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Comparative Outcomes of Catheter-Directed Thrombolysis Plus Anticoagulation vs Anticoagulation Alone to Treat Lower-Extremity Proximal Deep Vein Thrombosis
Study Questions:
What are the in-hospital outcomes and costs associated with catheter-directed thrombolysis (CDT) plus anticoagulation versus anticoagulation alone for patients with proximal deep venous thrombosis (DVT)?
Methods:
Using the Nationwide Inpatient Sample database of hospitalizations, patients with a proximal DVT were examined. Patients treated with CDT plus anticoagulation were compared to patients treated with anticoagulation alone. The primary outcome was in-hospital mortality. The secondary outcomes included bleeding complications, mean length of stay, and the costs associated with the hospitalization.
Results:
Of the 90,618 patients hospitalized for proximal DVT, 3,649 (4.1%) underwent CDT and were compared to 3,594 propensity-matched patients treated with anticoagulation alone. The utilization of CDT increased from 2.3% in 2005 to 5.9% in 2010. In-hospital mortality was not significantly different between the CDT and the anticoagulation-only groups (1.2% vs. 0.9%; odds ratio [OR], 1.40; 95% confidence interval [CI], 0.88-2.25; p = 0.15). Complications and additional procedures were more frequent in the CDT group, including rates of blood transfusion (11.1% vs. 6.5%; OR, 1.85; 95% CI, 1.57-2.20; p < 0.001), pulmonary embolism (17.9% vs. 11.4%; OR, 1.69; 95% CI, 1.49-1.94; p < 0.001), intracranial hemorrhage (0.9% vs. 0.3%; OR, 2.72; 95% CI, 1.40-5.30; p = 0.03), and vena cava filter placement (34.8% vs. 15.6%; OR, 2.89; 95% CI, 2.58-3.23; p < 0.001). The CDT group had a longer mean length of stay (7.2 vs. 5.0 days; OR, 2.27; 95% CI, 1.49-1.94; p < 0.001) and higher hospitalization costs ($85,094 vs. $28,164; p < 0.001) compared to the anticoagulation-only group.
Conclusions:
The authors concluded that in-hospital mortality was not different in patients with proximal DVT treated with CDT plus anticoagulation versus anticoagulation alone. They did report higher complications and utilization of additional procedures in the CDT group, which was associated with a longer length of stay and higher costs.
Perspective:
This analysis of a real-world sample of patients admitted for proximal DVT provides an important summary of the short-term outcomes associated with more aggressive (CDT plus anticoagulation) versus conservative (anticoagulation-alone) therapy choices. However, most vascular specialists view the use of CDT as a means to reduce long-term complications, namely the post-thrombotic syndrome (PTS). As we await the results of the ATTRACT trial (www.clinicaltrials.gov, NCT00790335), where patients with acute DVT are randomized to receive CDT plus anticoagulation versus anticoagulation alone and then followed for 24 months to assess for the development and severity of the PTS, this analysis will help us put the risks and benefits of such an intervention into perspective. Once the results of the ATTRACT trial are reported, a cost-effectiveness analysis will be crucial to understanding the potential societal implications of widespread CDT utilization.
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