Interventionist Treatment of Acute DVT

does not Represent any Advantge

over the Best Medical Treatment alone

Pascual Lozano VilardellVascular Surgery Department

Majorca. Spain

Introduction

DVT 3rd cause of CV morbidity/mortality

Incidence of DVT: 1/1 000

Posthrombotic syndrome (PTS)

50% in 2 years

Introduction: natural history DVT

Spontaneous thrombus recanalization

Iliofemoral 20% 5 years

Femoropopliteal 80% 6

months

Van Ramshorts B et al. Thrombus regresion in DVT. Circulation 1992;86:414-9

Akesson H et al. Venous function assesed during 5 year period after acite IF DVT treated with anticoagulation. Eur J Vasc Endovasc Surg 1990;4:43-8

Treatment for acute iliofemoral DVT

Systemic anticoagulation

Surgical thrombectomy (ST)

Systemic thrombolysis

Catheter-directed thrombolysis

(CDT)

CDT + stenting

Treatment for acute iliofemoral DVT

Treatment for acute iliofemoral DVT

CDT + stent

Broholm R et al. J Vasc Surg 2011;54:18-S-25S

CDT + stent

Broholm R et al. J Vasc Surg 2011;54:18-S-25S

Catheter Directed Thrombolysis

Enden et al. Long-term outcome after CDT vs standard treatment for acute IF DVT (the CaVenT study): a RCT. Lancet 2012;379:31-8

Catheter Directed Thrombolysis

Enden et al. Long-term outcome after CDT vs standard treatment for acute IF DVT (the CaVenT study): a RCT. Lancet 2012;379:31-8

Anticoagulation CDTPTS 6 months 32% 30% NSPTS 24 months 55% 41% P= .04QALY 24 months 31,6% 32,3% NS

Treatment for acute iliofemoral DVT

Casey et al. Treatment of acute iliofemoral deep vein thrombosis. J Vasc Surg 2012;55:1463-73

Catheter Directed Thrombolysis

Bleeding requiring trasfusion7,5%

CDTPTS RR 0.19 95% CI, 0.07-0.48Vein obstruction RR 0.38 95% CI, 0.18-0.37Venous reflux RR 0.39 95% CI, 0.16-1.01QOL -

Casey et al. Treatment of acute iliofemoral deep vein thrombosis. J Vasc Surg 2012;55:1463-73

Treatment for acute iliofemoral DVT

Low-evidence studies:

Methodological limitations

Lack of bias protection

Lack of comparability of studies

Analysis of surrogate outcomes

Lack of QOL analysis

Publication and reporting biases…

Bashir R et al. Comparative outcomes of catheter-directed thrombolysis plus anticoagulation vs anticoagulation alone to treat lower-extremity DVT. JAMA Intern Med 2014;174:1494-501

90 000DVT 3 649CDT

Bashir R et al. Comparative outcomes of catheter-directed thrombolysis plus anticoagulation vs anticoagulation alone to treat lower-extremity DVT. JAMA Intern Med 2014;174:1494-501

CDT ACMortality 1.2% 0.9%

Bashir R et al. Comparative outcomes of catheter-directed thrombolysis plus anticoagulation vs anticoagulation alone to treat lower-extremity DVT. JAMA Intern Med 2014;174:1494-501

CDT ACBlood trasfusion 11.1% 6.5% p <.001Pulmonary embolism 17.9% 11.4% p < .001Intracraneal hemorrhage 0.9% 0.3% p = .03Vena cava filter 34.8% 15.6% p < .001

Bashir R et al. Comparative outcomes of catheter-directed thrombolysis plus anticoagulation vs anticoagulation alone to treat lower-extremity DVT. JAMA Intern Med 2014;174:1494-501

CDT ACHospital charges 85 084 $ 28 164 $ p <.001

CONCLUSIONS

Interventionist treatment

More expensive (x 4)

High morbidity

High bleeding rate

No evidence about better QOL

CONCLUSIONS

Interventionist treatment of acute DVT does not

represent any advantge over anticoagulation

alone