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Interventionist Treatment of Acute DVT
does not Represent any Advantge
over the Best Medical Treatment alone
Pascual Lozano Vilardell
Vascular 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 CDT
PTS 6 months 32% 30% NS
PTS 24 months 55% 41% P= .04
QALY 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 trasfusion 7,5%
CDT
PTS RR 0.19 95% CI, 0.07-0.48
Vein obstruction RR 0.38 95% CI, 0.18-0.37
Venous reflux RR 0.39 95% CI, 0.16-1.01
QOL -
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
90 000 DVT
3 649 CDT
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 AC
Mortality 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 AC
Blood trasfusion 11.1% 6.5% p <.001
Pulmonary embolism 17.9% 11.4% p < .001
Intracraneal hemorrhage 0.9% 0.3% p = .03
Vena 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 AC
Hospital 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

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Interventiontionist Treatment of Acute DVT

  • 1. Interventionist Treatment of Acute DVT does not Represent any Advantge over the Best Medical Treatment alone Pascual Lozano Vilardell Vascular Surgery Department Majorca. Spain
  • 2. Introduction DVT 3rd cause of CV morbidity/mortality Incidence of DVT: 1/1 000 Posthrombotic syndrome (PTS) 50% in 2 years
  • 3. 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
  • 4. Treatment for acute iliofemoral DVT Systemic anticoagulation Surgical thrombectomy (ST) Systemic thrombolysis Catheter-directed thrombolysis (CDT) CDT + stenting
  • 5. Treatment for acute iliofemoral DVT
  • 6. Treatment for acute iliofemoral DVT
  • 7. CDT + stent Broholm R et al. J Vasc Surg 2011;54:18-S-25S
  • 8. CDT + stent Broholm R et al. J Vasc Surg 2011;54:18-S-25S
  • 9. 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
  • 10. 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 CDT PTS 6 months 32% 30% NS PTS 24 months 55% 41% P= .04 QALY 24 months 31,6% 32,3% NS
  • 11. Treatment for acute iliofemoral DVT Casey et al. Treatment of acute iliofemoral deep vein thrombosis. J Vasc Surg 2012;55:1463-73
  • 12. Catheter Directed Thrombolysis Bleeding requiring trasfusion 7,5% CDT PTS RR 0.19 95% CI, 0.07-0.48 Vein obstruction RR 0.38 95% CI, 0.18-0.37 Venous reflux RR 0.39 95% CI, 0.16-1.01 QOL - Casey et al. Treatment of acute iliofemoral deep vein thrombosis. J Vasc Surg 2012;55:1463-73
  • 13. 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…
  • 14. 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 90 000 DVT 3 649 CDT
  • 15. 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 AC Mortality 1.2% 0.9%
  • 16. 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 AC Blood trasfusion 11.1% 6.5% p <.001 Pulmonary embolism 17.9% 11.4% p < .001 Intracraneal hemorrhage 0.9% 0.3% p = .03 Vena cava filter 34.8% 15.6% p < .001
  • 17. 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 AC Hospital charges 85 084 $ 28 164 $ p <.001
  • 18. CONCLUSIONS Interventionist treatment More expensive (x 4) High morbidity High bleeding rate No evidence about better QOL
  • 19. CONCLUSIONS Interventionist treatment of acute DVT does not represent any advantge over anticoagulation alone