SIR Position Statement Addresses Appropriate Use of Endovascular Management of Acute Iliofemoral DVT

November 11, 2022—The Society of Interventional Radiology (SIR) announced the publication of a position statement on the endovascular management of acute iliofemoral deep vein thrombosis (DVT). The statement deems endovascular thrombus removal “an acceptable treatment option in selected patients with acute iliofemoral DVT.”

The position statement by Suresh Vedantham, MD, et al is available online in the Journal of Vascular and Interventional Radiology.

As explained in the press release, SIR convened a multidisciplinary writing group that conducted a comprehensive literature review. Evidence was used from 84 studies—including randomized 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 are for physicians to quickly identify DVT and provide prompt and adequate anticoagulation, symptom control, and functional recovery at the time of diagnosis.

The position statement recommends that for patients 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.

The position statement recommends 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.

According to SIR, the statement’s new recommendations were informed by findings from the ATTRACT (Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter-Directed Thrombolysis) clinical trial. Dr. Vedantham served as primary investigator of the ATTRACT trial.

In March 2017, Dr. Vedantham presented the 2-year results from the ATTRACT trial at the SIR Annual Scientific Meeting. In December 2017, the data were published by Dr. Vedantham et al in The New England Journal of Medicine (2017;377:2240-2252).

Dr. Vedantham commented in the current SIR press release, “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.”

Dr. Vedantham, who is an interventional radiologist with Washington University in St. Louis in St. Louis, Missouri, continued, “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.”

Kush R. Desai, MD, and Ronald S. Winokur, MD, who are Chair and Vice Chair, respectively, of SIR’s Venous Disease Clinical Specialty Council, were coauthors of the statement. Dr. Desai is an interventional radiologist with Northwestern Medicine in Chicago, Illinois. Dr. Winokur is an interventional radiologist with Weill Cornell Medicine in New York, New York.

Dr. Desai noted in the SIR press release, “Patient selection is the most important factor for success in the application of interventional treatments. Our recommendations follow the evidence so those who may benefit from endovascular treatment options are quickly identified to receive care and ensure positive outcomes.”

Dr. Winokur added, “Timing of intervention for acute DVT is important to optimize outcomes. 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 stated that it believes that adherence to the recommendations in the position statement allow for the use of endovascular therapy in a manner that optimizes benefit and minimizes harm.

SIR President Parag J. Patel, MD, an interventional radiologist with the Medical College of Wisconsin in Milwaukee, Wisconsin, stated in the press release, “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. 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.”