The Society of Interventional Radiology (SIR) published a position statement deeming endovascular thrombus removal “an acceptable treatment option in selected patients with acute iliofemoral deep vein thrombosis [DVT].” The position statement is published online on the Journal of Vascular and Interventional Radiology (JVIR) website.
SIR convened a multidisciplinary writing group that conducted a comprehensive literature review. The group used evidence from 84 studies—including randomised trials, systematic reviews and meta-analyses, prospective single-arm studies, and retrospective studies—to develop 17 recommendations to guide the use of endovascular venous intervention for the care of patients with acute iliofemoral DVT.
Among the key recommendations were for physicians to quickly identify DVT and provide prompt and adequate anticoagulation, symptom control and functional recovery at the time of diagnosis. For those with anatomically extensive and clinically severe DVT and low bleeding risk, a form of catheter-directed thrombolysis (CDT) is reasonable to use in carefully selected patients after evaluating their comorbidities and personal preferences.
“Endovascular management has been used to treat select patients with acute iliofemoral DVT for more than 25 years, but newer and better designed studies have shown us that such interventions are most effective and safest when applied to younger patients with severe DVT symptoms,” said Suresh Vedantham lead author and an interventional radiologist with the Washington University in St Louis (St Louis, USA).
“Most DVT patients will benefit from anticoagulation alone, and can be spared anything more invasive, but for those who are suffering from severe symptoms or are at the highest risk of developing lifestyle-limiting post-thrombotic syndrome, catheter-directed therapies are appropriate and effective in reducing symptom severity early and late,” said Vedantham.
Vedantham was the primary investigator on the ATTRACT trial, the findings of which were published in 2017 and informed the new recommendations. Vedantham lauded the efforts of the international thrombosis research community in conducting several pivotal randomised trials to enable well informed guidelines, and the strong support of the SIR Foundation in the development and conduct of ATTRACT.
Based on the findings of the ATTRACT trial, the position statement authors recommend against the use of CDT for most patients with DVT that is limited to the tibial, popliteal, and femoral veins, for patients with clinical factors that confer a moderate or high risk for bleeding, and for patients with only mild lower extremity symptoms.
“Patient selection is the most important factor for success in the application of interventional treatments,” said, Kush R Desai, chair of SIR’s Venous Disease Clinical Specialty Council, a co-author of the statement, and an interventional radiologist with Northwestern Medicine (Chicago, USA). “Our recommendations follow the evidence so those who may benefit from endovascular treatment options are quickly identified to receive care and ensure positive outcomes.”
“Timing of intervention for acute deep vein thrombosis is important to optimise outcomes,” said Ronald S Winokur, vice chair of SIR’s Venous Disease Clinical Specialty Council, co-author of the statement, and an interventional radiology with Weill Cornell Medicine (New York, USA). “Clear guidance on patient selection including an understanding of extent of disease and accounting for flow dynamics helps patients receive the best treatment at the right time.”
As further research proceeds, SIR believes that adherence to the recommendations in the position statement allow for the use of endovascular therapy in a manner that optimises benefit and minimizes harm.
“SIR is dedicated to the evidence-based practice of interventional radiology and ensuring our position statements and guidelines reflect the findings of the latest science so patients receive the best possible care,” said SIR President Parag J Patel, an interventional radiologist with the Medical College of Wisconsin (Milwaukee, USA). “Thank you to the authors for their time and energy to ensure that DVT patients have access to the care appropriate for their case and medical history.”