Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal

Vedantham, Suresh; Thorpe, Patricia E.; Cardella, John F.; Patel, Nilesh H.; Ferral, Héctor; Hofmann, Lawrence V.; d’Othée, Bertrand Janne; Antonaci, Vittorio P.; Brountzos, Elias; Brown, Daniel B.; Martin, Louis G.; Matsumoto, Alan H.; Meranze, Steven G.; Miller, Donald L.; Millward, Steven F.; Min, Robert J.; Neithamer, Calvin D.; Rajan, Dheeraj K.; Rholl, Kenneth S.; Schwartzberg, Marc S.; Swan, Timothy L.; Towbin, Richard B.; Wiechmann, Bret N.; Sacks, David

doi:10.1097/01.rvi.0000197348.57762.15

Cited by 152 publications

(88 citation statements)

References 70 publications

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“…15,16 Pharmacomechanical catheter-directed thrombolysis was performed in a manner consistent with published guidelines by board-certified physicians whose credentials were approved by the trial leadership. 14,17,18 A detailed description of these methods is provided in the Supplementary Appendix.…”

Section: Methodsmentioning

confidence: 99%

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Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis

et al. 2017

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BACKGROUND The post-thrombotic syndrome frequently develops in patients with proximal deep-vein thrombosis despite treatment with anticoagulant therapy. Pharmacomechanical catheter-directed thrombolysis (hereafter “pharmacomechanical thrombolysis”) rapidly removes thrombus and is hypothesized to reduce the risk of the post-thrombotic syndrome. METHODS We randomly assigned 692 patients with acute proximal deep-vein thrombosis to receive either anticoagulation alone (control group) or anticoagulation plus pharmacomechanical thrombolysis (catheter-mediated or device-mediated intrathrombus delivery of recombinant tissue plasminogen activator and thrombus aspiration or maceration, with or without stenting). The primary outcome was development of the post-thrombotic syndrome between 6 and 24 months of follow-up. RESULTS Between 6 and 24 months, there was no significant between-group difference in the percentage of patients with the post-thrombotic syndrome (47% in the pharmacomechanical-thrombolysis group and 48% in the control group; risk ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.11; P = 0.56). Pharmacomechanical thrombolysis led to more major bleeding events within 10 days (1.7% vs. 0.3% of patients, P = 0.049), but no significant difference in recurrent venous thromboembolism was seen over the 24-month follow-up period (12% in the pharmacomechanical-thrombolysis group and 8% in the control group, P = 0.09). Moderate-to-severe post-thrombotic syndrome occurred in 18% of patients in the pharmacomechanical-thrombolysis group versus 24% of those in the control group (risk ratio, 0.73; 95% CI, 0.54 to 0.98; P = 0.04). Severity scores for the post-thrombotic syndrome were lower in the pharmacomechanical-thrombolysis group than in the control group at 6, 12, 18, and 24 months of follow-up (P<0.01 for the comparison of the Villalta scores at each time point), but the improvement in quality of life from baseline to 24 months did not differ significantly between the treatment groups. CONCLUSIONS Among patients with acute proximal deep-vein thrombosis, the addition of pharmacomechanical catheter-directed thrombolysis to anticoagulation did not result in a lower risk of the post-thrombotic syndrome but did result in a higher risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute and others; ATTRACT ClinicalTrials.gov number, NCT00790335.)

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Section: Methodsmentioning

confidence: 99%

“…17,18 Stenting was encouraged for lesions that were causing 50% or greater narrowing of the diameter of the vein, robust collateral filling, or a mean pressure gradient of more than 2 mm Hg. Treatment was discontinued when there was at least 90% thrombus removal with restoration of flow or when there was a serious complication.…”

Section: Methodsmentioning

confidence: 99%

Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis

et al. 2017

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“…This statement supports the use of CDT as an adjunct to anticoagulant therapy to prevent PTS and provide rapid symptom relief from acute iliofemoral DVT in a carefully selected patient group 16. The same authors published a meta-analysis of 19 peer-reviewed comparative studies containing 1046 patients, which showed a technical success rate for thrombus removal via CDT of 90% 17. However, the analysis included only one randomised trial 18.…”

Section: Catheter-directed Thrombolysismentioning

confidence: 73%

The role of interventional radiology in the management of deep vein thrombosis

Mehrzad

Freedman

Harvey

et al. 2012

Postgraduate Medical Journal

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Deep venous thrombosis is a common life-threatening disorder with a significant mortality rate. The current standard anticoagulation therapy has proven inadequate in prevention of long-term post-thrombotic symptoms in patients with large clot burdens. Over the last two decades, advances in endovascular therapies have delivered a range of new treatment options including catheter-directed thrombolysis, percutaneous mechanical thrombectomy, venoplasty and stenting and inferior vena caval filter devices. Although there has been growing experience and guidelines in the treatment of deep vein thrombosis, there remains a wide variation in clinical practice nationally. This paper aims to raise the awareness of these emerging therapies and reviews the available evidence for their use.

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“…Several different studies have found evidence of asymptomatic pulmonary embolism at rates of 5.3% to 17%, in addition to a few symptomatic cases. [10][11][12][13] The vena cava filter prevents embolization by larger thrombi, but does not restrict the passage of microthrombi into pulmonary circulation. As a result, the benefit of using a cava filter in patients undergoing aspiration thrombectomy is not wellestablished in the literature.…”

Section: Indicationmentioning

confidence: 99%

Pulmonary embolism and stroke associated with mechanical thrombectomy

Bastianetto

Pinto

2014

J. vasc. bras.

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Mechanical thrombectomy offers the advantage of rapid removal of venous thrombi. It allows venous obstructions to be removed and requires shorter duration of infusion of thrombolytic agents. However, aspiration of thrombi can lead to complications, particularly pulmonary embolism and hemolysis. The validity of using vena cava filters during thrombectomy in order to avoid embolism has not yet been established. The authors report a case of massive pulmonary embolism associated with ischemic stroke in a patient with a hitherto undiagnosed patent foramen ovale. The patient developed respiratory failure and neurological deficit after thrombectomy. This case raise questions about the value of the thrombectomy for the treatment of proximal vein thrombosis due to the risks of this procedure. The authors also discuss the need for vena cava filters and ruling out a patent foramen ovale in patients undergoing thrombectomy.Keywords: thrombectomy; mechanical thrombolysis; pulmonary embolism; stroke. ResumoA trombectomia mecânica tem a vantagem de levar à rápida remoção dos trombos. Permite a desobstrução venosa e a redução do tempo de infusão de trombolíticos. A aspiração dos trombos pode levar a complicações, principalmente embolia pulmonar e hemólise. Algo que não está definido é a validade do uso de filtros de veia cava durante a trombectomia, com o objetivo de evitar a TEP maciça. Os autores relatam um caso de embolia pulmonar maciça associada a AVC isquêmico, em uma paciente que apresentava forame oval patente. Não havia o diagnóstico prévio da PFO. A paciente evoluiu com insuficiência respiratória e déficit neurológico logo após a trombectomia. Neste caso, questiona-se o valor da trombectomia para o tratamento da trombose venosa proximal, devido aos riscos deste procedimento. Os autores discutem sobre a necessidade de filtro de veia cava e sobre a pesquisa de forame oval nos pacientes que serão submetidos à trombectomia.Palavras-chave: trombectomia; trombólise mecânica; embolia pulmonar; acidente vascular cerebral.

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Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal

Cited by 152 publications

References 70 publications

Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis

Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis

The role of interventional radiology in the management of deep vein thrombosis

Pulmonary embolism and stroke associated with mechanical thrombectomy

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