interventiontionist treatment of acute dvt
TRANSCRIPT
Interventionist Treatment of Acute DVT
does not Represent any Advantge
over the Best Medical Treatment alone
Pascual Lozano VilardellVascular Surgery Department
Majorca. Spain
Introduction
DVT 3rd cause of CV morbidity/mortality
Incidence of DVT: 1/1 000
Posthrombotic syndrome (PTS)
50% in 2 years
Introduction: natural history DVT
Spontaneous thrombus recanalization
Iliofemoral 20% 5 years
Femoropopliteal 80% 6
months
Van 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
Treatment for acute iliofemoral DVT
Systemic anticoagulation
Surgical thrombectomy (ST)
Systemic thrombolysis
Catheter-directed thrombolysis
(CDT)
CDT + stenting
Treatment for acute iliofemoral DVT
Treatment for acute iliofemoral DVT
CDT + stent
Broholm R et al. J Vasc Surg 2011;54:18-S-25S
CDT + stent
Broholm R et al. J Vasc Surg 2011;54:18-S-25S
Catheter Directed Thrombolysis
Enden et al. Long-term outcome after CDT vs standard treatment for acute IF DVT (the CaVenT study): a RCT. Lancet 2012;379:31-8
Catheter Directed Thrombolysis
Enden et al. Long-term outcome after CDT vs standard treatment for acute IF DVT (the CaVenT study): a RCT. Lancet 2012;379:31-8
Anticoagulation CDTPTS 6 months 32% 30% NSPTS 24 months 55% 41% P= .04QALY 24 months 31,6% 32,3% NS
Treatment for acute iliofemoral DVT
Casey et al. Treatment of acute iliofemoral deep vein thrombosis. J Vasc Surg 2012;55:1463-73
Catheter Directed Thrombolysis
Bleeding requiring trasfusion7,5%
CDTPTS RR 0.19 95% CI, 0.07-0.48Vein obstruction RR 0.38 95% CI, 0.18-0.37Venous reflux RR 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
Treatment for acute iliofemoral DVT
Low-evidence studies:
Methodological limitations
Lack of bias protection
Lack of comparability of studies
Analysis of surrogate outcomes
Lack of QOL analysis
Publication and reporting biases…
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
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
CDT ACMortality 1.2% 0.9%
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
CDT ACBlood trasfusion 11.1% 6.5% p <.001Pulmonary embolism 17.9% 11.4% p < .001Intracraneal hemorrhage 0.9% 0.3% p = .03Vena cava filter 34.8% 15.6% p < .001
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
CDT ACHospital charges 85 084 $ 28 164 $ p <.001
CONCLUSIONS
Interventionist treatment
More expensive (x 4)
High morbidity
High bleeding rate
No evidence about better QOL
CONCLUSIONS
Interventionist treatment of acute DVT does not
represent any advantge over anticoagulation
alone