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Catheter-Directed Thrombolysis Adds Risk for DVT

N Engl J Med; 2017 Dec 7; Vedantham, et al

Publish date:: December 19, 2017

The addition of pharmacomechanical catheter-directed thrombolysis to anticoagulation therapy did not result in a lower risk of the post-thrombotic syndrome, but did result in a higher risk of major bleeding among patients with acute proximal deep-vein thrombosis (DVT), according to a recent study. 692 patients with acute proximal DVT were randomly assigned to receive either anticoagulation alone (control) or anticoagulation plus pharmacomechanical thrombolysis. The primary outcome was development of the post-thrombotic syndrome between 6 and 24 months of follow-up. Researchers found:

Between 6 and 24 months, there was no significant between-group difference in the percentage of patients with the post-thrombotic syndrome.
Pharmacomechanical thrombolysis led to more major bleeding events within 10 days, but no significant difference in recurrent venous thromboembolism was seen over the 24-month follow-up period.
Moderate-to-severe post-thrombotic syndrome occurred in 18% of patients in the pharmacomechanical-thrombolysis group vs 24% of those in the control group.

Citation:

Vedantham S, Goldhaber SZ, Kahn SR, et al. Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis. N Engl J Med. 2017;377:2240-2252. doi:10.1056/NEJMoa1615066.

Commentary:

Post-thrombotic syndrome occurs in approximately half of patients with proximal DVT. Post-thrombotic syndrome, resulting in a chronically swollen, painful leg, causes a great deal of morbidity for patients. Thrombolysis has been suggested as an intervention that could decrease the incidence of post-thrombotic syndrome. This study shows that intervention with both mechanical and chemical thrombolysis does not result in a lower rate of post-thrombotic syndrome than anticoagulation alone, but causes more major bleeding. At this point, the approach to non-leg threatening DVT is clear: anticoagulation, with thrombolysis reserved for unusually large or leg-threatening DVT. —Neil Skolnik, MD

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