Catheter thrombolysis + anticoagulation may be inferior to anticoagulation alone in DVT
1. There was no significant difference in in-hospital mortality amongst patients who underwent catheter-directed thrombolysis (CDT) in addition to anticoagulation, compared to anticoagulation alone in lower extremity proximal deep vein thrombosis (DVT).
2. The use of CDT and anticoagulation compared to anticoagulation alone was associated with greater bleeding risk, pulmonary embolism, vena cava filter placement, and total hospital days/charges.
Evidence Rating Level: 2 (Good)
Study Rundown: Deep vein thromboses (DVTs) are a major cause of cardiovascular morbidity and mortality. In those patients who have proximal DVTs (popliteal vein or above), many go on to develop postthrombotic syndrome in spite of anticoagulation. Some smaller studies have suggested that catheter-directed thrombolysis (CDT) may lead to improved outcomes and quality of life. This retrospective observational study showed no difference in in-hospital mortality amongst patients who underwent CDT in addition anticoagulation, compared to anticoagulation alon. In fact, CDT plus anticoagulation was associated with more bleeding complications, vena cava filter placements, and total hospital days and charges.
The strength of the study was the overall number of DVT cases they were able to include in the analysis. However, since CDT is not a heavily used procedure, this group was a small percentage of the population. Although the investigators attempted to control for a number of confounding variables, the nature of an observational study is such that it is impossible to account for the inherent differences in the CDT group versus the anticoagulation group. In addition, the investigators relied entirely on ICD9 codes to identify the appropriate diagnoses, which may not have been adequate to identify the appropriate patient population.
Click to read the study, published today in JAMA Internal Medicine
In-Depth [retrospective cohort]: This retrospective database review examined patients from the Nationwide Inpatient Sample (NIS) files of the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project, from January 2005 to December 2010, including roughly 1000 hospitals in 45 states. Patients were identified via ICD9 codes for proximal DVT, and those who had a pulmonary embolism were excluded. The CDT group had different demographic characteristics and comorbidities, and propensity-matching was used to create two matched groups. The primary end point was in-hospital mortality. Secondary end points included development of a pulmonary embolism, blood transfusion requirements, gastrointestinal bleeding, intracranial bleeding, procedure-related hematomas, vena cava filter placements, length of stay, and hospital charges.
A total of 90,618 cases were identified, of which 3649 (4.1%) underwent CDT and anticoagulation. The adjusted in-hospital mortality rates for the CDT group (1.2%) were not significantly different compared to anticoagulation alone (0.9%) (OR, 1.4; 95% CI, 0.88-2.25). The rates of blood transfusion (11.1% vs 6.5%, P<0.001), pulmonary embolism (17.9% vs 11.4%, P<0.001), intracranial hemorrhage (0.9% vs 0.3%, P=0.03), and vena cava filter placement (34.8% vs 15.6%, P<0.001) were significantly higher in the CDT group. In addition, the CDT group also had longer mean length of stay (7.2 vs 5.0, P<0.001) and higher mean hospital cost. It was noted that in centers that performed more than 5 CDT cases per year, there was significantly lower in-hospital mortality as compared to centers who did 5 or fewer CDT cases per year.
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