KEYWORDS: The goals of successful management of deep vein thrombosis (DVT) include relief of acute symptoms
Deep vein thrombosis; with restoration of venous patency, prevention of clot propagation and subsequent pulmonary embo-
Low-molecular-weight lism, and maintenance of venous valvular function. Valvular incompetence is the leading cause of
heparin; postthrombotic syndrome (PTS), which is characterized by chronic leg heaviness and aching, lower
Postthrombotic extremity edema, and impaired viability of subcutaneous tissues, which may lead to chronic trophic skin
syndrome; changes and venous ulceration.
Unfractionated heparin Anticoagulation with unfractionated or low-molecular-weight heparin followed by warfarin is rec-
ognized as the standard therapy for acute DVT. Although this approach may effectively prevent
recurrent thrombosis, it often fails to meet the other treatment goals. Recent studies have demonstrated
that early clot lysis through the use of catheter-directed thrombolytic therapy and other adjunctive endo-
vascular techniques rapidly restores venous patency, more effectively preserves valvular function, and
improves quality of life. When used in conjunction with anticoagulation, these minimally invasive endo-
vascular techniques have the potential to lead to improved long-term outcomes in patients with DVT.
© 2005 Elsevier Inc. All rights reserved.
Deep vein thrombosis (DVT) is a common condition, propagation and embolization. Anticoagulation typically
with ⬎250,000 new cases reported annually in the United consists of a short course of treatment with intravenous (IV)
States.1 When inadequately treated, DVT may be compli- unfractionated heparin (UFH) followed by a period of 3 to
cated acutely by the development of pulmonary embolism 6 months of oral warfarin.4 Results from several recent
(PE) and in the long-term by chronic venous insufficiency, randomized clinical trials demonstrate that outpatient anti-
also known as postthrombotic syndrome (PTS). As many as coagulant treatment with subcutaneous low-molecular-
7 million individuals experience complications of severe weight heparin (LMWH) is feasible, and may confer several
chronic venous disease,2 many cases of which are the direct advantages over inpatient treatment with IV UFH.5 The
result of previous DVT. The economic impact of compli- potential advantages of LMWH include once- or twice-daily
cations related to PTS have been estimated to account for as dosing due to its longer half-life and fixed dosages due to a
much as 75% of the total care cost of DVT.3 more predictable antithrombotic effect. The use of LMWH
therefore eliminates the need for laboratory monitoring,
reducing the costs associated with hospital stays in these
Current treatment of deep vein thrombosis patients and promoting earlier discharge.6
Although anticoagulation is useful in the reduction of
Historically, the standard treatment for DVT has been the
recurrent thrombotic events and the prevention of PE,7 used
administration of anticoagulant drugs to prevent thrombus
alone it is rarely able to facilitate clot lysis adequately.8
Preservation of valve function and prevention of PTS has
Requests for reprints should be addressed to Andrew Blum, MD,
Division of Vascular Interventional Radiology, Midwest Heart Specialists,
not been established with UFH use.8,9 Anticoagulation reg-
429 North York Road, Elmhurst, Illinois 60126. imens, along with their strengths and weaknesses, are fur-
E-mail address: ablum@midwestheart.com. ther explored by Merli elsewhere in this supplement.10 The
0002-9343/$ -see front matter © 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjmed.2005.06.007
32S The American Journal of Medicine, Vol 118 (8A), August 2005
objective of this article is to review the utility of thrombo- Table 1 Outcome of anticoagulation versus systemic
lytic therapy and other adjunctive endovascular techniques thrombolytic infusion for acute deep vein thrombosis: results
in the setting of more extensive iliofemoral DVT. of 13 studies
Lysis
Case study
Intervention
Clinical response
Figure 6 (A) Patency of inferior vena cava postthrombolysis. (B and C) Patency of femoral vein postthrombolysis.
36S The American Journal of Medicine, Vol 118 (8A), August 2005
lar techniques, followed by outpatient management with venous thrombosis: an interim report of a prospective trial. Br J Surg.
anticoagulation is highly recommended in such instances. 1979;66:838 – 843.
9. Arnesen H, Høiseth A, Ly B. Streptokinase or heparin in the treatment
Placement of temporary or permanent IVC filters before
of deep vein thrombosis: follow-up results of a prospective study. Acta
catheter-directed thrombolysis may benefit patients at high Med Scand. 1982;211:65– 68.
risk for PE and is a stand-alone option for those with 10. Merli G. Anticoagulants in the treatment of deep vein thrombosis.
complications from or contraindications for anticoagulation Am J Med. 2005;118(Suppl 8A)13S–20S.
therapy and thrombolysis. Surgical thrombectomy is re- 11. Meissner MH, Manzo RA, Bergelin RO, et al. Deep venous insuffi-
served for patients who have failed therapy with these ciency: the relationship between lysis and subsequent reflux. J Vasc
less-invasive techniques. With continuing development and Surg. 1993;18:596 – 608.
12. Killewich LA, Martin R, Cramer M, et al. An objective assessment of
a growing body of experience with these new and/or refined
the physiological changes in the postthrombotic syndrome. Arch Surg.
methods to treat DVT, the goals of successful management 1985;120:424 – 426.
are closer to being met. 13. Comerota A, Aldridge S. Thrombolytic therapy for acute deep venous
thrombosis. Semin Vasc Surg. 1992;5:76 – 81.
14. Elsharawy M, Elzayat E. Early results of thrombolysis vs. anticoagu-
lation in iliofemoral venous thrombosis: a randomized clinical trial.
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