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Treatment Strategies for Proximal Deep Vein Thrombosis: A Network Meta-analysis of Randomised Controlled Trials

  • Author Footnotes
    ‡ These authors contributed equally to the manuscript.
    Mohammed Ashrafi
    Footnotes
    ‡ These authors contributed equally to the manuscript.
    Affiliations
    Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK
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  • Author Footnotes
    ‡ These authors contributed equally to the manuscript.
    Saad B. Ahmad
    Footnotes
    ‡ These authors contributed equally to the manuscript.
    Affiliations
    Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK
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  • Stavros A. Antoniou
    Affiliations
    Department of Surgery, Mediterranean Hospital of Cyprus, Limassol, Cyprus
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  • Taha Khan
    Affiliations
    Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK
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  • George A. Antoniou
    Correspondence
    Corresponding author. The Royal Oldham Hospital, Room G37, Vascular Offices, J Block, Rochdale Road, Oldham OL1 2JH, UK.
    Affiliations
    Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK

    Division of Cardiovascular Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK
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  • Author Footnotes
    ‡ These authors contributed equally to the manuscript.
Published:January 24, 2022DOI:https://doi.org/10.1016/j.ejvs.2021.10.058

      Objective

      To investigate the outcomes of treatment strategies for proximal and iliofemoral deep vein thrombosis (DVT).

      Methods

      Randomised controlled trials (RCTs) investigating outcomes of catheter directed thrombolysis (CDT), ultrasound assisted CDT (USCDT), percutaneous aspiration thrombectomy (PAT), and best medical therapy (BMT) for proximal DVT from 2000 onwards were considered. MEDLINE, EMBASE, and CINAHL were searched using the Healthcare Databases Advanced Search interface developed by the National Institute for Health and Care Excellence. The primary outcome was the rate of post-thrombotic syndrome (PTS), which was defined using the Villalta scoring system (score of ≥5). Secondary outcomes included vessel patency, recurrence, bleeding, and mortality. The network of evidence was summarised using network plots, and random effects network meta-analyses were performed. The certainty of evidence was assessed using the Certainty In Network Meta-Analysis (CINeMA) approach.

      Results

      Seven RCTs meeting the inclusion criteria were identified. There were direct comparisons between medical therapy, CDT, and USCDT across outcomes, except for patency. There were no direct comparisons between medical therapy and PAT (except for patency), and USCDT and PAT. There was no significant difference observed in PTS between the treatment modalities for proximal and iliofemoral DVT (low certainty). There was a significant difference in patency rates between medical therapy and USCDT (odds ratio [OR] 9.46, 95% confidence interval [CI] 3.05 – 29.35; low certainty) and CDT (OR 2.03, 95% CI 1.46 – 2.80; low certainty) in favour of USCDT and CDT, respectively, for proximal DVT. USCDT significantly improved patency rates compared with CDT (OR 4.67, 95% CI 1.58 – 13.81; very low certainty) for proximal DVT. There was no significant difference in DVT recurrence, bleeding, or mortality between treatment groups for proximal and iliofemoral DVT (low to moderate certainty for most comparisons).

      Conclusion

      USCDT may improve patency rates compared with BMT and the other interventional treatment modalities used for the management of proximal DVT. However, no treatment modality showed superiority with regard to a reduction in PTS, and overall, the quality of available evidence is poor.

      Keywords

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      Linked Article

      • Management of Proximal DVT: Clinical Benefit of Endovenous Intervention Is Still in Question
        European Journal of Vascular and Endovascular SurgeryVol. 63Issue 2
        • Preview
          A recent systematic review by Ashrafi et al. aimed to compare various techniques for treating proximal and iliofemoral deep vein thrombosis (DVT).1 Sixty per cent of lower extremity DVTs are proximal, defined as those involving the popliteal and/or more proximal veins, thereby contributing to feared complications such as pulmonary embolism and post-thrombotic syndrome (PTS). PTS refers to the constellation of pain, oedema, ulceration, and limited mobility caused by venous insufficiency following DVT.
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