Pharmacomechanical Thrombolysis for DVT
Does the use of pharmacomechanical thrombolysis reduce the risk of the post-thrombotic syndrome (PTS) in patients with proximal deep-vein thrombosis (DVT)?
The ATTRACT trial investigators randomly assigned 692 patients with acute proximal DVT to receive either anticoagulation alone (control) or anticoagulation plus pharmacomechanical thrombolysis (intervention). The primary outcome was the development of PTS between 6 and 24 months of follow-up.
During 24 months of follow-up, there was no significant difference in the percent of patients with PTS in the two treatment groups (47% in intervention group and 48% in control group; relative risk [RR], 0.96; 95% confidence interval [CI], 0.82-1.11). Similarly, there was no difference in recurrent VTE between the intervention and control groups (12% vs. 8%, p = 0.09). The intervention group experienced more major bleeding within 10 days as compared to the control group (1.7% vs. 0.3%, respectively, p = 0.049). Moderate-to-severe PTS occurred in 18% of patients in the intervention group as compared to 24% of the control group (RR, 0.73; 95% CI, 0.54-0.98; p = 0.04). PTS severity scores were lower in the intervention group as compared to the control group at 6, 12, 18, and 24 months (p < 0.01 at each time point). However, improvement in quality of life from baseline to 24 months did not differ between the two groups.
The authors concluded that the use of pharmacomechanical thrombolysis in acute DVT did not lower the risk of PTS, but did result in more major bleeding.
The ATTRACT trial was designed to test the “open vein” hypothesis that patients with acute DVT would have fewer long-term complications if the vein is opened rapidly with thrombolysis. It is important to notice the high burden of PTS in patients with acute PTS (nearly 50% by 24 months). These study results inform us that pharmacomechanical thrombolysis should not be routinely used in patient with acute DVT. However, there may be selected patients for whom the risk of severe PTS is high and the periprocedural bleeding risk is low. Pharmacomechanical thrombolysis can be considered for these patients. Further data to identify which patients are most likely to benefit are needed.
Keywords: Anticoagulants, Catheters, Hemorrhage, Mechanical Thrombolysis, Postphlebitic Syndrome, Postthrombotic Syndrome, Primary Prevention, Quality of Life, Risk, Thrombolytic Therapy, Thrombosis, Vascular Diseases, Venous Thrombosis
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