Elsevier

International Journal of Cardiology

Volume 362, 1 September 2022, Pages 168-173
International Journal of Cardiology

Catheter directed thrombolysis for deep vein thrombosis in 2022: Rationale, evidence base and future directions

https://doi.org/10.1016/j.ijcard.2022.04.081Get rights and content

Highlights

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    Catheter Directed Thrombolysis for acute proximal deep vein thrombosis (DVT) and caval DVT has increasing utilized in the recent years and is associated with accelerated symptom resolution and improved quality of life.

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    Four randomized clinical trials have showed conflicting evidence and further studies are needed with improved patient selection to better understand the benefit of catheter directed thrombolysis over conventional therapy.

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    Successful catheter directed thrombolysis is associated with lower rates of moderate to severe post thrombotic syndrome and improved quality of life.

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    Adoption of novel devices, improvement in procedural techniques and appropriate selection of patients can all contribute to the improving safety of catheter directed thrombolysis and decreased rate of complications such as intracranial hemorrhage.

Abstract

Introduction

Catheter directed thrombolysis (CDT) has evolved as a treatment modality for patients diagnosed with proximal and caval deep vein thrombosis (DVT) and has shown to be superior in certain subset of patient population despite conflicting evidence as seen in the large 4 randomized controlled trials.

Rationale for CDT in acute DVT patients

DVT adversely affects the quality of life and adds significantly to the treatment and hospitalization costs. CDT and pharmaco-mechanical catheter directed thrombolysis (PCDT) has been shown to accelerate symptom resolution, decrease symptom severity and decrease recurrence rates with successful procedures in certain patients.

Randomized clinical trials (RCTs)

Four RCTs have evaluated the use of CDT and PCDT in acute proximal DVT patients suggesting clinical benefit compared to anticoagulation alone. These trials suggested using CDT for proximal DVT patients with a lower bleeding risk as CDT may decrease PTS. Successful CDT treatment showed improvement in moderate to severe symptoms of post thrombotic syndrome (PTS). However, these studies have limitations including the use of non-standard techniques, different equipment and different endpoints.

Future directions and conclusion

Our goal is to highlight the factors which can potentially improve CDT outcomes in proximal DVT patients. Based on studies, patients with proximal DVT and a low bleeding risk may benefit from early CDT by decreased symptom severity of PTS, however, improvement in procedural technique, equipment and procedural success rates is necessary. With appropriate patient selection, and objective endpoints, we can further establish the benefit of CDT and PCDT in acute DVT patients.

Introduction

The utilization of Catheter directed thrombolysis (CDT) as a treatment modality for patients with proximal and caval deep vein thrombosis (DVT) has increased over time despite conflicting evidence (Fig. 1) [1,2]. To date, there have been a total of four randomized controlled trials that evaluated the efficacy and safety of CDT for treatment of DVT [[3], [4], [5], [6]]. In this review, we discuss the lessons learnt from these trials and attempt to define the role of contemporary CDT as a treatment option for patients with proximal DVT.

Section snippets

Symptom resolution and quality of life

For many young active patients, persistent symptoms can be physically debilitating. 7–15% of patients with acute DVT, experience a recurrent episode of DVT [7,8]. DVT hospitalization and treatment costs exceed $4.9 to $7.5 billion per year in the US [9]. For patients that develop complications including post thrombotic syndrome, the quality of life declines dramatically, which mirrors that seen in chronic heart or lung disease [10]. CDT and Pharmaco-mechanical Catheter Directed Thrombolysis

Randomized controlled trials (RCT) of CDT plus anticoagulation versus anticoagulation alone

There are four RCT comparing CDT plus anticoagulation vs anticoagulation alone as preferred first line treatment options in patients diagnosed with proximal DVT (Table 1).

The need for better techniques

The benefit of CDT is directly related to the adequacy of thrombus removal. This is evident from the CAVA trial, where successful CDT was associated with improved symptom severity and quality of life in patients undergoing CDT [24]. We need to optimize CDT techniques so that the success rates and outcomes of CDT can be improved. Another factor that can improve CDT outcomes is use of intravascular ultrasound and adjunctive angioplasty and stenting of any obstructive lesion [24]. We expected that

Conclusion

PCDT for patients with DVT has the potential for accelerated symptom resolution, reducing incidence of moderate to severe PTS and recurrent DVT in patients with acute proximal DVT. The evidence base for net benefits of CDT in contemporary clinical practice remains limited and conflicting as seen in the above mentioned RCTs. However, on detailed analyses, CDT did show a potential benefit in a subgroup of iliofemoral DVT patients. Optimal patient, device and operator selection is important and

Funding and grant support

None.

Disclosures

Dr. Riyaz Bashir has equity interest in Thrombolex Inc. Dr. Bashir receives research support from the NIH.

Dr. Maninder Singh: Research funding support from Donald Guthrie research foundation.

Dr. Muhammad Umar Khalid and Dr. Vladimir Lakhter have no disclosures.

Declaration of Competing Interest

Dr. Riyaz Bashir has equity interest in Thrombolex Inc. Dr. Bashir receives research support from the NIH.

Dr. Muhammad Umar Khalid, Dr. Maninder Singh, and Dr. Vladimir Lakhter have no conflicts of interest.

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