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'''Editors-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]] '''Associate Editor-In-Chief''': [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]; [[User:Kashish Goel|Kashish Goel,M.D.]]
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| [[File:Siren.gif|30px|link=Deep vein thrombosis resident survival guide]]|| <br> || <br>
| [[Deep vein thrombosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}} ; [[User:Kashish Goel|Kashish Goel, M.D.]]; '''Assistant Editor(s)-In-Chief:''' [[User:Justine Cadet|Justine Cadet]]
{{Deep vein thrombosis}}
{{Deep vein thrombosis}}
==Overview==
==Overview==
Percutaneous transcatheter treatment of patients with deep venous thrombosis (DVT) includes:
Operative venous thrombectomy can be considered for the treatment of iliofemoral deep vein thrombosis (DVT), mainly when [[catheter directed thrombolysis]] (CDT) and [[pharmacomechanical catheter directed thrombolysis]] (PCDT) can not be performed.<ref name="pmid22315268">{{cite journal |author=Kearon C, Akl EA, Comerota AJ, ''et al.'' |title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e419S–94S |year=2012 |month=February |pmid=22315268 |doi=10.1378/chest.11-2301 |url=}}</ref>
*Thrombus removal with catheter-directed thrombolysis,
*Mechanical thrombectomy,
*Angioplasty,
*Stenting of venous obstructions
 
==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, patients who may benefit from catheter-directed thrombolysis include:
** Iliofemoral [[DVT]]
** Symptoms < 14 days
** Good functional status
** Life expectancy ≥1 year
** Low risk of bleeding
 
* ACCP recommendations for Catheter-Directed Thrombolysis are:
{{cquote|In patients with acute proximal DVT of the leg, we suggest anticoagulant therapy alone over CDT (Grade 2C).}}
 
==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.
* ACCP recommendations in this regard are:
{{cqoute|In patients with acute proximal DVT of the leg, we suggest anticoagulant therapy alone over systemic thrombolysis (Grade 2C)}}
 
* Further, ACCP recommends using catheter-directed thrombolysis over systemic thrombolysis if resources and expertise is available.
*
 
 
==Mechanical thrombectomy==
{{main|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]].
 
==Inferior vena cava filter==
{{main|Inferior vena cava filter}}
[[Inferior vena cava filter]] reduces pulmonary embolism<ref name="pmid9459643">{{cite journal |author=Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral F, Huet Y, Simonneau G |title=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 |journal=N Engl J Med |volume=338 |issue=7 |pages=409-15 |year=1998 |id=PMID 9459643}}</ref> and is an option for patients with an absolute contraindication to anticoagulant treatment (e.g., cerebral hemorrhage) or those rare patients who have objectively documented recurrent PEs while on anticoagulation, an [[inferior vena cava filter]] (also referred to as a ''[[Greenfield filter]]'') may prevent pulmonary embolisation of the leg clot.  However these filters are themselves potential foci of thrombosis,<ref name="pmid16009794">{{cite journal |author= |title=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 |journal=Circulation |volume=112 |issue=3 |pages=416-22 |year=2005 |id=PMID 16009794}}</ref> IVC filters are viewed as a temporary measure for preventing life-threatening pulmonary embolism.<ref name="pmid17636834">{{cite journal |author=Young T, Aukes J, Hughes R, Tang H |title=Vena caval filters for the prevention of pulmonary embolism |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD006212 |year=2007 |pmid=17636834 |doi=10.1002/14651858.CD006212.pub2}}</ref>
 
==ACCP Guidelines Catheter-directed Thrombolysis of Acute DVT of the Leg (DO NOT EDIT)==
<ref name="pmid18574272">{{cite journal |author=Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ |title=Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) |journal=Chest |volume=133 |issue=6 Suppl |pages=454S–545S |year=2008 |month=June |pmid=18574272 |doi=10.1378/chest.08-0658 |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=18574272 |accessdate=2012-01-04}}</ref>
{{cquote|
'''1.''' In selected patients with extensive acute proximal DVT (eg, iliofemoral DVT, symptoms for <14 days, good functional status, life expectancy of >1 year) who have a low risk of bleeding, we suggest that catheter-directed thrombolysis (CDT) may be used to reduce acute symptoms and postthrombotic morbidity if appropriate expertise and resources are available (Grade 2B).
 
'''2.''' After successful CDT in patients with acute DVT, we suggest correction of underlying venous lesions using balloon angioplasty and stents (Grade 2C).
 
'''3.''' We suggest pharmacomechanical thrombolysis (eg, with inclusion of thrombus fragmentation and/or aspiration) in preference to CDT alone to shorten treatment time if appropriate expertise and resources are available (Grade 2C).
 
'''4.''' After successful CDT in patients with acute DVT, we recommend the same intensity and duration of anticoagulant therapy as for comparable patients who do not undergo CDT (Grade 1C)}}.
 
===Recommendation for systemic Thrombolytic therapy===
{{cquote|
'''1.''' In selected patients with extensive proximal DVT (eg, symptoms for < 14 days, good functional status, life expectancy of > 1 year) who have a low risk of bleeding, we suggest that systemic thrombolytic therapy may be used to reduce acute symptoms and postthrombotic morbidity if CDT is not available (Grade 2C)}}.
 
===Recommendation for percutaneous venous Thrombectomy===
{{cquote|
'''1.''' In patients with acute DVT, we suggest that they should not be treated with percutaneous mechanical thrombectomy alone (Grade 2C)}}.
 
===Recommendation for operative venous Thrombectomy===
{{cquote|
'''1.''' In selected patients with acute iliofemoral DVT (eg, symptoms for < 7 days, good functional status, and life expectancy of > 1 year), we suggest that operative venous thrombectomy may be used to reduce acute symptoms and postthrombotic morbidity if appropriate expertise and resources are available (Grade 2B). If such patients do not have a high risk of bleeding, we suggest that catheter-directed thrombolysis is usually preferable to operative venous thrombectomy (Grade 2C).


'''2.''' In patients who undergo operative venous thrombectomy, we recommend the same intensity and duration of anticoagulant therapy afterwards as for comparable patients who do not undergo venous thrombectomy (Grade 1C)}}.
== Surgery ==
A single small randomized controlled trial showed that operative venous thrombectomy and anticoagulation therapy may lead to better iliac vein patency and less [[post-thrombotic syndrome]] as compared to [[anticoagulation therapy]] alone.<ref name="pmid9413377">{{cite journal| author=Plate G, Eklöf B, Norgren L, Ohlin P, Dahlström JA| title=Venous thrombectomy for iliofemoral vein thrombosis--10-year results of a prospective randomised study. | journal=Eur J Vasc Endovasc Surg | year= 1997 | volume= 14 | issue= 5 | pages= 367-74 | pmid=9413377 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9413377  }} </ref>
Operative venous thrombectomy is invasive and requires general anesthesia.  It also carries a small risk of [[pulmonary embolism]]. Operative venous thrombectomy should be considered only if all of the following criteria are met:<ref name="pmid22315268">{{cite journal |author=Kearon C, Akl EA, Comerota AJ, ''et al.'' |title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e419S–94S |year=2012 |month=February |pmid=22315268 |doi=10.1378/chest.11-2301 |url=}}</ref>
* Iliofemoral DVT
* Symptoms < 7 days
* Good functional status
* Life expectancy ≥1 year


===Recommendation for vena caval Filters===
==2012 American College of Chest Physicians Evidence-Based Clinical Practice Guidelines on Antithrombotic Therapy for VTE Disease: Antithrombotic Therapy and Prevention of Thrombosis (DO NOT EDIT)<ref name="pmid22315268">{{cite journal |author=Kearon C, Akl EA, Comerota AJ, ''et al.'' |title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e419S–94S |year=2012 |month=February |pmid=22315268 |doi=10.1378/chest.11-2301 |url=}}</ref>==
{{cquote|
'''1.''' For patients with DVT, we recommend against the routine use of a vena cava filter in addition to anticoagulants (Grade 1A).


'''2.''' For patients with acute proximal DVT, if anticoagulant therapy is not possible because of the risk of bleeding, we recommend placement of an inferior vena cava (IVC) filter (Grade 1C).
===Treatment of Acute DVT===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with acute proximal DVT of the leg, we suggest anticoagulant therapy alone over operative venous thrombectomy      ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''.<nowiki>"</nowiki>
|}


'''3.''' For patients with acute DVT who have an IVC filter inserted as an alternative to anticoagulation, we recommend that they should subsequently receive a conventional course of anticoagulant therapy if their risk of bleeding resolves (Grade 1C)}}.
==2011 AHA Scientific Statement-Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension (DO NOT EDIT)<ref name="pmid21422387">{{cite journal|author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 |pmid=21422387 | doi=10.1161/CIR.0b013e318214914f| pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref>==


===Recommendation for Immobilization for the Treatment of Acute DVT===
===Recommendations for Endovascular Thrombolysis and Surgical Venous Thrombectomy (DO NOT EDIT)<ref name="pmid21422387">{{cite journal|author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 |pmid=21422387 | doi=10.1161/CIR.0b013e318214914f| pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref>===
{{cquote|
'''1.''' In patients with acute DVT, we recommend early ambulation in preference to initial bed rest when this is feasible (Grade 1A)}}.


==Guidelines Resources==
{|class="wikitable"
* Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)<ref name="pmid18574272">{{cite journal |author=Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ |title=Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) |journal=Chest |volume=133 |issue=6 Suppl |pages=454S–545S |year=2008 |month=June |pmid=18574272 |doi=10.1378/chest.08-0658 |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=18574272 |accessdate=2012-01-04}}</ref>
|-
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Surgical venous thrombectomy by experienced surgeons may be considered in patients with IFDVT ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''.<nowiki>"</nowiki>
|}


==References==
==References==
{{reflist|2}}  
{{reflist|2}}  
 
[[Category:Needs overview]]
[[Category:Disease]]
[[Category:Cardiology]]
[[Category:Hematology]]
[[Category:Hematology]]
[[Category:Pulmonology]]
[[Category:Angiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Mature chapter]]
[[Category:Vascular surgery]]
[[Category:Up-To-Date]]
[[Category:Cardiovascular diseases]]


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Latest revision as of 16:14, 21 August 2014
Resident
Survival
Guide

Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] ; Kashish Goel, M.D.; Assistant Editor(s)-In-Chief: Justine Cadet

Deep Vein Thrombosis Microchapters

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Overview

Operative venous thrombectomy can be considered for the treatment of iliofemoral deep vein thrombosis (DVT), mainly when catheter directed thrombolysis (CDT) and pharmacomechanical catheter directed thrombolysis (PCDT) can not be performed.[1]

Surgery

A single small randomized controlled trial showed that operative venous thrombectomy and anticoagulation therapy may lead to better iliac vein patency and less post-thrombotic syndrome as compared to anticoagulation therapy alone.[2] Operative venous thrombectomy is invasive and requires general anesthesia. It also carries a small risk of pulmonary embolism. Operative venous thrombectomy 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

2012 American College of Chest Physicians Evidence-Based Clinical Practice Guidelines on Antithrombotic Therapy for VTE Disease: Antithrombotic Therapy and Prevention of Thrombosis (DO NOT EDIT)[1]

Treatment of Acute DVT

Class II
"1. In patients with acute proximal DVT of the leg, we suggest anticoagulant therapy alone over operative venous thrombectomy (Level of Evidence: C)."

2011 AHA Scientific Statement-Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension (DO NOT EDIT)[3]

Recommendations for Endovascular Thrombolysis and Surgical Venous Thrombectomy (DO NOT EDIT)[3]

Class IIb
"1. Surgical venous thrombectomy by experienced surgeons may be considered in patients with IFDVT (Level of Evidence: B)."

References

  1. ↑ 1.0 1.1 1.2 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)
  2. ↑ Plate G, Eklöf B, Norgren L, Ohlin P, Dahlström JA (1997). "Venous thrombectomy for iliofemoral vein thrombosis--10-year results of a prospective randomised study". Eur J Vasc Endovasc Surg. 14 (5): 367–74. PMID 9413377.
  3. ↑ 3.0 3.1 Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; et al. (2011). "Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association". Circulation. 123 (16): 1788–830. doi:10.1161/CIR.0b013e318214914f. PMID 21422387.

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