June 17, 2019
UK NICE Guidance Addresses Percutaneous Mechanical Thrombectomy for Acute DVT
June 18, 2019—The United Kingdom's National Institute for Health and Care Excellence (NICE) announced interventional procedure guidance on percutaneous mechanical thrombectomy for acute deep vein thrombosis (DVT) of the leg. The complete document is available on the NICE website, here.
The document states that health care professionals are expected to fully take the guidance into account when exercising their judgment, but the guidance does not override the individual responsibility of health care professionals to make decisions that are appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or caretaker.
The recommendations include the following:
- Regarding the safety of percutaneous mechanical thrombectomy for acute DVT of the leg, current evidence shows there are well-recognized but infrequent complications.
- For acute iliofemoral DVT, the evidence on efficacy is limited in quality and quantity; therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research.
- For distal DVT that does not extend into the common femoral vein, the evidence on efficacy is inconclusive; therefore, this procedure should only be used in the context of research.
Clinicians wishing to perform percutaneous mechanical thrombectomy for acute iliofemoral DVT should:
- Inform the clinical governance leads in their NHS trusts.
- Ensure that patients understand the procedure's safety and efficacy, as well as any uncertainties about these provide them with clear written information to support shared decision-making, and use NICE's information for the public.
Other recommendations include that clinicians enter details of all patients who undergo the procedure onto the British Society of Interventional Radiology's Venous registry and that further research reports the patient selection criteria, including the site of the clot, symptom severity, and age of patients.
The recommendations were developed by NICE after a review of the published literature on the efficacy and safety of this procedure. This included a comprehensive literature search and detailed review of the evidence from 14 sources, which was discussed by the committee. The evidence included two randomized controlled trials (one of which also had a published subgroup analysis), one systematic review, two registries, three nonrandomized comparative studies, four case reports, and one conference abstract that reported safety data.
The specialist advisers and the committee considered the key efficacy outcomes to be clot removal, reduction in postthrombotic syndrome, patient-reported outcomes (including quality-of-life scores), and reduction in pulmonary embolism. The key safety outcomes were bleeding, hemolysis, vessel damage (including stenosis), clot embolization, and rethrombosis.
Among the committee comments, it was noted that patient selection is important and patients should be assessed by a multidisciplinary team that includes a vascular surgeon, interventional radiologist, and hematologist. Additionally, the procedure is likely to have a better outcome when it is performed within 14 days of presentation of a DVT.