Catheter-directed thrombolysis for deep vein thrombosis

Purpose of review: Strong proof-of-concept evidence suggests that catheter-directed thrombolysis (CDT) may enable prevention of the post-thrombotic syndrome (PTS) in patients with deep vein thrombosis (DVT). The goal of this review is to summarize recent publications and thereby improve physicians' ability to make sound clinical judgments on employing CDT. Recent findings: Anticoagulation and compression therapy are necessary elements of PTS prevention efforts, but are not sufficient to prevent PTS in many DVT patients. Patients with acute iliofemoral DVT represent a subgroup at particularly high risk of developing recurrent venous thromboembolism and PTS. Three comparative studies and the preliminary results of one ongoing European randomized controlled trial (RCT) (the CaVenT trial) suggest that CDT is reasonably well tolerated and that it may provide superior clinical outcomes for patients with extensive proximal DVT. In the US, the ongoing NIH-sponsored ATTRACT trial should clarify the risk-benefit ratio of pharmacomechanical CDT for acute proximal DVT. In the meantime, the preponderance of available evidence suggests that CDT (with anticoagulation) should be routinely considered as first-line therapy for patients with extensive acute iliofemoral DVT, low expected bleeding risk, and good functional status. Summary: CDT should be employed for DVT patients who have severe clinical manifestations such as acute circulatory limb threat, for patients who have not achieved therapeutic objectives with initial anticoagulation, and as first-line therapy for selected patients with acute iliofemoral DVT.