The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial

Vedantham S, et al.; ATTRACT Trial Investigators. Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis. N Engl J Med. 2017 Dec 7;377(23):2240-2252. Free full-text.

Summary: The ATTRACT trial sought to “determine whether pharmacomechanical thrombolysis prevents the post-thrombotic syndrome in patients with proximal deep-vein thrombosis” (p.2241). A total of 692 patients were enrolled at 56 centers in the US from December 2009 through December 2014. They were between the ages of 16 and 75, and had symptomatic proximal deep-vein thrombosis involving the femoral, common femoral, or iliac vein (p. 2241).

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Caprini Risk Assessment Model for DVTs

Cronin M, Dengler N, Krauss ES, et al. Completion of the Updated Caprini Risk Assessment Model (2013 Version). Clin Appl Thromb Hemost. 2019 Jan-Dec;25:1076029619838052.

Abstract: The Caprini risk assessment model (RAM) has been validated in over 250,000 patients in more than 100 clinical trials worldwide. Ultimately, appropriate treatment options are dependent on precise completion of the Caprini RAM. As the numerical score increases, the clinical venous thromboembolism rate rises exponentially in every patient group where it has been properly tested. The 2013 Caprini RAM was completed by specially trained medical students via review of the presurgical assessment history, medical clearances, and medical consults. The Caprini RAM was completed for every participant both preoperatively and predischarge to ensure that any changes in the patient’s postoperative course were captured by the tool. This process led to the development of completion guidelines to ensure consistency and accuracy of scoring. The 2013 Caprini scoring system provides a consistent, thorough, and efficacious method for risk stratification and selection of prophylaxis for the prevention of venous thrombosis.

D-dimer testing to determine the duration of anticoagulation therapy

Palareti G, Cosmi B, Legnani C, et al.; DULCIS Investigators. D-dimer to guide the duration of anticoagulation in patients with venous thromboembolism: a management study. Blood. 2014 Jul 10;124(2):196-203.

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The optimal duration of anticoagulation in patients with venous thromboembolism (VTE) is uncertain. We investigated whether persistently negative D-dimers in patients with vein recanalization or stable thrombotic burden can identify subjects at low recurrence risk. Outpatients with a first VTE (unprovoked or associated with weak risk factors) were eligible after at least 3 months (12 in those with residual thrombosis) of anticoagulation. They received serial D-dimer measurements using commercial assays with predefined age/sex-specific cutoffs and were followed for up to 2 years. Of 1010 patients, anticoagulation was stopped in 528 (52.3%) with persistently negative D-dimer who subsequently experienced 25 recurrences (3.0% pt-y; 95% confidence interval [CI], 2.0-4.4%). Of the remaining 482 patients, 373 resumed anticoagulation and 109 refused it. Recurrent VTE developed in 15 patients (8.8% pt-y; 95% CI, 5.0-14.1) of the latter group and in 4 of the former (0.7% pt-y; 95% CI, 0.2-1.7; hazard ratio = 2.92; 95% CI, 1.87-9.72; P = .0006). Major bleeding occurred in 14 patients (2.3% pt-y; 95% CI, 1.3-3.9) who resumed anticoagulation. Serial D-dimer measurement is suitable in clinical practice for the identification of VTE patients in whom anticoagulation can be safely discontinued. This study was registered at as #NCT00954395.

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Thrombolysis for acute deep vein thrombosis

Watson L, Broderick C, Armon MP. Thrombolysis for acute deep vein thrombosis. Cochrane Database Syst Rev. 2016 Nov 10;11(11):CD002783.

Main results: Seventeen RCTs with 1103 participants were included. These studies differed in the both thrombolytic agent used and in the technique used to deliver it. Systemic, loco-regional and catheter-directed thrombolysis (CDT) were all included. Fourteen studies were rated as low risk of bias and three studies were rated as high risk of bias. We combined the results as any (all) thrombolysis compared to standard anticoagulation. Complete clot lysis occurred significantly more often in the treatment group at early follow-up (RR 4.91; 95% CI 1.66 to 14.53, P = 0.004) and at intermediate follow-up (RR 2.44; 95% CI 1.40 to 4.27, P = 0.002; moderate quality evidence). A similar effect was seen for any degree of improvement in venous patency. Up to five years after treatment significantly less PTS occurred in those receiving thrombolysis (RR 0.66, 95% CI 0.53 to 0.81; P < 0.0001; moderate quality evidence). This reduction in PTS was still observed at late follow-up (beyond five years), in two studies (RR 0.58, 95% CI 0.45 to 0.77; P < 0.0001; moderate quality evidence). Leg ulceration was reduced although the data were limited by small numbers (RR 0.87; 95% CI 0.16 to 4.73, P = 0.87). Those receiving thrombolysis had increased bleeding complications (RR 2.23; 95% CI 1.41 to 3.52, P = 0.0006; moderate quality evidence). Three strokes occurred in the treatment group, all in trials conducted pre-1990, and none in the control group. There was no significant effect on mortality detected at either early or intermediate follow-up. Data on the occurrence of pulmonary embolism (PE) and recurrent DVT were inconclusive. Systemic thrombolysis and CDT had similar levels of effectiveness. Studies of CDT included two trials in femoral and iliofemoral DVT, and results from these are consistent with those from trials of systemic thrombolysis in DVT at other levels of occlusion.

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The value of a cross-discipline team-based approach for resection of renal cell carcinoma with IVC tumor thrombus: A report of a large, contemporary, single-institution experience.

Master VA, Ethun CG, Kooby DA, Staley CA 3rd, Maithel SK. The value of a cross-discipline team-based approach for resection of renal cell carcinoma with IVC tumor thrombus: A report of a large, contemporary, single-institution experience. J Surg Oncol. 2018 Dec; 118(8):1219-1226.

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Introduction: We report the evolution of the largest, contemporary, single-institution experience with this complex procedure to highlight the value of a cross-discipline, team-based approach.

Methods: Patients from a prospectively maintained database who underwent resection of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumor thrombus from 2005 to 2016 at a single-institution were included for analysis.

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Prognostic factors in splanchnic vein thromboses

Ageno W, et al. Long-term Clinical Outcomes of Splanchnic Vein Thrombosis: Results of an International Registry. JAMA Intern Med. 2015 Sep;175(9):1474-80. doi: 10.1001/jamainternmed.2015.3184.

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RESULTS: Of the 604 patients (median age, 54 years; 62.6% males), 21 (3.5%) did not complete follow-up. The most common risk factors for SVT were liver cirrhosis (167 of 600 patients [27.8%]) and solid cancer (136 of 600 [22.7%]); the most common sites of thrombosis were the portal vein (465 of 604 [77.0%]) and the mesenteric veins (266 of 604 [44.0%]). Anticoagulation was administered to 465 patients in the entire cohort (77.0%) with a mean duration of 13.9 months; 175 of the anticoagulant group (37.6%) received parenteral treatment only, and 290 patients (62.4%) were receiving vitamin K antagonists. The incidence rates (reported with 95% CIs) were 3.8 per 100 patient-years (2.7-5.2) for major bleeding, 7.3 per 100 patient-years (5.8-9.3) for thrombotic events, and 10.3 per 100 patient-years (8.5-12.5) for all-cause mortality. During anticoagulant treatment, these rates were 3.9 per 100 patient-years (2.6-6.0) for major bleeding and 5.6 per 100 patient-years (3.9-8.0) for thrombotic events. After treatment discontinuation, rates were 1.0 per 100 patient-years (0.3-4.2) and 10.5 per 100 patient-years (6.8-16.3), respectively. The highest rates of major bleeding and thrombotic events during the whole study period were observed in patients with cirrhosis (10.0 per 100 patient-years [6.6-15.1] and 11.3 per 100 patient-years [7.7-16.8], respectively); the lowest rates were in patients with SVT secondary to transient risk factors (0.5 per 100 patient-years [0.1-3.7] and 3.2 per 100 patient-years [1.4-7.0], respectively).

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