Catheter-Based Therapies and Other Management Strategies for Deep Vein Thrombosis and Post-Thrombotic Syndrome

Abstract

Acute deep vein thrombosis (DVT) causes substantial short-term and long-term patient morbidity. Medical, lifestyle, and compressive therapies have been investigated for the prevention of pulmonary embolism (PE) and recurrence of venous thromboembolism (VTE). However, patient-centered outcomes such as resolution of presenting DVT symptoms and late occurrence of post-thrombotic syndrome (PTS) have not been prioritized to the same degree. Imaging-guided, catheter-based endovascular therapy has been used in selected patients to alleviate these sequelae, but important questions remain about their optimal use. In this article, we review the available evidence and summarize the rationale for use of catheter-based therapy in specific patient groups.

Pediatric May‐Thurner Syndrome—Systematic review and individual patient data meta‐analysis

“…[39][40][41] These observations led to the "open vein hypothesis," according to which early removal of DVT was thought to result in improved longterm DVT outcomes due to preservation of vein valve function and prevention of venous obstruction. 42,43 However, RCTs investigating the efficacy of catheter-directed and pharmaco-mechanical thrombolysis to prevent PTS in adults with lower limb DVT through early thrombus removal, including the CaVenT, 44,45 ATTRACT, 46,47 and CAVA 48 trials, showed that the benefit of this treatment modality was far more modest than predicted, and only benefited selected patients. This could be due to the fact that vein wall damage may occur earlier than expected.…”

“…52 Nonetheless, current adult guidelines recommend the use of stents 53 and/or angioplasty 54 in flow-limiting persistent iliac obstructions. 53 Although the indication for image-guided thrombus removal remains controversial, experts consider that selected adult patients with acute iliofemoral DVT and low risk of bleeding may benefit from this therapeutic modality, 42,46,55 and this is reflected in the most recent guidelines for venous thrombosis management in adults. 56 There are several limitations to this study, one of which is the variability in the assessment of predictors and outcomes.…”

“…Although the indication for image‐guided thrombus removal remains controversial, experts consider that selected adult patients with acute iliofemoral DVT and low risk of bleeding may benefit from this therapeutic modality, 42,46,55 and this is reflected in the most recent guidelines for venous thrombosis management in adults 56 …”

Prevalence and predictors of alternative diagnoses on whole-leg ultrasound negative for acute deep venous thrombosis

“…In our analysis, older age, leg swelling and previous DVT were independent predictors of finding alternative diagnoses in patients without acute DVT on whole-leg ultrasound. A frequent complication of DVT includes the post-thrombotic syndrome (PTS) with a relatively high number of patients between 20 to 50% within 2 years of DVT diagnosis [ 21 , 22 ]. Clinical manifestations of PTS typically include limb pain, heaviness, edema and pruritus [ 23 ].…”

“…Clinical manifestations of PTS typically include limb pain, heaviness, edema and pruritus [ 23 ]. PTS is a form of CVI that occurs due to chronic venous obstruction and damaged vein valves [ 21 , 22 ]. Duplex ultrasound is the first imaging test of choice to evaluate for signs of CVI and post-thrombotic changes [ 24 ].…”