ANTICOAGULATION THERAPY OR CATHETER DIRECTED THROMBOLYSIS Alice Marinho, Carlos Veterano, Maricruz...
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Transcript of ANTICOAGULATION THERAPY OR CATHETER DIRECTED THROMBOLYSIS Alice Marinho, Carlos Veterano, Maricruz...
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
Introdução à Medicina II March 2011
Measure:
Lysis
Patency
Complications
Recurrency
Recovery of limb function
Image 6 – Clot formation
3. Aims3. Aims
Introdução à Medicina II March 2011
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
Introdução à Medicina II March 2011
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
Introdução à Medicina II March 2011
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
Introdução à Medicina II March 2011
SPSS – calculating Odds RatioGraphPad Prism – building Forest Plots
Image 11 –GraphPad’s window
4. Methodology: Statistical Analysis4. Methodology: Statistical Analysis
Introdução à Medicina II March 2011
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
Introdução à Medicina II March 2011
OR = (a/c)/(b/d)Greater with AT
Greater with CDT
5. Results: Venous Obstruction5. Results: Venous Obstruction
Introdução à Medicina II March 2011
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
Introdução à Medicina II March 2011
[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
Introdução à Medicina II March 2011
THROMBOCYTOPENIA
5. Results: Anticoagulation Therapy Complications5. Results: Anticoagulation Therapy Complications
Introdução à Medicina II March 2011
• 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
Introdução à Medicina II March 2011
http://users.med.up.pt/mimed10133/website_intromed/
8. Website8. Website