Thrombectomy Can Improve DVT, VTE Outcomes

Alice Goodman

November 30, 2009

December 1, 2009 (New York, New York) — Major changes in the most recent version of the American College of Chest Physicians (ACCP) guidelines could lead to improved outcomes for patients with extensive deep vein thrombosis (DVT). All physicians need to do is follow them, but widespread adoption of these changes will take time, experts announced here at the 36th Annual VEITH Symposium.

"The most remarkable change in the guidelines is that venous thrombectomy is now recommended for extensive DVT [i.e., iliofemoral DVT]. Before 2008, anticoagulation was the standard of care. Currently, with these new guidelines, most physicians just leave that type of clot where it is and use anticoagulation. We have a long way to go, although there is increasing recognition of the benefits of clot removal. Even some academic centers are not using thrombectomy," said Anthony J. Comerota, MD, director of the Jobst Vascular Center in Toledo, Ohio, speaking at the symposium.

Thrombectomy was added to the ACCP guidelines for the treatment of extensive DVT on the basis of data from a randomized controlled trial showing that thrombectomy with arterio-venous fistula was superior to anticoagulation. Arterio-venous fistula added to thrombectomy increases the blood flow velocity after the clot is removed, reducing the likelihood of rethrombosis.

In addition, 2 randomized trials from Europe showed that catheter-directed thrombolysis of iliofemoral DVT improved patency, reflux, and length of hospital stay compared with anticoagulation. Now clot removal with either thrombectomy or catheter-based thrombolysis should be the new standard of care, Dr. Comerota told listeners. The guidelines suggest pharmacomechanical prophylaxis instead of catheter-directed thrombolysis alone to shorten treatment time.

"There is a 'culture of anticoagulation' among physicians, even for patients with the most extensive DVT. Unfortunately, physicians accept leaving large burdens of clot in the venous system, which obstructs venous return and causes venous hypertension and severe postthrombotic morbidity. Quality of life can be preserved if the venous system remains patent, and many patients will continued to have normal venous valve function after successful clot removal. I believe that this should be the goal of therapy in patients with extensive DVT," Dr. Comerota said.

At present, catheter-directed thrombolysis with or without mechanical techniques may be used for extensive [iliofemoral] DVT," Dr. Comerota explained. "This practice change needs to be recognized and implemented by physicians in the community," he added.

Professional Education Needed

Thrombolysis is generally reserved for extensive clot, such as iliofemoral thrombosis. In 2008, ACCP published new evidence-based clinical guidelines for the treatment of venous thromboembolic disease, which, for the first time, suggested the use of pharmacomechanical thrombolysis in the treatment of certain cases of acute DVT, such as iliofemoral thrombosis. It is important that we, as vascular surgeons, continue to educate the numerous physicians who treat DVT about the appropriate and recently updated guidelines to ensure that patients are getting adequate therapy," said Frank R. Arko, MD, chief of endovascular surgery and associate professor at University of Texas Southwestern Medical Center in Dallas.

Dr. Comerota reports relationships with Bristol Myers Squibb/Sanofi-Aventis, Covidien, Cook, and the National Institutes of Health. Dr. Arko reports being a consultant to Covidien.

36th Annual VEITH Symposium. Presented November 20, 2009.


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