Mestrado Integrado em Medicina
ILIO-FEMORAL THROMBOSIS
ANTICOAGULATION THERAPY
OR
CATHETER DIRECTED THROMBOLYSIS
Introdução à Medicina II
May 2011
Alice Marinho, Carlos Veterano, Maricruz Nunes, Patrícia Baptista,
Pedro Aguiar, Pedro Campelo, Rosana Dias, Sandra Santos, Sara Peixoto
Class 20
1. Background
Introdução à Medicina II
March 2011
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
1. Background
Anticoagulation
therapy
Ilio-femoral
thrombosis
Introdução à Medicina II
Catheter directed
thrombolysis
March 2011
1. Background: Anticoagulation Therapy
ANTICOAGULATION THERAPY
Unfractionated
heparin
Vitamin K
Antagonists
Low-molecularweight Heparin
(Enexoparin)
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
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 3
Image 4
T. Wicky Stephan; Acute Deep Vein Thrombosis and Thrombolysis; 2009
Introdução à Medicina II
March 2011
2. Research question
Introdução à Medicina II
March 2011
3. Aims
Measure:

Lysis

Patency

Complications

Recurrency

Recovery of limb function
Image 6 – Clot formation
Introdução à Medicina II
March 2011
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
4. Methodology: Selection Criteria
Inclusion criteria
Exclusion criteria
• Condition under study: deepvenous thrombosis
• Affected vein: iliofemoral vein
• Idiom: other than Portuguese,
• Treatment used: anticoagulation
English or Spanish
therapy or CDT
• Population: other that adult
• Variables
measured:
efficency,
life
treatment,
recurrency,
mortality,
quality
after
Image 10
humans with no other significant
health problems.
patency,
venous obstruction, etc.
Introdução à Medicina II
March 2011
4. Methodology: Articles’ Selection
Pubmed, Scopus,
Cochrane
215 articles
Read title
Read Abstract
33 articles
Read full text
23 articles included
15 systematic reviews
Introdução à Medicina II
8 clinical trials
4 clinical trials that
compare both treatments
March 2011
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
Add 1
point if
Randomization and doubleblinding are appropriate
Introdução à Medicina II
NO = 0
Deduct 1
point if
Randomization and doubleblinding are not appropriate

March 2011
4. Methodology: Quality Assessement
JADAD SCALE
Numeric scale 0-5
4 clinical trials
2 with 3 points
Introdução à Medicina II
2 with 5 points
March 2011
4. Methodology: Statistical Analysis
SPSS – calculating Odds Ratio
GraphPad Prism – building Forest Plots
Image 11 –
GraphPad’s window
Introdução à Medicina II
March 2011
5. Results: Lysis
Lysis
Treatment
CDT
AT
II
III
a
b
I
c
Grade of DVT lysis
SATISFACTORY
RESULTS
Grade I
< 50% lysis
Grade II
50 – 99% lysis
Grade III
complete lysis
d
OR = (a/c)/(b/d)
Greater with AT
Greater with CDT
Introdução à Medicina II
March 2011
5. Results: Venous Obstruction
Venous
Obstruction
Treatment
CDT
AT
+
a
b
-
c
d
OR = (a/c)/(b/d)
Greater with AT
Greater with CDT
Introdução à Medicina II
March 2011
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
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
March 2011
5. Results: Anticoagulation Therapy Complications
THROMBOCYTOPENIA
Introdução à Medicina II
Type I
Caused by
hipersensibility
> 1% of
patients
Type II
Caused by
imune reaction
1% of
patients
March 2011
5. Results: CDT Complications
• Occurence of bleeding in 5 – 11%b of the patients
puncture
site bleeding
intracranial
haemorrhage
(uncommon)
•Pulmonary embolism: 4,5%
[1]
[1]
• Death: 0% – 0,4%
Lung
Bad measure
of efficacy
Image 14
[1]
• Pain: caused by the application of a stent
Introdução à Medicina II
The thrombus goes to the
lungs trough the vena cava.
[2]
[1] Gogalniceanu P., Indications for thrombolysis in Deep
Venous Thrombosis
[2] Bækgaard N., Long-Term Results using Catheterdirected Thrombolysis in 103 Lower Limbs with Acute
Iliofemoral Venous Thrombosis
March 2011
6. Discussion
Catheter Directed
Thrombolysis
allows
Effective lysis
Greater patency
Less venous obstruction
Anticoagulation
Therapy
prevents
Recurrent DVT
Pulmonary Embolism
Salvage of venous valves
Reduced PTS
Introdução à Medicina II
March 2011
7. Conclusion
Anticoagulation
Therapy
VS
Catheter Directed
Thrombolysis
Introdução à Medicina II
March 2011
8. Website
http://users.med.up.pt/mimed10133/website_intromed/
Introdução à Medicina II
March 2011