Suresh Vedantham, professor of Radiology, Interventional Radiology Section, Washington University School of Medicine in St Louis, USA, spoke to Interventional News on the latest from the paper “Quality improvement guidelines for the treatment of lower-extremity deep vein thrombosis with use of endovascular thrombus removal” hot on the heels of its online publication in the Journal of Vascular and Interventional Radiology (JVIR).
What prompted the need for new guidelines?
The quality improvement guidelines for catheter-directed thrombolysis for deep vein thrombosis have been updated to reflect current practice, and have a substantially improved evidence foundation due to inclusion of information from new studies including two randomised trials. During the last decade, there have been major changes in the key pillars of clinical deep vein thrombosis practice. New oral anticoagulant classes have been introduced; the completed SOX trial (Compression stockings to prevent the post-thrombotic syndrome) has cast major doubt on the idea that compression stockings can prevent the post-thrombotic syndrome; and the practice of catheter-directed thrombolysis has evolved considerably to incorporate improved patient selection, technical refinements (including the frequent use of thrombectomy devices, stents, and retrievable caval filters), and longitudinal care by endovascular practitioners.
Why is this paper important currently?
A new study published in Journal of the American Medical Association (JAMA) (see page 21)observed a substantially higher risk of adverse safety outcomes in patients who received catheter-directed thrombolysis plus anticoagulation vs. anticoagulation alone in real-world US practice between 2005 and 2010. While this study’s non-randomised methodology and reliance on administrative coding data likely introduced substantial bias into the comparison, physicians who offer catheter-directed thrombolysis should work hard to meet the high standard of safety that is being demanded by the medical community. We must not take for granted the risks involved in routinely offering thrombolytic therapy to patients with deep vein thrombosis who, after all, are being treated not in a life-saving capacity (as with myocardial infarction or stroke) but to optimise limb function and quality of life.
What are the key updates in the revised guidelines?
Key changes include: a) safety thresholds that are a little more stringent, reflecting the improved safety observed in catheter-directed thrombolysis studies between 2006–2013 compared to before; b) a focus on ensuring longitudinal care to optimally assess the outcomes of therapy and to reduce unnecessary late risks such as those from long-term inferior vena cava filter implantation; and c) sections that succintly summarise measures to prevent bleeding and pulmonary embolism during and after catheter-directed thrombolysis.
How will this paper serve as a tool for local quality improvement programmes?
This article offers physicians a template around which to design internal deep vein thrombosis quality improvement programmes. The authors’ ambition is for practicing physicians to build strong longitudinal care systems around deep vein thrombosis care, to ensure that patients can be provided catheter-directed thrombolysis as safely and as effectively as possible.
This article represents the best consensus quality improvement tool we could develop within the bounds of existing catheter-directed thrombolysis studies, which are still quite limited in scope and methodology. We hope and expect that the next version of these guidelines will be created with the benefit of additional randomised trial data, including that from the National Institute for Health-sponsored, multicentre, randomised, assessor-blinded, ATTRACT (Acute venous thrombosis: thrombus removal with adjunctive catheter-directed thrombolysis) trial which has nearly completed patient accrual.