The technique has potential to reduce chronic discomfort and disability substantially.

Anticoagulation after lower-extremity deep venous thrombosis (DVT) can prevent thrombus extension, embolization, recurrence, and death, but does not prevent common chronic sequelae such as edema, pain, hyperpigmentation, and skin breakdown (collectively known as postthrombotic syndrome [PTS]). Systemic thrombolysis can prevent PTS but increases bleeding risk. In catheter-directed thrombolysis (CDT), a catheter with side-holes is embedded in the thrombus and releases a thrombolytic agent over several days.

Investigators in Norway randomized 209 adults with first-time iliofemoral DVT to conventional treatment with heparin and warfarin or to conventional treatment plus CDT. CDT patients underwent venography to determine the extent of thrombus, followed by catheter insertion (usually into the popliteal vein). Use of additional modalities, such as angioplasty and stents, was permitted at the discretion of the treating physicians. Patients in both groups were advised to use knee-high compression stockings for 2 years.

At 6 months, prevalence of iliofemoral patency was significantly higher (66% vs. 47%) in CDT patients, and PTS occurred with equal frequency (about 30%) in both groups. After 24 months, however, prevalence of PTS was significantly lower (41% vs. 56%) in patients who underwent CDT. Three major and 17 other bleeding complications occurred in the CDT group; none were life-threatening.

Comment: Despite some methodologic weaknesses, this unblinded study adds important data to an otherwise sparse evidence base for CDT and suggests that this technique can substantially reduce chronic discomfort and disability after DVT. For now, however, American College of Chest Physicians guidelines recommend CDT only for “selected patients with extensive acute proximal DVT.”

Source: Journal Watch General Medicine