Deep vein thrombosis surgery
Editors-in-Chief: C. Michael Gibson, M.S., M.D. Associate Editor-In-Chief: Ujjwal Rastogi, MBBS [1]; Kashish Goel,M.D.
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Catheter-Directed Thrombolysis
- Catheter-Directed Thrombolysis for acute DVT has been evaluated in small randomized trials and have shown that it may preserve venous valve function, reduce post-thrombotic syndrome and improve quality of life. However, evidence regarding mortality, recurrent VTE and major bleeding is lacking.
- According to ACCP guidelines[1], catheter-directed thrombolysis should be considered only in patients who meet all of the following criteria:
- Iliofemoral DVT
- Symptoms < 14 days
- Good functional status
- Life expectancy ≥1 year
- Low risk of bleeding
ACCP recommendations[1]:
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1. In patients with acute proximal DVT of the leg, we suggest anticoagulant therapy alone over CDT (Grade 2C). 2. In patients with acute DVT of the leg who undergo thrombosis removal, we recommend the same intensity and duration of anticoagulant therapy as in similar patients who do not undergo thrombosis removal. |
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Systemic thrombolysis
- Systemic thrombolysis has also been shown to reduce the incidence to post-thrombotic syndrome, but with increased risk of bleeding.
- Conditions where systemic thrombolysis may be considered are similar to those mentioned in catheter-directed thrombolysis.
- Further, ACCP[1] recommends using catheter-directed thrombolysis over systemic thrombolysis if resources and expertise is available.
- Major contraindications
- Structural intracranial disease
- Previous intracranial hemorrhage
- Ischemic stroke within 3 mo
- Active bleeding
- Recent brain or spinal surgery
- Recent head trauma with fracture or brain injury
- Bleeding diathesis
- Relative contraindications
- Systolic BP >180 mm Hg
- Diastolic BP >110 mm Hg
- Recent bleeding (nonintracranial)
- Recent surgery
- Recent invasive procedure
- Ischemic stroke more that 3 mo previously
- Anticoagulation (eg, VKA therapy)
- Traumatic cardiopulmonary resuscitation
- Pericarditis or pericardial fl uid
- Diabetic retinopathy
- Pregnancy
- Age >75 y
- Low body weight (eg, <60 kg)
- Female sex
- Black race
ACCP recommendations[1]:
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1. In patients with acute proximal DVT of the leg, we suggest anticoagulant therapy alone over systemic thrombolysis (Grade 2C). 2. In patients with acute DVT of the leg who undergo thrombosis removal, we recommend the same intensity and duration of anticoagulant therapy as in similar patients who do not undergo thrombosis removal. |
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Mechanical thrombectomy
Percutaneous mechanical thrombectomy without concomitant thrombolysis has not been examined in randomized trials and its use is not recommended as it often fails to remove most of the thrombus. It can also dislodge the clot leading to a high-risk of pulmonary embolus.
Operative venous thrombectomy
- A single small randomized controlled trial showed that operative venous thrombectomy may lead to better iliac vein patency and less post-thrombotic syndrome.
- It should be considered only if all of the following criteria are met[1]:
- Iliofemoral DVT
- Symptoms < 7 days
- Good functional status
- Life expectancy ≥1 year
- ACCP recommends catheter-directed thrombolysis above operative venous thrombectomy, if required.
ACCP recommendations[1]:
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1. In patients with acute proximal DVT of the leg, we suggest anticoagulant therapy alone over operative venous thrombectomy (Grade 2C). 2. In patients with acute DVT of the leg who undergo thrombosis removal, we recommend the same intensity and duration of anticoagulant therapy as in similar patients who do not undergo thrombosis removal. |
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Inferior vena cava filter
- Inferior vena cava filters decrease the incidence of pulmonary embolism[2], but also increase the risk of recurrent DVT[3].
- IVC filter does not effect the combined incidence of recurrent VTE.
- IVC filter increases the risk of post-thrombotic syndrome.
- Retrievable IVC filters may be considered in those with an absolute contraindication to anticoagulation, to reduce the risk of PE[4]. However, these filters should be removed to prevent long-term complications.[1]
- Anticoagulation should be started as soon as the bleeding risk resolves.
ACCP recommendations[1]:
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1. In patients with acute DVT of the leg, we recommend against the use of an IVC filter in addition to anticoagulants (Grade 1B). 2. In patients with acute proximal DVT of the leg and contraindication to anticoagulation, we recommend the use of an IVC fi lter (Grade 1B). 3. In patients with acute proximal DVT of the leg and an IVC filter inserted as an alternative to anticoagulation, we suggest a conventional course of anticoagulant therapy if their risk of bleeding resolves (Grade 2B). |
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Guidelines Resources
- Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Edition)[1]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Kearon C, Akl EA, Comerota AJ; et al. (2012). "Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e419S–94S. doi:10.1378/chest.11-2301. PMID 22315268. Unknown parameter
|month=ignored (help) - ↑ Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral F, Huet Y, Simonneau G (1998). "A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group". N Engl J Med. 338 (7): 409–15. PMID 9459643.
- ↑ "Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study". Circulation. 112 (3): 416–22. 2005. PMID 16009794.
- ↑ Young T, Aukes J, Hughes R, Tang H (2007). "Vena caval filters for the prevention of pulmonary embolism". Cochrane database of systematic reviews (Online) (3): CD006212. doi:10.1002/14651858.CD006212.pub2. PMID 17636834.