Thrombolysis for acute deep vein thrombosis

Abstract

A B S T R A C T BackgroundStandard treatment for deep vein thrombosis aims to reduce immediate complications. Use of thrombolysis or clot dissolving drugs could reduce the long-term complications of post-thrombotic syndrome (PTS) including pain, swelling, skin discolouration, or venous ulceration in the affected leg. This is the third update of a review first published in 2004. ObjectivesTo assess the effects of thrombolytic therapy and anticoagulation compared to anticoagulation alone for the management of people with acute deep vein thrombosis (DVT) of the lower limb as determined by the effects on pulmonary embolism, recurrent venous thromboembolism, major bleeding, post-thrombotic complications, venous patency and venous function. Search methodsFor this update the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (February 2016). In addition the CIS searched the Cochrane Register of Studies (CENTRAL (2016, Issue 1)). Trial registries were searched for details of ongoing or unpublished studies. Selection criteriaRandomised controlled trials (RCTs) examining thrombolysis and anticoagulation versus anticoagulation for acute DVT were considered. Data collection and analysisFor this update (2016), LW and CB selected trials, extracted data independently, and sought advice from MPA where necessary. We assessed study quality with the Cochrane risk of bias tool. For dichotomous outcomes, we calculated the risk ratio (RR) and corresponding 95% confidence interval (CI). Data were pooled using a fixed-effect model unless significant heterogeneity was identified in which case a random-effects model was used. GRADE was used to assess the overall quality of the evidence supporting the outcomes assessed in this review. Main resultsSeventeen RCTs with 1103 participants were included. These studies differed in the both thrombolytic agent used and in the technique used to deliver it. Systemic, loco-regional and catheter-directed thrombolysis (CDT) were all included. Fourteen studies were rated as low risk of bias and three studies were rated as high risk of bias. We combined the results as any (all) thrombolysis compared to standard anticoagulation. Complete clot lysis occurred significantly more often in the treatment group at early follow-up (RR 4.91; 95% CI 1.66 Thrombolysis for acute deep vein thrombosis (Review) Post-throm botic syndrom e (late, 5 year f ollow-up af ter treatm ent) Study population RR 0.58 (0.45 to 0.77) 211 (2 RCTs) ⊕⊕⊕ M ODERATE 1 72 (of 107) patients treated with standard anticoagulation developed PTS com pared to 41 (of 104) treated with throm bolysis 673 per 1000 390 per 1000 (303 to 518)* The risk in the intervention group (and its 95% conf idence interval) is based on the assum ed risk in the com parison group and the relative effect of the intervention (and its 95% CI). CI:Conf idence interval; DVT: deep vein throm bosis; PTS: post-throm botic syndrom e RCT: random ised controlled trial; RR: Risk ratio GRADE Working Group grades of evidence High quality: We are very c...

Deep vein thrombosis

“…Selection of patients must be guided by a multidisciplinary approach, with inputs from a vascular surgeon and interventional radiologist, and must consider patient preferences 2845464748…”

Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis

“…In the pharmacomechanical-thrombolysis group, there were more early major bleeds than in the control group, but less major bleeding (1.7% of patients, with no fatal or intracranial bleeds) occurred in association with the procedure than in past studies of thrombolysis for deep-vein thrombosis. 3,7,18,34–36 …”

“…5,6 Small randomized trials have suggested that active removal of acute thrombus may preserve venous function and prevent the post-thrombotic syndrome (the “open-vein hypothesis”). 3,7,8 …”

Should catheter-directed thrombolysis be the standard of care for pregnancy-related iliofemoral deep vein thrombosis?

“…PTS is thought to be caused by venous hypertension due to persistent venous obstruction/insufficiency after inflammatory destruction of venous valves following a DVT 9. A systemic review showed that systemic thrombolysis offers a significant advantage, reducing the incidence of PTS by one-third 10. This may be due to early recanalisation reducing the inflammatory destruction of valves following a DVT.…”

“…Despite the dose reduction, evidence suggests that CDT is as effective as systemic thrombolysis in reducing the incidence of PTS 10. Current evidence on the use of CDT in pregnancy is limited but have demonstrated successful clot lysis with no complications to the fetus 16.…”