Previous trials have shown that catheter-directed thrombolysis (CDT) for proximal deep vein thrombosis has a lower rate of post-thrombotic syndrome compared with systemic anticoagulation alone. However, a new retrospective cohort study shows that the mortality rates are equivalent and the rates of transfusion, IVC filter placement, PE, and intracranial hemorrhage are all significantly higher for CDT.
Patients with proximal deep vein thrombosis (DVT) are at high risk for postthrombotic syndrome (PTS), even if they receive systemic anticoagulation therapy. Recently, a small randomized trial showed that catheter-directed thrombolysis (CDT) can prevent PTS (number needed to treat, 7; NEJM JW Gen Med Jan 12 2012), but CDT’s effect on mortality and adverse events are unknown. Therefore, clinical practice and guidelines vary (Chest 2012; 141:2 Suppl:e419S; Circulation 2011; 123:1788).
From a national database, researchers identified ≈90,000 patients with principal diagnoses of proximal lower-extremity or caval DVT. The 3600 patients from this cohort who received CDT were compared with a similar number of propensity-matched patients who received systemic anticoagulation alone. The CDT and anticoagulation-alone groups had similar mortality (1.2% vs. 0.9%), but CDT patients were significantly more likely to require transfusion (11.1% vs. 6.5%) or inferior vena cava (IVC) filter placement (34.8% vs. 15.6%) or to experience pulmonary embolism (17.9% vs. 11.4%) or intracranial hemorrhage (0.9% vs. 0.3%). CDT also was associated significantly with longer mean length of stay (7.2 vs. 5.0 days) and higher hospital charges (≈US$85,000 vs. ≈$28,000).
CDT is only definitely indicated for massive proximal DVT WITH associated ischemia.
Bashir R et al. Comparative outcomes of catheter-directed thrombolysis plus anticoagulation vs anticoagulation alone to treat lower-extremity proximal deep vein thrombosis. JAMA Intern Med 2014 Jul 21; [e-pub ahead of print]. Link.