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Management of Proximal DVT: Clinical Benefit of Endovenous Intervention Is Still in Question

Open ArchivePublished:December 24, 2021DOI:https://doi.org/10.1016/j.ejvs.2021.11.002
      A recent systematic review by Ashrafi et al. aimed to compare various techniques for treating proximal and iliofemoral deep vein thrombosis (DVT).
      • Ashrafi M.
      • Ahmad S.B.
      • Antoniou S.A.
      • Khan T.
      • Antoniou G.A.
      Treatment strategies for proximal deep vein thrombosis: a network metaanalysis of randomised controlled trials.
      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. PTS affects up to 50% of patients with proximal DVT and contributes to substantial morbidity and healthcare costs.
      • Ashrafi M.
      • Ahmad S.B.
      • Antoniou S.A.
      • Khan T.
      • Antoniou G.A.
      Treatment strategies for proximal deep vein thrombosis: a network metaanalysis of randomised controlled trials.
      ,
      • Makedonov I.
      • Kahn S.R.
      • Galanaud J.P.
      Prevention and management of the post-thrombotic syndrome.
      Various treatment strategies have emerged that aim to reduce the sequelae of DVT. Medical therapy, involving anticoagulation and compression, remains the standard approach. However, treatment has evolved to include early invasive intervention for vessel recanalisation.
      • Midulla M.
      • Chevallier O.
      • Comby P.O.
      • Giordano G.
      • Pescatori L.C.
      • Falvo N.
      • et al.
      Endovascular management of the deep venous thrombosis: a new challenging role for the endovascular specialist in 2020.
      Ashrafi et al. compared medical and endovenous techniques using meta-analyses of seven randomised controlled trials. Endovenous strategies included catheter directed thrombolysis (CDT), ultrasound assisted CDT (USACDT), and percutaneous aspiration thrombectomy (PAT), often with additional balloon venoplasty and/or stenting to relieve residual stenosis.
      There were significantly better patency rates following both USACDT and CDT compared with medical therapy (odds ratio [OR] 9.46 with 95% confidence interval [CI] 3.05 – 29.35 and OR 2.03 with 95% CI 1.46 – 68 2.80, respectively), with USACDT also showing improved patency rates over CDT (OR 4.67, 95% CI 1.58 – 13.81). However, there was no significant difference in the rate of PTS, recurrence, bleeding, or mortality between treatment modalities.
      Several limitations to this study exist. Notably, the overall quality of the available evidence is low. Among included studies, there was significant patient heterogeneity, such as in the prevalence of underlying clotting diatheses. There was also heterogeneity in treatment protocols, with varying use of numerous anticoagulants and thrombolytics. Additionally, most of the studies did not follow patients beyond one year. These discrepancies make direct comparison difficult and highlight the lack of clarity regarding best therapy for particular patient populations.
      Ultimately, no superior treatment modality was identified regarding the primary and most secondary outcomes, although USACDT outperformed other modalities in achieving vein patency. However, patency does not seem to correspond with other desired outcomes, such as reduction of PTS, and thus does not indicate a clinically significant benefit of USACDT. Multiple strategies for treating proximal DVT are acceptable, and the management approach remains at the discretion of the provider and his or her expertise. Further high quality studies of representative populations with adequate power and follow up duration are needed to determine treatment superiority, which has proven difficult for this condition despite its prevalence.

      References

        • Ashrafi M.
        • Ahmad S.B.
        • Antoniou S.A.
        • Khan T.
        • Antoniou G.A.
        Treatment strategies for proximal deep vein thrombosis: a network metaanalysis of randomised controlled trials.
        Eur J Vasc Endovasc Surg. 2022; 63: 323-334
        • Makedonov I.
        • Kahn S.R.
        • Galanaud J.P.
        Prevention and management of the post-thrombotic syndrome.
        J Clin Med. 2020; 9: 923
        • Midulla M.
        • Chevallier O.
        • Comby P.O.
        • Giordano G.
        • Pescatori L.C.
        • Falvo N.
        • et al.
        Endovascular management of the deep venous thrombosis: a new challenging role for the endovascular specialist in 2020.
        Catheter Cardiovasc Interv. 2021; 98: 748-755

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