Abstract :
Venous thromboembolism (VTE) is a highly prevalent disorder with an incidence of nearly 1 million cases per year in the United States. In recent years, endovascular techniques that enable rapid venous thrombus removal or inferior vena cava (IVC) interruption have undergone major refinements, yet have not been readily welcomed by the physician community. Clinical reports and publications by different subspecialists and their professional societies reflect wide inconsistencies in the use of endovascular procedures and fail to reflect a contemporary understanding of the health consequences of deep vein thrombosis (DVT). This article updates physicians on key treatment considerations, including the use of endovascular interventions, that should influence clinical decision-making for acute DVT. Postthrombotic syndrome (PTS) occurs in 25% to 50% of patients with proximal DVT receiving standard anticoagulant therapy. PTS often leads to chronic lifestyle-limiting symptoms, work disability, major quality of life impairment, and high costs to patients and society. Although evidence from observational and randomized control studies has shown that early thrombus removal is likely to prevent PTS, bleeding complications remain a significant concern with thrombolytic therapy. For these reasons, the use of adjunctive endovascular thrombolysis should be accepted as appropriate for patients with life-threatening, limb-threatening, or organ-threatening complications of DVT, as well as for patients who fail to exhibit an acceptable response to initial anticoagulant therapy if they do not have additional risk factors for bleeding and such an approach is consistent with their preferences. Based on available evidence, the first-line use of endovascular thrombolysis should routinely be offered to patients with acute iliofemoral DVT who do not have risk factors for bleeding. A randomized controlled trial of permanent IVC filters added to the information available about these devices, but the data from this study have been susceptible to widely varying interpretations. The advent of retrievable IVC filters has resulted in greater utilization, but better studies are needed to determine the proper indications for their use. Endovascular therapy shows great promise for improving DVT outcomes, but its proper utilization remains uncertain. This uncertainty may be rooted in the absence of a US-based randomized controlled trial that challenges existing paradigms of DVT treatment. To reinvent and reorient DVT clinical practice patterns, physicians should (1) include PTS prevention as a key goal of initial DVT therapy; (2) recognize that iliofemoral DVT is a distinct clinical entity; (3) recognize the health significance of PTS in interpreting DVT trial results; and (4) embrace a new concept of health impairment caused by DVT with recognition of a broad range of DVT treatments and treatment outcomes.
