methods, especially in combination with the standard anticoagulation treatment for DVT, as well as adverse reaction to thrombolytic agents used in some catheter based treatments (Pernès 2012). Therefore, there is clinical benefit to be gained from the development of a non-invasive technique to treat acute DVT.…”