ANTICOAGULATION THERAPY OR CATHETER DIRECTED THROMBOLYSIS 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 ILIO-FEMORAL THROMBOSIS Mestrado Integrado em Medicina

1. Background Introdução à Medicina II March 2011

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

1. Background Introdução à Medicina II March 2011 Anticoagulation therapy Catheter directed thrombolysis

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

1. Background: Catether directed-thrombolysis Introdução à Medicina II March 2011  Thrombolytic agent: urokinase or streptokinase or rtPA  Venous approach to ilio-femoral vein: popliteal common femoral  Cava filters, venous stents and angioplastic balloon  Thrombolytic agent: urokinase or streptokinase or rtPA  Venous approach to ilio-femoral vein: popliteal common femoral  Cava filters, venous stents and angioplastic balloon Image 4Image 3 T. Wicky Stephan; Acute Deep Vein Thrombosis and Thrombolysis; 2009 Image 5

2. Research question Introdução à Medicina II March 2011

Measure: Lysis Patency Complications Recurrency Recovery of limb function Image 6 – Clot formation 3. Aims 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) Introdução à Medicina II March 2011 Image 9 Image 7 Image 8 Data bases: Pubmed, Scopus, Cochrane

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. Introdução à Medicina II March 2011 Image 10

4. Methodology: Articles’ Selection 215 articles 33 articles 23 articles included Read title Read Abstract Read full text Introdução à Medicina II March 2011 Pubmed, Scopus, Cochrane 4 clinical trials that compare both treatments 15 systematic reviews 8 clinical trials

Introdução à Medicina II March 2011 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 = 1NO = 0 Add 1 point if Randomization and double- blinding are appropriate Deduct 1 point if  Randomization and double- blinding are not appropriate

Introdução à Medicina II March clinical trials 2 with 3 points 2 with 5 points Numeric scale 0-5

Introdução à Medicina II March 2011 SPSS – calculating Odds Ratio GraphPad Prism – building Forest Plots Image 11 – GraphPad’s window

Introdução à Medicina II March 2011 Treatment CDTAT Lysis II III ab Icd OR = (a/c)/(b/d) Greater with AT Greater with CDT Grade of DVT lysis Grade I < 50% lysis Grade II 50 – 99% lysis Grade III complete lysis SATISFACTORY RESULTS 5. Results: Lysis

Introdução à Medicina II March 2011 Treatment CDTAT Venous Obstruction +ab -cd OR = (a/c)/(b/d) Greater with AT Greater with CDT 5. Results: Venous Obstruction

Introdução à Medicina II March 2011 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. 5. Results: Patency

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

Introdução à Medicina II March 2011 THROMBOCYTOPENIA 5. Results: Anticoagulation Therapy Complications

Introdução à Medicina II March 2011 Occurence of bleeding in 5 – 11%b of the patients Pulmonary embolism: 4,5% Death: 0% – 0,4% Pain: caused by the application of a stent puncture site bleeding [1] Bad measure of efficacy intracranial haemorrhage (uncommon) [2] [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 Lung The thrombus goes to the lungs trough the vena cava. Image Results: CDT Complications

Introdução à Medicina II March Discussion Catheter Directed Thrombolysis Anticoagulation Therapy Effective lysis Greater patency Less venous obstruction Recurrent DVT Pulmonary Embolism Salvage of venous valves Reduced PTS allowsprevents

Introdução à Medicina II March 2011 Anticoagulation Therapy Catheter Directed Thrombolysis VS 7. Conclusion

Introdução à Medicina II March Website