1. 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

2. 1. Background Introdução à Medicina II March 2011

3. 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

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

5. 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

6. 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

7. 2. Research question Introdução à Medicina II March 2011

8. Measure: Lysis Patency Complications Recurrency Recovery of limb function Image 6 – Clot formation 3. Aims Introdução à Medicina II March 2011

9. 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

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. Introdução à Medicina II March 2011 Image 10

11. 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

12. 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

13. Introdução à Medicina II March 2011 4 clinical trials 2 with 3 points 2 with 5 points Numeric scale 0-5

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

15. 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

16. 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

17. 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

18. 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

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

20. 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 14 5. Results: CDT Complications

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

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

23. Introdução à Medicina II March 2011 http://users.med.up.pt/mimed10133/website_intromed/ 8. Website