Guidelines for Early Thrombus Removal in Acute DVT Published

April 20, 2012—The Society for Vascular Surgery and the American Venous Forum have issued clinical practice guidelines for early thrombus removal strategies in acute deep venous thrombosis (DVT). The guidelines, which were drafted by Mark H. Meissner, MD, et al, were published April 2 online ahead of print in the Journal of Vascular Surgery.

According to the guidelines, the anticoagulant treatment of acute DVT has historically been directed toward the prevention of recurrent venous thromboembolism. However, such treatment does not always protect against late manifestations of postthrombotic syndrome. By restoring venous patency and preserving valvular function, early thrombus removal strategies can potentially decrease postthrombotic morbidity.

Therefore, the Society for Vascular Surgery and the American Venous Forum assigned a committee of experts in venous disease to develop evidence-based practice guidelines for early thrombus removal strategies, including catheter-directed pharmacologic thrombolysis, pharmacomechanical thrombolysis, and surgical thrombectomy.

As detailed in the Journal of Vascular Surgery, these evidence-based recommendations were developed through a systematic review and meta-analysis of the relevant literature, supplemented when necessary by less rigorous data. Recommendations are made according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology, incorporating the strength of the recommendation (strong, 1; weak, 2) and an evaluation of the level of the evidence (A through C).

On the basis of the best evidence currently available, the guidelines recommend against routine use of the term “proximal venous thrombosis” in favor of a more precise characterization of thrombi as involving the iliofemoral or femoropopliteal venous segments (grade 1A).

The guidelines also suggest the use of early thrombus removal strategies in ambulatory patients with good functional capacity and a first episode of iliofemoral DVT of < 14 days in duration (grade 2C) and strongly recommend their use in patients with limb-threatening ischemia due to iliofemoral venous outflow obstruction (grade 1A).

Pharmacomechanical strategies are suggested rather than catheter-directed pharmacologic thrombolysis alone if resources are available, and surgical thrombectomy should be considered if thrombolytic therapy is contraindicated (grade 2C).

According to the investigators, most data regarding early thrombus removal strategies are of low quality but suggest important patient benefits with respect to reducing postthrombotic morbidity. It is anticipated that these guidelines will be revised as additional evidence becomes available.