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Interventionist Treatment of Acute DVT does not Represent any Advantge over the Best Medical Treatment alone

Pascual Lozano VilardellVascular Surgery DepartmentMajorca. Spain

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IntroductionDVT 3rd cause of CV morbidity/mortalityIncidence of DVT: 1/1 000Posthrombotic syndrome (PTS) 50% in 2 years

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Introduction: natural history DVT Spontaneous thrombus recanalization

Iliofemoral20% 5 yearsFemoropopliteal80% 6 monthsVan 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

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Treatment for acute iliofemoral DVT Systemic anticoagulationSurgical thrombectomy (ST)Systemic thrombolysisCatheter-directed thrombolysis (CDT)CDT + stenting

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Treatment for acute iliofemoral DVT

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Treatment for acute iliofemoral DVT

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CDT + stentBroholm R et al. J Vasc Surg 2011;54:18-S-25S

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CDT + stentBroholm R et al. J Vasc Surg 2011;54:18-S-25S

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Catheter Directed Thrombolysis

Enden et al. Long-term outcome after CDT vs standard treatment for acute IF DVT (the CaVenT study): a RCT. Lancet2012;379:31-8

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Catheter Directed ThrombolysisEnden et al. Long-term outcome after CDT vs standard treatment for acute IF DVT (the CaVenT study): a RCT. Lancet2012;379:31-8AnticoagulationCDTPTS 6 months32%30%NSPTS 24 months55%41%P= .04QALY 24 months31,6%32,3%NS

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Treatment for acute iliofemoral DVT

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

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Catheter Directed ThrombolysisBleeding requiring trasfusion7,5%CDTPTSRR 0.19 95% CI, 0.07-0.48Vein obstructionRR 0.38 95% CI, 0.18-0.37Venous refluxRR 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

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Treatment for acute iliofemoral DVT Low-evidence studies:Methodological limitationsLack of bias protectionLack of comparability of studiesAnalysis of surrogate outcomesLack of QOL analysisPublication and reporting biases

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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

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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

CDTACMortality1.2%0.9%

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Bashir R et al. Comparative outcomes of catheter-directed thrombolysis plus anticoagulation vs anticoagulation alone to treat lower-extremity DVT. JAMA Intern Med 2014;174:1494-501CDTACBlood trasfusion11.1%6.5%p