The good, bad and the ugly of the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis trial from the viewpoint of clinicians

Abstract

Acute deep venous thrombosis (DVT) can be complicated by post-thrombotic syndrome, which is associated with significant morbidity and healthcare costs. The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) was the largest and most controversial randomized controlled trial evaluating the use of pharmacomechanical catheter-directed thrombolysis (CDT) for the prevention of post-thrombotic syndrome after acute DVT. This study aimed to evaluate clinicians' opinion on the ATTRACT trial and its impact on clinical practice. MethodsAn online survey consisting of 10 core multiple choice items and a maximum of 5 follow-up open-ended questions was delivered to vascular surgeons, interventional radiologists, hematologists, and interventional cardiologists affiliated with 10 international societies between April 23 and July 1, 2019. Clinicians' views on the main limitations of the ATTRACT trial, its impact on patient selection for thrombolysis and the need for a new trial were evaluated. ResultsOut of 15,650 contacted clinicians, 451 (3%) completed the survey, with 74% vascular surgeons, 24% interventional radiologists, 2% hematologists, and 0.2% interventional cardiologists. The majority of respondents (79%) were aware of the results of the ATTRACT trial before completing the survey and routinely performed pharmacomechanical CDT (PCDT) in their centers (70%). Only 20% of clinicians considered ATTRACT to be a welldesigned and well-performed trial. The inclusion of femoropopliteal DVT was reported as the main limitation of the trial by 55% of respondents. Despite half of the participating clinicians reporting no change in their clinical practice, equal number of clinicians (14%) were encouraged and discouraged from treating iliofemoral DVT. More than one-half of the respondents thought that the use of PCDT would be defensible in a court of law despite the increased risk of bleeding reported in the study. Nearly two-thirds of participating clinicians recommended performing a trial limited to iliofemoral DVT, with a follow-up period of 5 years, quality of life as the primary outcome measure, and standardization of thrombolysis protocol across the trial sites. ConclusionsATTRACT failed to provide the long-awaited indisputable evidence on the use of PCDT. Surveyed clinicians were aware of the limitations of this trial and the need for further evidence on the subject.Deep venous thrombosis (DVT) is an important healthcare concern, with an annual incidence of approximately 1 in 2000 in the general population resulting in a 2% to 5% lifetime risk. 1,2 In addition to often severe localized symptoms, it can be complicated by well-recognized life-threatening pulmonary embolism in the acute setting or frequently debilitating post-thrombotic syndrome (PTS) in the longer term. 3 PTS, which is associated with significant impairment in quality of life and considerable healthcare costs, is estimated to affect almost 50% of patients in the first 2 years after an acute episode of DVT despite adequ...

Interventionelle Therapie der akuten iliofemoralen Thrombose

“…Therapie der akuten iliofemoralen DVT hat in mehreren Studien in ihren verschiedenen Modalitäten gezeigt, dass eine hohe technische Erfolgsrate möglich und die PTS-Inzidenz niedriger als bei der konservativen Therapie ist[12,13]. In den großen neueren RCTs Attract und Cava konnte im Gegensatz zur Cavent-Studie dieser Nachweis nicht geführt werden, allerdings wurden in diesen Studien viele Limitationen identifiziert[14,15], was viele Anwender als Argument zur Fortführung der CDT und PMT bewog[16].Die größte Achillesferse der interventionellen Therapie bleibt die in allen RCTs nachgewiesene höhere Blutungskomplikationsrate, wohingegen Lungenembolien keine wesentliche Rolle im Komplikationsspektrum spielen. Zukünftige Strategien müssen auf eine Minimierung des Blutungsrisikos abzielen, denn der klinische Benefit einer PTS-Verhinderung darf nicht durch eine zu hohe Komplikationsrate erkauft werden.…”