DVT Awareness Month: Management of DVT

Venogram of thrombus treated with pharmacomechanical thrombolysis

Venogram of thrombus treated with pharmacomechanical thrombolysis

In honor of DVT Awareness Month, we highlight a well-read article in Vascular Disease Management: “Endovascular Intervention for Lower-Extremity Deep Venous Thrombosis” by Frank R. Arko, MD, M. Zachary Arko, and Erin H. Murphy, MD. Arko et al describe the clinical picture, diagnosis, and management options for deep venous thrombosis. Arko offers some insight into alternatives for diagnosis:

“While venography remains the gold standard for DVT diagnosis, this is both invasive and impractical as a standard diagnostic tool. Alternatively, lower-extremity duplex ultrasound can accurately diagnose DVT and is minimally invasive, low-risk, convenient and more cost-effective. Ultrasonographic evidence of DVT includes non-compressible or partially compressible venous segments, continuous venous flow patterns and the absence of normally phasic flow variation. The sensitivity and specificity of duplex ultrasonography in diagnosing proximal lower-extremity DVT is 95–97%, respectively.17,18 While the sensitivity and specificity drop to only 75% when used for the diagnosis of distal calf DVT, these patients may be screened with a repeat ultrasound in 5–7 days if clinical suspicion is high.12,17,18 Workup with a hypercoagulable panel has been suggested in patients <50 years of age, an absence of additional risk factors for DVT, a family history of thromboembolic disorders, unusual thrombus location or recurrence of DVT. These patients should be screened for protein C or S deficiency, antithrombin deficiency, factor V Leiden, protein C resistance, prothrombin gene mutation 2021A and antiphospholipid antibody syndrome.12 Further, it mat be prudent to screen patients <50 years of age presenting with left lower-extremity DVT for May-Thurner syndrome, a condition caused by compression of the left common iliac vein by the right common iliac artery against the fifth lumbar vertebra, which can predispose patients to DVT. Diagnosis of these conditions is important, as these patients may require additional treatment.19″

The authors present available therapies for DVT as of the publication of the article, in March 2011, including anticoagulants, surgery, catheter-directed thrombolysis, ultrasound-accelerated thrombolysis, and percutaneous mechanical thrombectomy.

In the last 2 years, new options for therapy have been discussed. For example, at ISET 2013, research was presented that showed promising results for DVT patients treated with a combination therapy. Rheolytic pharmacomechanical thrombectomy using combination therapy reduced treatment time from more than 2 days to less than 24 hours, according to phase II results of the multi-center PEARL registry. Also, dabigatran etexilate (Pradaxa) was supported in the RE-MEDY and RE-SONATE trials as a long-term prevention therapy for DVT. And in November 2012, the FDA approved rivaroxaban (XARELTO) for treatment of DVT, pulmonary embolism (PE), and long-term prevention of recurrent DVT and PE.

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