ANTICOAGULATION THERAPY OR

CATHETER DIRECTED THROMBOLYSIS

Alice Marinho, Carlos Veterano, Maricruz Nunes, Patrícia Baptista, Pedro Aguiar, Pedro Campelo, Rosana Dias, Sandra Santos, Sara Peixoto

Class 20

Introdução à Medicina IIMay 2011

ILIO-FEMORAL THROMBOSISILIO-FEMORAL THROMBOSIS

Mestrado Integrado em Medicina

1. Background1. Background

Introdução à Medicina II March 2011

1. Background1. Background

Image 1

Deep Venous Thrombosis (DVTs)

Ilio-femoral Vein

Deep Venous Thrombosis (DVTs)

Ilio-femoral Vein

“Deep venous thrombosis (DVTs) are a significant cause of morbidity

and mortality in the general population” [1]

Introdução à Medicina II March 2011

[1] Gogalniceanu P, Johnston CJ, Khalid U, Holt PJ, Hincliffe R, Loftus IM, Thompson MM; Indications for thrombolysis in deep venous thrombosis, 2009

1. Background1. Background

Introdução à Medicina II March 2011

Anticoagulation Anticoagulation therapytherapy

Catheter directed Catheter directed thrombolysisthrombolysis

1. Background: Anticoagulation Therapy1. Background: Anticoagulation Therapy

Introdução à Medicina II March 2011

Low-molecular-weight Heparin(Enexoparin)

Unfractionated heparin

ANTICOAGULATION THERAPY

Raham Ali et Al.; A comparison of different treatment managements in patients with acute deep vein thrombosis by the effects on enhancing venous ontflow in the lower limb, 2009

Image 2

Vitamin K Antagonists

1. Background: Catether directed-thrombolysis1. Background: Catether directed-thrombolysis

Introdução à Medicina II March 2011

Thrombolytic agent: urokinase or streptokinase or rtPA

Venous approach to ilio-femoral vein: popliteal

common femoral

Cava filters, venous stents and angioplastic balloon

Thrombolytic agent: urokinase or streptokinase or rtPA

Venous approach to ilio-femoral vein: popliteal

common femoral

Cava filters, venous stents and angioplastic balloon

Image 4Image 3

T. Wicky Stephan; Acute Deep Vein Thrombosis and Thrombolysis; 2009

Image 5

2. Research question2. Research question

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Measure:

Lysis

Patency

Complications

Recurrency

Recovery of limb function

Image 6 – Clot formation

3. Aims3. Aims

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4. Methodology: Query4. Methodology: Query

(venous thrombosis OR thrombus OR clot OR venous blockage) AND (femoral

vein OR ilio-femoral vein) AND (heparin OR catheter directed thrombolysis OR

anticoagulation therapy OR thrombolytic therapy)

(venous thrombosis OR thrombus OR clot OR venous blockage) AND (femoral

vein OR ilio-femoral vein) AND (heparin OR catheter directed thrombolysis OR

anticoagulation therapy OR thrombolytic therapy)

Introdução à Medicina II March 2011

Image 9

Image 7

Image 8

Data bases: Pubmed , Scopus, CochraneData bases: Pubmed , Scopus, Cochrane

4. Methodology: Selection Criteria4. Methodology: Selection Criteria

Inclusion criteria

• Condition under study: deep-

venous thrombosis

• Affected vein: iliofemoral vein

• Treatment used: anticoagulation

therapy or CDT

• Variables measured: mortality,

efficency, life quality after

treatment, recurrency, patency,

venous obstruction, etc.

Exclusion criteria

• Idiom: other than Portuguese,

English or Spanish

• Population: other that adult

humans with no other significant

health problems.

Introdução à Medicina II March 2011

Image 10

4. Methodology: Articles’ Selection4. Methodology: Articles’ Selection

215 articles215 articles

33 articles33 articles

23 articles included

23 articles included

Read titleRead

Abstract

Read full text

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Pubmed, Scopus, Cochrane

4 clinical trials that compare both

treatments

4 clinical trials that compare both

treatments

15 systematic reviews

15 systematic reviews 8 clinical trials 8 clinical trials

4. Methodology: Quality Assessment4. Methodology: Quality Assessment

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JADAD SCALEJADAD SCALEa) Was the study described as randomized?

b) Was the study described as double-blind?

c) Was there a description of withdrawals and drop-outs?

YES = 1 NO = 0

Add 1 point if

Randomization and double-blinding are appropriate

Deduct 1 point if

Randomization and double-blinding are not appropriate

4. Methodology: Quality Assessement4. Methodology: Quality Assessement

Introdução à Medicina II March 2011

JADAD SCALEJADAD SCALE

4 clinical trials

2 with 3 points 2 with 5 points

Numeric scale 0-5

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SPSS – calculating Odds RatioGraphPad Prism – building Forest Plots

Image 11 –GraphPad’s window

4. Methodology: Statistical Analysis4. Methodology: Statistical Analysis

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OR = (a/c)/(b/d)Greater with AT

Greater with CDT

Grade of DVT lysis

Grade I < 50% lysis

Grade II 50 – 99% lysis

Grade III complete lysis

SATISFACTORY RESULTS

SATISFACTORY RESULTS

5. Results: Lysis5. Results: Lysis

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OR = (a/c)/(b/d)Greater with AT

Greater with CDT

5. Results: Venous Obstruction5. Results: Venous Obstruction

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In short-term follow-up, patients treated with CDT obtain better patency

than those treated with standard anticoagulation therapy. [1,2,3]

[1] M. Elshrawy et al. Early results of thrombolysis vs anticoagulation in iliofemoral venous thrombosis. A randomized clinical trial. 2002, Eur J Vasc endovasc Surg

[2] Ali F. AbuRahma, MD et al. Ilio femoral deep vein thrombosis: conventional therapy versus lysis and percutaneous transluminal angioplasty and stenting. 2001, annals of surgery.

[3] T. Enden et al. Catheter-directed thrombolysis vs anticoagulation therapy alone in deep vein thrombosis: results of an open randomized, controlled trial reporting on short-term patency. 2009, Journal of Thrombosis and Haemostasis.

5. Results: Patency5. Results: Patency

5_Results: Recurrency5_Results: Recurrency

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[4] Y. J. Park et al. Restoration of patency in iliofemoral deep vein thrombosis with catheter-diected thrombolysis does not always prevent post-thrombotic damage

[5] Ali F. AbuRahma, MD et al. Ilio femoral deep vein thrombosis: conventional therapy versus lysis and percutaneous transluminal angioplasty and stenting. 2001, annals of surgery.

[6] N.Baekgaard et al. Long-term results using catheter directed thrombolysis in 103 lower limbs with acute iliofemoral venous thrombosis. 2010, Eur J Vasc Endovasc Surg.

CDT followed by anticoagulation therapy

leads to much lower recurrency rate than

anticoagulation alone. [4,5,6]

Image 13 – Thrombus formation

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THROMBOCYTOPENIA

5. Results: Anticoagulation Therapy Complications5. Results: Anticoagulation Therapy Complications

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• Occurence of bleeding in 5 – 11%b of the patients

•Pulmonary embolism: 4,5%

• Death: 0% – 0,4%

• Pain: caused by the application of a stent

puncture site bleeding

puncture site bleeding

[1]

Bad measure of efficacy

Bad measure of efficacy

intracranial haemorrhage (uncommon)

intracranial haemorrhage (uncommon)

[2]

[1]

[1]

[1] Gogalniceanu P., Indications for thrombolysis in Deep Venous Thrombosis[2] Bækgaard N., Long-Term Results using Catheter-directed Thrombolysis in 103 Lower Limbs with Acute Iliofemoral Venous Thrombosis

LungThe thrombus goes to the lungs trough the vena cava.

Image 14

5. Results: CDT Complications5. Results: CDT Complications

Introdução à Medicina II March 2011

6. Discussion6. Discussion

CatheterCatheter DirectedDirected ThrombolysisThrombolysis

AnticoagulationAnticoagulation TherapyTherapy

Effective lysis

Greater patencyLess venous obstruction

Recurrent DVT

Pulmonary Embolism

Salvage of venous valves

Reduced PTS

allows prevents

Introdução à Medicina II March 2011

Anticoagulation Anticoagulation TherapyTherapy

Catheter Directed Catheter Directed ThrombolysisThrombolysis

VS

7. Conclusion7. Conclusion

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http://users.med.up.pt/mimed10133/website_intromed/

8. Website8. Website