Anticoagulation therapy OR catheter directed thrombolysis

1
Anticoagulation therapy OR catheter directed
thrombolysis
Mestrado Integrado em Medicina
ILIO-FEMORAL THROMBOSIS

• Alice Marinho, Carlos Veterano, Maricruz Nunes,
  Patrícia Baptista,
• Pedro Aguiar, Pedro Campelo, Rosana Dias, Sandra
  Santos, Sara Peixoto
• Class 20

Introdução à Medicina II
May 2011
2
1. Background
Introdução à Medicina II


March 2011
3
1. Background
Deep Venous Thrombosis (DVTs) Ilio-femoral Vein
Deep venous thrombosis (DVTs) are a significant
cause of morbidity and mortality in the general
population 1
Image 1
1 Gogalniceanu P, Johnston CJ, Khalid U, Holt
PJ, Hincliffe R, Loftus IM, Thompson MM
Indications for thrombolysis in deep venous
thrombosis, 2009
Introdução à Medicina II


March 2011
4
1. Background
Introdução à Medicina II


March 2011
5
1. Background Anticoagulation Therapy
ANTICOAGULATION THERAPY
Low-molecular-weight Heparin (Enexoparin)
Unfractionated heparin
Vitamin K Antagonists
Image 2
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
Introdução à Medicina II


March 2011
6
1. Background Catether directed-thrombolysis

• Thrombolytic agent urokinase or streptokinase
  or rtPA
• Venous approach to ilio-femoral vein popliteal
  
• common femoral
• Cava filters, venous stents and angioplastic
  balloon

Image 5
Image 4
Image 3
T. Wicky Stephan Acute Deep Vein Thrombosis and
Thrombolysis 2009
Introdução à Medicina II


March 2011
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2. Research question
Whats the best treatment for ilio-femoral
thrombosis ANTICOAGULATION THERAPY OR
CATHETER DIRECTED TROMBOLYSIS ?
Introdução à Medicina II


March 2011
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3. Aims

• Measure
• Lysis
• Patency
• Complications
• Recurrency
• Recovery of limb function

Image 6 Clot formation
Introdução à Medicina II


March 2011
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4. 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)
Data bases Pubmed , Scopus, Cochrane
Image 8
Image 7
Image 9
Introdução à Medicina II


March 2011
10
4. 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.
Image 10
Introdução à Medicina II


March 2011
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4. Methodology Articles Selection
Pubmed, Scopus, Cochrane
4 clinical trials that compare both treatments
15 systematic reviews
8 clinical trials
Introdução à Medicina II


March 2011
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4. Methodology Quality Assessment
Jadad scale
a) 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
Deduct 1 point if
Randomization and double-blinding are appropriate

• Randomization and double-blinding are not
  appropriate

Introdução à Medicina II


March 2011
13
4. Methodology Quality Assessement
Jadad scale
Numeric scale 0-5
Introdução à Medicina II


March 2011
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4. Methodology Statistical Analysis
SPSS calculating Odds Ratio GraphPad Prism
building Forest Plots
Image 11 GraphPads window
Introdução à Medicina II


March 2011
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5. Results Lysis
Treatment Treatment
CDT AT
Lysis II III a b
Lysis I c d
Grade of DVT lysis
Grade I lt 50 lysis Grade II 50 99 lysis Grade III complete lysis

OR (a/c)/(b/d)
Greater with AT Greater with CDT
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March 2011
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5. Results Venous Obstruction
Treatment Treatment
CDT AT
Venous Obstruction a b
Venous Obstruction - c d
OR (a/c)/(b/d)
Greater with AT Greater with CDT
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March 2011
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5. Results Patency
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.
Introdução à Medicina II


March 2011
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5_Results Recurrency
CDT followed by anticoagulation therapy leads to
much lower recurrency rate than anticoagulation
alone. 4,5,6
Image 13 Thrombus formation
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.
Introdução à Medicina II


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5. Results Anticoagulation Therapy Complications
Introdução à Medicina II


March 2011
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5. Results CDT Complications

• Occurence of bleeding in 5 11b of the
  patients
• Pulmonary embolism 4,5
• Death 0 0,4
• Pain caused by the application of a stent

puncture site bleeding
intracranial haemorrhage (uncommon)
1
1
Bad measure of efficacy
Image 14
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
2
Introdução à Medicina II


March 2011
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6. Discussion
Catheter Directed Thrombolysis
Anticoagulation Therapy
allows
prevents
Effective lysis Greater patency Less venous
obstruction
Recurrent DVT Pulmonary Embolism
Salvage of venous valves Reduced PTS
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March 2011
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7. Conclusion
Anticoagulation Therapy
VS
Catheter Directed Thrombolysis
Introdução à Medicina II


March 2011
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8. Website
http//users.med.up.pt/mimed10133/website_intromed
/
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March 2011