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Anticoagulation therapy OR catheter directed thrombolysis

Mestrado Integrado em Medicina. ILIO-FEMORAL THROMBOSIS. 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.

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Anticoagulation therapy OR catheter directed thrombolysis

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  1. Mestrado Integrado em Medicina ILIO-FEMORAL THROMBOSIS Anticoagulation therapyORcatheterdirected thrombolysis Alice Marinho, Carlos Veterano, Maricruz Nunes, Patrícia Baptista, Pedro Aguiar, Pedro Campelo, Rosana Dias, Sandra Santos, Sara Peixoto Class20 Introdução à Medicina II May 2011

  2. 1. Background Introdução à Medicina II March 2011

  3. 1. Background Deep Venous Thrombosis (DVTs) Ilio-femoral Vein “Deep venous thrombosis (DVTs) are a significant cause of morbidity and mortality in the general population” [1] Image 1 [1] Gogalniceanu P, Johnston CJ, Khalid U, Holt PJ, Hincliffe R, Loftus IM, Thompson MM; Indications for thrombolysis in deep venous thrombosis, 2009 Introdução à Medicina II March 2011

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

  5. 1. Background: Anticoagulation Therapy ANTICOAGULATION THERAPY Unfractionatedheparin Vitamin K Antagonists Low-molecular-weight Heparin (Enexoparin) Image 2 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 Introdução à Medicina II March 2011

  6. 1. Background: Catetherdirected-thrombolysis • Thrombolytic agent: urokinase or streptokinase or rtPA • Venous approach to ilio-femoral vein:popliteal • common femoral • Cava filters, venous stents and angioplastic balloon Image 5 Image 3 Image 4 T. Wicky Stephan; Acute Deep Vein Thrombosis and Thrombolysis; 2009 Introdução à Medicina II March 2011

  7. 2. Researchquestion What’sthebesttreatmentfor ilio-femoralthrombosis: ANTICOAGULATION THERAPY OR CATHETER DIRECTED TROMBOLYSIS ? Introdução à Medicina II March 2011

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

  9. 4. Methodology: Query (venousthrombosisORthrombusORclotORvenousblockage) AND (femoral veinORilio-femoralvein) AND(heparinORcatheterdirected thrombolysis ORanticoagulationtherapyORthrombolytictherapy) Data bases: Pubmed , Scopus, Cochrane Image 8 Image 7 Image 9 Introdução à Medicina II March 2011

  10. 4. Methodology: SelectionCriteria Image 10 Introdução à Medicina II March 2011

  11. 4. Methodology: Articles’ Selection Pubmed, Scopus, Cochrane 215 articles Readtitle ReadAbstract 33 articles Readfulltext 23 articlesincluded 4 clinicaltrialsthat compare bothtreatments 15 systematicreviews 8 clinicaltrials Introdução à Medicina II March 2011

  12. 4. Methodology: QualityAssessment Jadad scale a) Wasthestudydescribed as randomized?b) Wasthestudydescribed as double-blind?c) Wasthere a descriptionofwithdrawalsanddrop-outs? YES = 1 NO = 0 Add 1 point if Deduct 1 point if • Randomizationanddouble-blinding are appropriate • Randomizationanddouble-blinding are notappropriate Introdução à Medicina II March 2011

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

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

  15. 5. Results: Lysis OR = (a/c)/(b/d) Greater with AT Greater with CDT SATISFACTORY RESULTS Introdução à Medicina II March 2011

  16. 5. Results: VenousObstruction OR = (a/c)/(b/d) Greater with AT Greater with CDT Introdução à Medicina II March 2011

  17. 5. Results: Patency 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. Introdução à Medicina II March 2011

  18. 5_Results: Recurrency CDT followed by anticoagulation therapy leads to much lower recurrency rate than anticoagulation alone. [4,5,6] Image 13 – Thrombus formation [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. Introdução à Medicina II March 2011

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

  20. 5. Results: CDT Complications • Occurenceofbleedingin 5 – 11%b ofthepatients • Pulmonaryembolism: 4,5% • Death: 0% – 0,4% • Pain: causedbytheapplicationof a stent puncture site bleeding intracranial haemorrhage (uncommon) [1] [1] Bad measure of efficacy The thrombus goes to the lungs trough the vena cava. Lung Image 14 [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 [2] Introdução à Medicina II March 2011

  21. 6. Discussion CatheterDirectedThrombolysis AnticoagulationTherapy allows prevents Effectivelysis Greaterpatency Lessvenousobstruction Recurrent DVT PulmonaryEmbolism Salvageofvenousvalves Reduced PTS Introdução à Medicina II March 2011

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

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

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