Journal of Vascular and Interventional Radiology
Quality improvement guidelineQuality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal
Section snippets
Methodology and Limitations
SIR creates its Standards of Practice documents with use of the following process: Standards documents of relevance and timeliness are conceptualized by the Standards of Practice Committee members. A recognized expert is identified to serve as the principal author, with additional authors assigned depending on the project's magnitude.
An in-depth literature search is performed with use of electronic medical literature databases. A critical review of peer-reviewed articles is performed with
Disease Processes
Venous thromboembolism (VTE) refers to the single common disease entity with two principal manifestations: DVT and PE. A patient with a proved episode of DVT and/or PE is said to have had an episode of VTE.
Pulmonary embolism (PE) refers most commonly to the intravascular migration of a venous thrombus to the pulmonary arterial circulation. Proved PE refers to PE that is documented by a positive pulmonary angiogram, an unequivocally positive helical CT scan, a high probability
Pretreatment Assessment
A careful medical history and directed physical examination will usually yield most of the information needed to determine the appropriateness of endovascular therapy. Patients should be queried about known VTE risk factors, details of prior VTE episodes and treatments, the duration and exact nature of preexisting and more recent limb symptoms, and common PE symptoms such as dyspnea, chest pain, palpitations, hemoptysis, and syncope. Identification of PE is important because systemic PE
Indications and Contraindications
For any particular DVT patient, the decision to use endovascular therapy depends on a balanced assessment of the likelihood that the patient will experience treatment success, the degree to which this benefit would be clinically meaningful to the patient, and the likelihood that the patient will suffer a major complication. The challenge in making this clinical determination is heightened by the lack of conclusive randomized trial data that characterize the actual safety and efficacy of
Venous Access
Venous access for endovascular DVT treatment should be obtained in percutaneous fashion in nearly all instances. Common sites include the popliteal veins, internal jugular veins, common femoral veins, and the tibial veins. Real-time ultrasound guidance is highly recommended for internal jugular vein, popliteal vein, and posterior tibial vein punctures, because it provides visualization of adjacent arterial structures and minimizes the number of needle passes, leading to fewer access site
Immediate Post-Procedure Follow-Up Care
After thrombolysis is discontinued, the patient is typically given anticoagulation to therapeutic levels using unfractionated heparin. The use of low molecular weight heparins immediately after thrombolysis has not been studied. If unfractionated heparin is used, it may be either continued or halted briefly before venous sheath removal, but complete reversal of its effects is generally not desirable. If heparin is discontinued to permit sheath removal, it may be restarted soon after hemostasis
Long-Term Follow-Up Care
Patients treated for DVT with endovascular thrombus removal must have diligent long-term clinical follow-up for the best clinical outcomes to be obtained. Two major elements of standard DVT care should be instituted. One element is transition to outpatient therapy with a vitamin K antagonist, a low molecular weight heparin, or another appropriate anticoagulant (5). Appropriate INR monitoring must be arranged when vitamin K antagonists are used. The other element is use of graduated compression
Success Rates
The major goals of endovascular DVT therapy for acute DVT are several: (a) elimination of thrombus and re-establishment of venous patency; (b) provision of immediate symptom resolution; (c) prevention of recurrent DVT, valvular dysfunction, and PTS; (d) prevention of PE; and (e) preservation of limb and visceral organ function.
There currently exist no large multicenter randomized trials that have quantified the actual efficacy of CDT for DVT. Analysis of the available literature is limited by
Complications
Complications are stratified on the basis of outcome, per SIR reporting standards (Table 5). Published rates for individual types of complications are highly dependent on patient selection and may therefore vary from those reported in the literature. It is also recognized that a single complication can cause a rate to cross above a complication-specific threshold when only a small volume of patients are treated, for example early in a quality improvement program. In this situation, the overall
Conclusion
The use of endovascular methods to treat lower extremity DVT is feasible and has shown potential to speed symptomatic relief and prevent PTS-related disability. The quality improvement guidelines presented here are intended to improve the interventionalist's ability to coordinate the patient selection process, to perform these procedures in the safest possible manner, and to obtain the best clinical results.
Acknowledgments
Dr. Suresh Vedantham authored the first draft of this document and served as topic leader during the subsequent revisions of the draft. Drs. John F. Cardella and Robert Morgan chair the Standards of Practice Committees for SIR and CIRSE, respectively. Dr. David Sacks is Councilor of the SIR Standards Division. All other authors are listed alphabetically. Other members of the Standards of Practice Committee and SIR who participated in the development of this clinical practice guideline are
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2019, Annals of Vascular Surgery
None of the authors have identified a conflict of interest.
This article first appeared in J Vasc Interv Radiol 2006; 17:435–448.
Address correspondence to Tricia McClenny, 3975 Fair Ridge Dr, Suite 400 North, Fairfax, VA 22033