Prakash Saha (London, UK), speaking during the Venous and Lymphatic Challenges programme at CX (15–18 April, London, UK), outlined the three key steps to optimising treatment of acute deep vein thrombosis: identification, management, and surveillance. He added that the last step, surveillance, had not received “a lot of focus”.
According to Saha, 1 in 1,000 patients in the UK have a deep vein thrombosis and, of these, 30% will go on to develop post-thrombotic syndrome. But, the proportion of patients who develop post-thrombotic syndrome rises to more than 90% if they have iliofemoral involvement—which 10–15% of patients do. Overall, he noted, deep vein thrombosis costs the NHS £1 billion per year.
In terms of managing deep vein thrombosis, Saha reported that the focus has been on managing patients in an ambulatory setting, ensuring ultrasound is available 24/7 for identifying patients, providing early anticoagulation treatment, and “increasingly” identifying patients who need early triage and transfer for interventional treatments.
However, the optimal pathway for managing deep vein thrombosis should involve surveillance as well as identification and management. Saha noted that, generally, “there has been less concern about long-term outcomes”, and this meant that the third part of the pathway, surveillance, has received less focus. Furthermore, he stated that a multidisciplinary team—including primary care physicians, specialist nurses, interventional radiologists, and vascular specialists among others—should oversee the pathway.
The first step of the pathway—identification—involves accurate diagnosis, safety and timely treatment, and avoiding pulmonary embolism. Although ultrasound is the “cornerstone” of this part of the pathway, Saha said, it has limitations—such as a lack of availability of equipment or ultrasound imagers. “Innovations (for example, portable ultrasonography or specialist nurse-led procedures) may over these issues,” he observed. Another important part of identification is having access to cross-sectional imaging modalities such as computed tomography venogram.
Management—the second step in the pathway—involves good patient information, conservative measures (where appropriate), anticoagulation, and interventional treatments. Saha commented that the “BLAST tool” could be used to help determine which patients would benefit from catheter-directed thrombectomy, with BLAST standing for “bleeding risk, life expectancy, the anatomy of the deep vein thrombosis, the severity of the deep vein thrombosis, and timing”. An important factor in managing patients with deep vein thrombosis, Saha observed, was to recognise that these patients are “different from aneurysm patients”, because they are “young”, with an average age of 39 years and “tech savy”. Therefore, medical apps had a potential role in their management. Ultimately, Saha explained, the “key to good outcomes” was choosing the right patient, choosing the safest technique, proper planning (which “prevents poor technique”), and—to quote Gerard O’Sullivan (Galway, Republic of Ireland)— “making sure the first cases go OK. Maybe not perfect, but not disastrous.”
Surveillance was an important step in the pathway, Saha said, because deep vein thrombosis can lead to “chronic problems”. He added that the “St Thomas’ post-interventional protocol” (that is, the protocol of Guy’s and St Thomas’ NHS Foundation Trust) included full therapeutic low-molecular weight heparin (LMWH) ultrasound on the day after the procedure, and spilt dose LMWH for two weeks and ultrasound. Other steps in the protocol include ultrasound surveillance at six weeks, three months, six months, and yearly after the procedure. He added that there was also a need to assess Villalta scores and quality of life measures.