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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Overview
Percutaneous transcatheter treatment of patients with deep venous thrombosis (DVT) includes:
- 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, 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 for Catheter-Directed Thrombolysis are:
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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 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 for systemic thrombolysis are:
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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:
- Iliofemoral DVT
- Symptoms < 7 days
- Good functional status
- Life expectancy ≥1 year
- ACCP recommends catheter-directed thrombolysis above operative venous thrombectomy, if required.
ACCP recommendation:
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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 filter reduces pulmonary embolism[1] 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,[2] IVC filters are viewed as a temporary measure for preventing life-threatening pulmonary embolism.[3]
Recommendation for vena caval Filters
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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). 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) |
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Recommendation for Immobilization for the Treatment of Acute DVT
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1. In patients with acute DVT, we recommend early ambulation in preference to initial bed rest when this is feasible (Grade 1A) |
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Guidelines Resources
- Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)[4]
References
- ↑ 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.
- ↑ Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ (2008). "Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest. 133 (6 Suppl): 454S–545S. doi:10.1378/chest.08-0658. PMID 18574272. Retrieved 2012-01-04. Unknown parameter
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