Management of venous thromboembolism: A Systematic Review for a Practice Guideline

Johns Hopkins University, Baltimore, Maryland, United States
Annals of internal medicine (Impact Factor: 17.81). 03/2007; 146(3):211-22. DOI: 10.7326/0003-4819-146-3-200702060-00150
Source: PubMed


New treatments are available for treatment of venous thromboembolism.
To review the evidence on the efficacy of interventions for treatment of deep venous thrombosis (DVT) and pulmonary embolism.
MEDLINE, MICROMEDEX, the Cochrane Controlled Trials Register, and Cochrane Database of Systematic Reviews from the 1950s through June 2006.
Randomized, controlled trials; systematic reviews of trials; and observational studies; all restricted to English-language articles.
Paired reviewers assessed study quality and abstracted data. The authors pooled results about optimal duration of anticoagulation.
This review includes 101 articles. Low-molecular-weight heparin (LMWH) is modestly superior to unfractionated heparin at preventing recurrent DVT and is at least as effective as unfractionated heparin for treatment of pulmonary embolism. Outpatient treatment of venous thromboembolism is likely to be effective and safe in carefully chosen patients, with appropriate services available. Inpatient or outpatient use of LMWH is cost-saving or cost-effective compared with unfractionated heparin. In observational studies, catheter-directed thrombolysis safely restored vein patency in select patients. Moderately strong evidence supports early use of compression stockings to reduce postthrombotic syndrome. Limited evidence suggests that vena cava filters are only modestly efficacious for prevention of pulmonary embolism. Conventional-intensity oral anticoagulation beyond 12 months may be optimal for patients with unprovoked venous thromboembolism, although patients with transient risk factors benefit little from more than 3 months of therapy. High-quality trials support use of LMWH in place of oral anticoagulation, particularly in patients with cancer. Little evidence is available to guide treatment of venous thromboembolism during pregnancy.
The authors could not address all management questions, and excluded non-English-language literature.
The strength of evidence varies across the study questions but generally is strong.

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    • "Miniati et al. [20] reported normalised perfusion in 65% of patients after 1 year in patients who survived extensive PE. Patients with PE are currently recommended at least 6 months of anticoagulation treatment in current guidelines both from Europe and USA [8] [9] [21]. Whether a strategy of follow-up of PE patients with V/P SPECT and cessation of treatment after documented resolution of PE is feasible and safe needs to be evaluated in a properly randomised trial. "
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    ABSTRACT: Background: Pulmonary embolism (PE) is diagnosed with imaging techniques such as ventilation/perfusion (V/P) lung scintigraphy or multidetector computed tomography of the pulmonary arteries (MDCT). Lung scintigraphy can be performed with planar (V/P PLANAR) and tomographic (V/P SPECT) techniques. V/P SPECT has higher sensitivity and specificity than V/P PLANAR. As nephrotoxic contrast media are not used during V/P SPECT, examinations can be repeated for evaluation of resolution of perfusion defects after PE. However, the value of residual perfusion defects identified using V/P SPECT for the prediction of recurrent PE has not been thoroughly evaluated. Material and methods: We evaluated resolution and recurrence of PE in 227 patients (mean age 63 ± 17 years, 134[59%] women) with PE undergoing ≥ 2 SPECT examinations in 2005-2007. PE was defined as minor (<20% perfusion defect on SPECT, n=86), medium (20-50% perfusion defect on SPECT, n=99), or major (>50% perfusion defect on SPECT, n=42). Results: At second V/P SPECT examination, complete resolution of perfusion defects had occurred in 45 (52%) patients with minor PE after 8.2 ± 7.4 months, in 29 (29%) of patients with medium PE after 6.2 ± 5.9 months, and in 2(5%) of patients with major PE after 6.5 ± 0.7 months. During 47 ± 24 months of follow up, 37(16 %) patients suffered recurrent PE. Of these 37, 34 (92%) showed residual perfusion defects at the second V/P SPECT examination. Recurrence of PE was also predicted by advanced age and female gender. However, in multivariate regression analysis, recurrence was only predicted by age (p=0.0013) and residual perfusion defect on V/P SPECT (p=0.0039). Conclusion: In conclusion, complete resolution of PE was common in patients with minor PE, whereas residual perfusion defects were widespread in patients with medium and major PE. PE patients identified with persistent perfusion defects at follow-up SPECT have a high risk of PE recurrence.
    Full-text · Article · Sep 2012 · Thrombosis Research
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    • "The treatment of VTE usually consists of 3 to 6 months anticoagulation with warfarin [6-12], but this regime is associated with high bleeding complications and recurrent thromboses in cancer patients [13,14]. Three randomised controlled trials have demonstrated low molecular weight heparin (LMWH) to be superior to warfarin in the management of cancer associated thrombosis (CAT) and LMWH is now recommended as the anticoagulant of choice in patients with malignant disease [9,11,12,14-18]. "
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    ABSTRACT: The treatment of cancer associated thrombosis (CAT) is well established, with level 1A evidence to support the recommendation of a low molecular weight heparin (LMWH) by daily injection for 3-6 months. However, registry data suggest compliance to clinical guidelines is poor. Clinicians face particular challenges in treating CAT in advanced cancer patients due to shorter life expectancy, increased bleeding risk and concerns that self injection may be too burdensome. For these reasons decision making around the diagnosis and management of CAT in people with advanced cancer, can be complex, and should focus on its likely net benefit for the patient. We explored factors that influence doctors' decision making in this situation and sought to gain an understanding of the barriers and facilitators to the application of best practice. Think aloud exercises using standardised case scenarios, and individual in depth interviews were conducted. All were transcribed. The think aloud exercises were analysed using Protocol Analysis and the interviews using Framework Analysis.Participants: 46 participants took part in the think aloud exercises and 45 participants were interviewed in depth. Each group included oncologists, palliative physicians and general practitioners and included both senior doctors and those in training.Setting: Two Strategic Health Authority regions, one in the north of England and one in Wales. The following key issues arose from the data synthesis: the importance of patient prognosis; the concept of "appropriateness"; "benefits and burdens" of diagnosis and treatment; LMWH or warfarin for treatment and sources of information which changed practice. Although interlinked, they do describe distinct aspects of the factors that influence doctors in their decisions in this area. The above factors are issues doctors take into account when deciding whether to send a patient to hospital for investigation or to anticoagulate a patient with confirmed or suspected VTE. Many factors interweave and are themselves influenced by and dependent on each other. It is only after all are taken into account that the doctor arrives at the point of referring the patient for investigation. Some factors including logistic and organisational issues appeared to influence whether a patient would be investigated or treated with LMWH for a confirmed VTE. It is important that services are optimised to ensure that these do not hinder the appropriate investigation and management of individual patients.
    Full-text · Article · Jul 2012 · BMC Medical Informatics and Decision Making
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    • "Placement of an IVC filter may prevent fatal pulmonary embolism due to venous return. However, some scholars think that filter placement is not associated with a reduced incidence of symptomatic pulmonary embolism (25). In this study, none of the patients suffered from symptomatic pulmonary embolism, including the 28 patients who didn't receive IVC filter placement. "
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    ABSTRACT: We wanted to evaluate the feasibility of catheter-directed thrombolysis with a continuous infusion of low-dose urokinase for treating non-acute (less than 14 days) deep venous thrombosis of the lower extremity. The clinical data of 110 patients who were treated by catheter-directed thrombolysis with a continuous infusion of low-dose urokinase for lower extremity deep venous thrombosis was analysed. Adjunctive angioplasty or/and stenting was performed for the residual stenosis. Venous recanalization was graded by pre- and post-treatment venography. Follow-up was performed by clinical evaluation and Doppler ultrasound. A total of 112 limbs with deep venous thrombosis with a mean symptom duration of 22.7 days (range: 15-38 days) were treated with a urokinase infusion (mean: 3.5 million IU) for a mean of 196 hours. After thrombolysis, stent placement was performed in 25 iliac vein lesions and percutaneous angioplasty (PTA) alone was done in five iliac veins. Clinically significant recanalization was achieved in 81% (90 of 112) of the treated limbs; complete recanalization was achieved in 28% (31 of 112) and partial recanalization was achieved in 53% (59 of 112). Minor bleeding occurred in 14 (13%) patients, but none of the patients suffered from major bleeding or symptomatic pulmonary embolism. During follow-up (mean: 15.2 months, range: 3-24 months), the veins were patent in 74 (67%) limbs. Thirty seven limbs (32%) showed progression of the stenosis with luminal narrowing more than 50%, including three with rethrombosis, while one revealed an asymptomatic iliac vein occlusion; 25 limbs (22%) developed mild post-thrombotic syndrome, and none had severe post-thrombotic syndrome. Valvular reflux occurred in 24 (21%) limbs. Catheter-directed thrombolysis with a continuous infusion of low-dose urokinase combined with adjunctive iliac vein stenting is safe and effective for removal of the clot burden and for restoration of the venous flow in patients with non-acute lower extremity deep venous thrombosis.
    Full-text · Article · Jan 2011 · Korean journal of radiology: official journal of the Korean Radiological Society
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