Early thrombus removal strategies for acute deep venous thrombosis: Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum

Mark H. Meissner, Peter Gloviczki, Anthony J. Comerota, Michael Dalsing, Bo G. Eklof, David L. Gillespie, Joann M. Lohr, Robert B. McLafferty, M. Hassan Murad, Frank Padberg, Peter Pappas, Joseph D. Raffetto, Thomas W. Wakefield

Research output: Contribution to journalArticle

197 Citations (Scopus)

Abstract

Background: The anticoagulant treatment of acute deep venous thrombosis (DVT) has been historically directed toward the prevention of recurrent venous thromboembolism. However, such treatment imperfectly protects against late manifestations of the postthrombotic syndrome. By restoring venous patency and preserving valvular function, early thrombus removal strategies can potentially decrease postthrombotic morbidity. Objective: A committee of experts in venous disease was charged by the Society for Vascular Surgery and the American Venous Forum to develop evidence-based practice guidelines for early thrombus removal strategies, including catheter-directed pharmacologic thrombolysis, pharmacomechanical thrombolysis, and surgical thrombectomy. Methods: Evidence-based recommendations are based on a systematic review and meta-analysis of the relevant literature, supplemented when necessary by less rigorous data. Recommendations are made according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, incorporating the strength of the recommendation (strong: 1; weak: 2) and an evaluation of the level of the evidence (A to C). Results: On the basis of the best evidence currently available, we recommend against routine use of the term "proximal venous thrombosis" in favor of more precise characterization of thrombi as involving the iliofemoral or femoropopliteal venous segments (Grade 1A). We further suggest the use of early thrombus removal strategies in ambulatory patients with good functional capacity and a first episode of iliofemoral DVT of <14 days in duration (Grade 2C) and strongly recommend their use in patients with limb-threatening ischemia due to iliofemoral venous outflow obstruction (Grade 1A). We suggest pharmacomechanical strategies over catheter-directed pharmacologic thrombolysis alone if resources are available and that surgical thrombectomy be considered if thrombolytic therapy is contraindicated (Grade 2C). Conclusions: Most data regarding early thrombus removal strategies are of low quality but do suggest patient-important benefits with respect to reducing postthrombotic morbidity. We anticipate revision of these guidelines as additional evidence becomes available.

Original languageEnglish
Pages (from-to)1449-1462
Number of pages14
JournalJournal of Vascular Surgery
Volume55
Issue number5
DOIs
StatePublished - May 2012

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Practice Guidelines
Venous Thrombosis
Thrombosis
Thrombectomy
Catheters
Postthrombotic Syndrome
Morbidity
Evidence-Based Practice
Thrombolytic Therapy
Venous Thromboembolism
Anticoagulants
Meta-Analysis
Ischemia
Extremities
Guidelines
Therapeutics

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery

Cite this

Early thrombus removal strategies for acute deep venous thrombosis : Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum. / Meissner, Mark H.; Gloviczki, Peter; Comerota, Anthony J.; Dalsing, Michael; Eklof, Bo G.; Gillespie, David L.; Lohr, Joann M.; McLafferty, Robert B.; Murad, M. Hassan; Padberg, Frank; Pappas, Peter; Raffetto, Joseph D.; Wakefield, Thomas W.

In: Journal of Vascular Surgery, Vol. 55, No. 5, 05.2012, p. 1449-1462.

Research output: Contribution to journalArticle

Meissner, MH, Gloviczki, P, Comerota, AJ, Dalsing, M, Eklof, BG, Gillespie, DL, Lohr, JM, McLafferty, RB, Murad, MH, Padberg, F, Pappas, P, Raffetto, JD & Wakefield, TW 2012, 'Early thrombus removal strategies for acute deep venous thrombosis: Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum', Journal of Vascular Surgery, vol. 55, no. 5, pp. 1449-1462. https://doi.org/10.1016/j.jvs.2011.12.081
Meissner, Mark H. ; Gloviczki, Peter ; Comerota, Anthony J. ; Dalsing, Michael ; Eklof, Bo G. ; Gillespie, David L. ; Lohr, Joann M. ; McLafferty, Robert B. ; Murad, M. Hassan ; Padberg, Frank ; Pappas, Peter ; Raffetto, Joseph D. ; Wakefield, Thomas W. / Early thrombus removal strategies for acute deep venous thrombosis : Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum. In: Journal of Vascular Surgery. 2012 ; Vol. 55, No. 5. pp. 1449-1462.
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abstract = "Background: The anticoagulant treatment of acute deep venous thrombosis (DVT) has been historically directed toward the prevention of recurrent venous thromboembolism. However, such treatment imperfectly protects against late manifestations of the postthrombotic syndrome. By restoring venous patency and preserving valvular function, early thrombus removal strategies can potentially decrease postthrombotic morbidity. Objective: A committee of experts in venous disease was charged by the Society for Vascular Surgery and the American Venous Forum to develop evidence-based practice guidelines for early thrombus removal strategies, including catheter-directed pharmacologic thrombolysis, pharmacomechanical thrombolysis, and surgical thrombectomy. Methods: Evidence-based recommendations are based on a systematic review and meta-analysis of the relevant literature, supplemented when necessary by less rigorous data. Recommendations are made according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, incorporating the strength of the recommendation (strong: 1; weak: 2) and an evaluation of the level of the evidence (A to C). Results: On the basis of the best evidence currently available, we recommend against routine use of the term {"}proximal venous thrombosis{"} in favor of more precise characterization of thrombi as involving the iliofemoral or femoropopliteal venous segments (Grade 1A). We further suggest the use of early thrombus removal strategies in ambulatory patients with good functional capacity and a first episode of iliofemoral DVT of <14 days in duration (Grade 2C) and strongly recommend their use in patients with limb-threatening ischemia due to iliofemoral venous outflow obstruction (Grade 1A). We suggest pharmacomechanical strategies over catheter-directed pharmacologic thrombolysis alone if resources are available and that surgical thrombectomy be considered if thrombolytic therapy is contraindicated (Grade 2C). Conclusions: Most data regarding early thrombus removal strategies are of low quality but do suggest patient-important benefits with respect to reducing postthrombotic morbidity. We anticipate revision of these guidelines as additional evidence becomes available.",
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