What Will It Take to Initiate a Move Toward a More Aggressive Therapeutic Approach to Venous Thromboembolism?

摘要

Recent decades have engendered significant advances in the treatment of venous thromboembolism (VTE). However, patients with deep vein thrombosis (DVT) continue to experience complications, highlighting the need for more effective approaches. A systematic approach involving prophylaxis, early detection, triage, risk assessment, and aggressive anticoagulation or lytic therapy can be of great clinical benefit. Articles in the current published literature report caval interruption, anticoagulant therapy, and catheter-directed lytic therapies (CDT) as being effective in clot resolution. More recently, more aggressive new treatment approaches have been considered for acute VTE. Patients who present with symptomatic pulmonary embolism (PE) appear more likely to die of recurrent PE and are nearly 4 times as likely (1.5% vs. 0.4%) to die of PE within the next year, compared with patients who present with acute DVT. Although heparins possess anti-inflammatory properties, they do not guarantee the prevention of damage to venous valves. Advances in caval filter technology have made them easier to insert, position accurately, and remove based on clinical reports. Thrombolysis has proved to hasten clot resolution, and is usually safe when there are no contraindications. However, only 54% of pulmonologists surveyed have ever used this therapy for PE and only 28% have used it for DVT. Clinical reports show considerable potential for this therapy to prevent clinical sequelae of DVT such as PE, postthrombotic syndrome and chronic thrombo-embolic pulmonary hypertension. Yet the adoption for this treatment has been slow and appears to be only in its early stages. The current standard of care does not promote direct lysis of thrombi, and anticoagulation therapy alone may not always be sufficient. Clinical evidence strongly suggests that CDT offers significant potential in promoting effective clot dissolution and removal. A new paradigm, including the identification and involvement of stakeholders and key players appears to be a crucial step. Evidence from rigorous clinical studies and randomized control trials should be reviewed by potential stakeholders, individual physician specialists, and organizational experts to develop a new treatment paradigm. Ideally, this would be a standardized protocol for thromboembolism that outlines a step-by-step comprehensive plan that ensures early detection and, when appropriate, careful consideration of aggressive clot resolution.