Thrombolysis for deep venous thrombosis

Thrombolytic therapy uses plasminogen activating substances such as streptokinase, urokinase and alteplase to attempt to dissolve clots in the venous system.

• thrombolysis is not routinely recommended for patients with lower limb DVT (1,5)
• thrombolytic agent is often delivered locally to the clot via a catheter since this may reduce the risk of haemorrhage due to systemic fibrinogenolysis.
• useful during the acute phase of venous thrombosis to prevent valvular damage, post-thrombotic syndrome (PTS), and recurrent venous thrombosis (2)
  • the CaVenT trial reported that patients treated with CDT had significantly less PTS at 2 years compared with those treated with anticoagulation (41 vs 56 %) (3)
• catheter-directed thrombolysis (CDT) and/or thrombectomy is currently reserved for patients with
  • iliofemoral DVT and/or limb-threatening circulatory compromise
  • acute or subacute symptoms
  • a low risk of bleeding (4).

NICE recommendations:

• consider catheter-directed thrombolytic therapy for patients with symptomatic iliofemoral DVT who have:
  • symptoms of less than 14 days' duration and
  • good functional status and
  • a life expectancy of 1 year or more and
  • a low risk of bleeding (5)

Reference:

• (1) Scottish Intercollegiate Guidelines Network (SIGN) 2010. Prevention and Management of Venous Thromboembolism.
• (2) Jenkins JS, Michael P. Deep Venous Thrombosis: An Interventionalist’s Approach. The Ochsner Journal. 2014;14(4):633-640.
• (3) Piran S, Schulman S. Management of venous thromboembolism: an update. Thromb J. 2016;14(Suppl 1):23
• (4) Wang K-L, Chu P-H, Lee C-H, et al. Management of Venous Thromboembolisms: Part I. The Consensus for Deep Vein Thrombosis . Acta Cardiologica Sinica. 2016;32(1):1-22
• (5) NICE (March 2020). Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing