Deep vein thrombosis surgery
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
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Surgery
Mechanical Thrombectomy
- Percutaneous mechanical thrombectomy without concomitant thrombolysis has not been examined in randomized trials.
- 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 embolism.
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]
| “ |
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]
| “ |
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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Angioplasty
Angioplasty is the mechanical widening of a narrowed or totally obstructed blood vessel. These obstructions are often caused by atherosclerosis. The term angioplasty is a portmanteau of the words angio (from the Latin/Greek word meaning "vessel") and plasticos (Greek: "fit for moulding"). Angioplasty has come to include all manner of vascular interventions typically performed in a minimally invasive or percutaneous method.
ACC/AHA Guidelines- Recommendations for Percutaneous Transluminal Venous Angioplasty and Stenting (DO NOT EDIT)
| Class IIa |
| "1. Stent placement in the iliac vein to treat obstructive lesions after CDT, PCDT, or surgical venous thrombectomy is reasonable (Level of Evidence: C)." |
| "2. For isolated obstructive lesions in the common femoral vein, a trial of percutaneous transluminal angioplasty without stenting is reasonable (Level of Evidence: C)." |
| "3. The placement of iliac vein stents to reduce PTS symptoms and heal venous ulcers in patients with advanced PTS and iliac vein obstruction is reasonable (Level of Evidence: C)" |
| "4. After venous stent placement, the use of therapeutic anticoagulation with similar dosing, monitoring, and duration as for IFDVT patients without stents is reasonable (Level of Evidence: C)" |
| Class IIb |
| "1. After venous stent placement, the use of antiplatelet therapy with concomitant anticoagulation in patients perceived to be at high risk of rethrombosis may be considered (Level of Evidence: C) " |
Guidelines Resources
- Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Edition)[1]
- Guidelines on the management of Pulmonary embolism: Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension[5]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 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.
- ↑ 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.