Catheter-directed thrombolysis versus full anticoagulation alone in treating proximal iliofemoral deep venous thrombosis

Abstract

Dear Editor,

Venous thromoemolism (VTE) continues to be a major morbid condition in spite of much advancement in diagnostic and therapeutic measures. The incidence of VTE has been reported to be over 100 per 100,000 for some areas in the United States.¹

Understanding the pathophysiology of the condition and the impact on proximal iliocaval occlusive disease has contributed to the improvement in the utilization of therapeutic measures to prevent and/or minimize post-thrombotic syndrome (PTS).

Full anticoagulation should be the initial therapy for VTE, even though it is associated with higher rate of PTS; the most up-to-date document from the College of Chest Physicians Clinical Practice Guidelines is in favor of full anticoagulation instead of catheter-directed thrombolysis (CDT).^2,3 On the other hand, recommendations from the Society of Vascular Surgeons (SVS) and the American Venous Forum are in favor of using CDT with or without pharmacomechanical therapy (PMT) for patients with proximal iliofemoral DVT.⁴ Multiple retrospective and prospective studies have highlighted that CDT is associated with significant improvement in PTS and was associated with a better quality of life.^4–12

Although, many interventionists still use temporary inferior vena cava (IVC) filters before lysis, there is no level 1-evidence that a filter is needed, and it has been suggested that they should only be used in select cases.^4,13

CDT can be performed with a standard infusion catheter or via Ultrasound Endowave catheter (ECHO); still, there is no recommendation for one modality over the other.⁴ In conclusion, CDT with or without PMT is superior to full anticoagulation alone for treating patients with proximal iliofemoral DVT. There is no current consensus to recommend ECHO versus standard Catheter for CDT. This treatment modality should be offered to our patients as long as they have no contraindication to thrombolysis.

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