July 21st, 2014
Study Finds Flaws in Catheter-Directed Thrombolysis for DVT
Larry Husten, PHD
In recent years, catheter-directed thrombolysis (CDT) has been added to the current standard of anticoagulation therapy in some patients with deep vein thrombosis (DVT). The hope was that CDT would help reduce the high rate of post-thrombotic syndrome (PTS), but now an observational study finds no benefits and some important disadvantages associated with CDT.
In a report published in JAMA Internal Medicine, Riyaz Bashir and colleagues analyzed data from more than 90,000 patients hospitalized for DVT, 3649 of whom received CDT plus anticoagulation. In-hospital mortality did not differ significantly between the CDT patients and matched controls who received anticoagulation alone (1.2% and 0.9%, respectively; p=0.15). However, the CDT group had significantly higher rates of pulmonary embolism, intracranial hemorrhage, and vena cava filter placement. The CDT group also had longer and more expensive hospital stays.
The authors acknowledge the limitations of observational studies and call for randomized trials “to evaluate the magnitude of the effect of CDT on outcomes such as mortality, PTS and recurrence of DVT.” They conclude that CDT “should be offered only to patients with a low bleeding risk. … it is imperative that the magnitude of benefit from CDT be substantial to justify the increased initial resource utilization and bleeding risks of this therapy.”
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This is a timely study because there has been an increase in CDT use without an accompanying increase in randomized data. However, there are some limitations in this registry that need to be highlighted- in some institutions, temporary IVC filters are placed as part of the CDT procedure, so may not necessarily reflect a complication but rather can be part of the protocol. Also, if a patient already has a PE and is noted to have residual large burden of DVT, they may be referred for CDT to help prevent another embolus- this, in part, may account for higher rates of PE in CDT treated patients. Despite these issues, this registry study identifies a lot of problems with the increasing use of CDT, in particular the increased risk of intracranial hemorrhage is concerning and may reflect variable doses of thrombolytics. As the authors highlight we need randomized data on CDT to determine exactly the risks and benefits associated with this procedure, as well as standardized approaches and dosages to this technique.