Deep-Vein Thrombosis
http://www.100md.com
《新英格兰医药杂志》
To the Editor: In Table 2 of their article on the treatment of deep-vein thrombosis, Bates and Ginsberg (July 15 issue)1 list ocular surgery within the past 10 days as an absolute contraindication for anticoagulant therapy. The data for the table are derived from a secondary source.2 The most commonly performed eye surgery in the United States is refractive surgery, such as laser-assisted in situ keratomileusis (LASIK) and photoreactive keratectomy, followed closely by cataract surgery. With all three of these operations, the vascular tree is typically not violated in most cases. Accordingly, it seems unwise to consider recent performance of these operations as an absolute contraindication for anticoagulation, since the potential morbidity and mortality associated with deep-vein thrombosis that is not treated with anticoagulation are much greater than the risk of an ocular complication of a procedure that is often associated with no blood loss. There are other intraocular procedures that are associated with some bleeding, and perhaps a recent trabeculectomy or subretinal surgery would be appropriate to consider as a relative contraindication for anticoagulation. Most intraocular laser procedures are also associated with little or no bleeding and would therefore be safe in the setting of anticoagulation. The best practice would be to ask the patient's ophthalmologist about the advisability of anticoagulation on a case-by-case basis, since most types of recent ocular surgery are not of concern.
Michael S. Korenfeld, M.D.
Washington University
Washington, MO 63090
michaelkorenfeld@hotmail.com
References
Bates SM, Ginsberg JS. Treatment of deep-vein thrombosis. N Engl J Med 2004;351:268-277.
Abrams J, Frishman WH, Bates SM, Weitz JI, Opie LH. Pharmacologic options for treatment of ischemic disease. In: Antman EM, ed. Cardiovascular therapeutics: a companion to Braunwald's Heart Disease. 2nd ed. Philadelphia: W.B. Saunders, 2002:97-153.
To the Editor: In their review, Bates and Ginsberg fail to endorse catheter-directed thrombolysis for any indications of deep-vein thrombosis beyond phlegmasia. We believe their recommendations are too restrictive and that many additional patients with acute iliofemoral deep-vein thrombosis would benefit from catheter-directed thrombolysis.
Anticoagulant therapy provides distinctly suboptimal late outcomes with respect to limb status in many patients with deep-vein thrombosis.1 In contrast, strategies directed at early thrombus removal tend to improve such outcomes.2,3 Catheter-directed thrombolysis is safer, faster, and more effective in removing an acute iliofemoral venous thrombus than were previous thrombolytic methods.4 In one study, patients with acute iliofemoral deep-vein thrombosis who were treated successfully with urokinase catheter-directed thrombolysis plus anticoagulation had a superior health-related quality of life and fewer post-thrombotic symptoms at 22 months of follow-up as compared with a retrospective matched cohort treated with anticoagulation alone.5
Randomized trials are under way to quantify more precisely the risk–benefit ratio for catheter-directed thrombolysis. In the meantime, we believe that physicians should carefully weigh the risks and benefits of catheter-directed thrombolysis for each of their ambulatory patients who has acute iliofemoral deep-vein thrombosis and to use catheter-directed thrombolysis for those with a reasonable life expectancy and no predisposition to bleeding.
Suresh Vedantham, M.D.
Neil Khilnani, M.D.
Robert Min, M.D.
Society of Interventional Radiology
Fairfax, VA 22030
vedanthams@mir.wustl.edu
References
Strandness DE Jr, Langlois Y, Cramer M, Randlett A, Thiele BL. Long-term sequelae of acute venous thrombosis. JAMA 1983;250:1289-1292.
Elliot MS, Immelman EJ, Jeffery P, et al. A comparative randomized trial of heparin versus streptokinase in the treatment of acute proximal venous thrombosis: an interim report of a prospective trial. Br J Surg 1979;66:838-843.
Plate G, Eklof B, Norgren L, Ohlin P, Dahlstrom JA. Venous thrombectomy for iliofemoral venous thrombosis -- 10-year results of a prospective randomised study. Eur J Vasc Endovasc Surg 1997;14:367-374.
Mewissen MW, Seabroook GR, Meissner MH, Cynamon J, Labropoulous N, Haughton SH. Catheter-directed thrombolysis for lower extremity deep vein thrombosis: report of a national multicenter registry. Radiology 1999;211:39-49.
Comerota AJ, Throm RC, Mathias SD, Haughton S, Mewissen M. Catheter-directed thrombolysis for iliofemoral deep venous thrombosis improves health-related quality of life. J Vasc Surg 2000;32:130-137.
The authors reply: As noted in our article, the role of thrombolytic therapy in patients with deep-vein thrombosis remains controversial. Consequently, this treatment is generally reserved for those patients most likely to benefit from this intervention; that is, those who have limb-threatening thrombosis with a short duration of symptoms and a low risk of bleeding.1
Dr. Vedantham and colleagues suggest that this recommendation is overly conservative. However, there have been no randomized trials comparing catheter-directed thrombolytic therapy with anticoagulation, and the true benefits, risks, and economic costs, as compared with those of traditional therapy, are unknown. The results of the cited studies are interesting, but both studies had methodologic shortcomings. Specifically, bias in patient selection was probable in the National Venous Thrombosis Registry,2 given that only 473 patients were enrolled at 63 centers in one year.3 Treatment was not randomly assigned in the study by Comerota and colleagues4 and, as acknowledged by the authors, patients treated with anticoagulants may have been more likely to have coexisting conditions and, thus, a lower quality of life. Furthermore, it is not clear that consecutive patients were invited to participate in the study, and although Vedantham et al. state that the treatment cohorts were matched, there was a significant difference in age, suggesting that patients were not similar at baseline. A systematic review suggests that catheter-directed thrombolysis is more hazardous than anticoagulant therapy, on the basis of an increased risk of major hemorrhage (11.3 percent vs. 5.9 percent),2 and a decision analysis suggests that patients are not willing to risk potential adverse outcomes associated with thrombolytic therapy to prevent the post-thrombotic syndrome.5
Until properly designed studies show a benefit, thrombolytic therapy, which is more expensive and associated with a greater risk of serious complications, should be reserved for patients who are most likely to benefit and least likely to be harmed by the intervention. We agree that this decision should be made on an individual basis. However, all the risks, the possible lack of long-term benefits, and acknowledgment of the absence of high-quality supportive data must be discussed with the patient.
Shannon M. Bates, M.D.C.M.
Jeffrey S. Ginsberg, M.D.
McMaster University
Hamilton, ON L8N 3Z5, Canada
batesm@mcmaster.ca
References
Hyers TM, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease. Chest 2001;119:Suppl:176S-193S.
Wells PS, Forster AJ. Thrombolysis in deep vein thrombosis: is there still an indication? Thromb Haemost 2001;86:499-508.
Mewissen MW, Seabrook GR, Meissner MH, Cynamon J, Labropoulos N, Haughton SH. Catheter-directed thrombolysis for lower extremity deep vein thrombosis: report of a national multicenter registry. Radiology 1999;211:39-49.
Comerota AJ, Throm RD, Mathias SD, Haughton S, Mewissen M. Catheter-directed thrombolysis for iliofemoral deep venous thrombosis improves health-related quality of life. J Vasc Surg 2000;132:130-137.
O'Meara JJ III, McNutt RA, Evans AT, Moore SW, Downs SM. A decision analysis of streptokinase plus heparin compared with heparin alone for deep-vein thrombosis. N Engl J Med 1994;330:1865-1869.
Michael S. Korenfeld, M.D.
Washington University
Washington, MO 63090
michaelkorenfeld@hotmail.com
References
Bates SM, Ginsberg JS. Treatment of deep-vein thrombosis. N Engl J Med 2004;351:268-277.
Abrams J, Frishman WH, Bates SM, Weitz JI, Opie LH. Pharmacologic options for treatment of ischemic disease. In: Antman EM, ed. Cardiovascular therapeutics: a companion to Braunwald's Heart Disease. 2nd ed. Philadelphia: W.B. Saunders, 2002:97-153.
To the Editor: In their review, Bates and Ginsberg fail to endorse catheter-directed thrombolysis for any indications of deep-vein thrombosis beyond phlegmasia. We believe their recommendations are too restrictive and that many additional patients with acute iliofemoral deep-vein thrombosis would benefit from catheter-directed thrombolysis.
Anticoagulant therapy provides distinctly suboptimal late outcomes with respect to limb status in many patients with deep-vein thrombosis.1 In contrast, strategies directed at early thrombus removal tend to improve such outcomes.2,3 Catheter-directed thrombolysis is safer, faster, and more effective in removing an acute iliofemoral venous thrombus than were previous thrombolytic methods.4 In one study, patients with acute iliofemoral deep-vein thrombosis who were treated successfully with urokinase catheter-directed thrombolysis plus anticoagulation had a superior health-related quality of life and fewer post-thrombotic symptoms at 22 months of follow-up as compared with a retrospective matched cohort treated with anticoagulation alone.5
Randomized trials are under way to quantify more precisely the risk–benefit ratio for catheter-directed thrombolysis. In the meantime, we believe that physicians should carefully weigh the risks and benefits of catheter-directed thrombolysis for each of their ambulatory patients who has acute iliofemoral deep-vein thrombosis and to use catheter-directed thrombolysis for those with a reasonable life expectancy and no predisposition to bleeding.
Suresh Vedantham, M.D.
Neil Khilnani, M.D.
Robert Min, M.D.
Society of Interventional Radiology
Fairfax, VA 22030
vedanthams@mir.wustl.edu
References
Strandness DE Jr, Langlois Y, Cramer M, Randlett A, Thiele BL. Long-term sequelae of acute venous thrombosis. JAMA 1983;250:1289-1292.
Elliot MS, Immelman EJ, Jeffery P, et al. A comparative randomized trial of heparin versus streptokinase in the treatment of acute proximal venous thrombosis: an interim report of a prospective trial. Br J Surg 1979;66:838-843.
Plate G, Eklof B, Norgren L, Ohlin P, Dahlstrom JA. Venous thrombectomy for iliofemoral venous thrombosis -- 10-year results of a prospective randomised study. Eur J Vasc Endovasc Surg 1997;14:367-374.
Mewissen MW, Seabroook GR, Meissner MH, Cynamon J, Labropoulous N, Haughton SH. Catheter-directed thrombolysis for lower extremity deep vein thrombosis: report of a national multicenter registry. Radiology 1999;211:39-49.
Comerota AJ, Throm RC, Mathias SD, Haughton S, Mewissen M. Catheter-directed thrombolysis for iliofemoral deep venous thrombosis improves health-related quality of life. J Vasc Surg 2000;32:130-137.
The authors reply: As noted in our article, the role of thrombolytic therapy in patients with deep-vein thrombosis remains controversial. Consequently, this treatment is generally reserved for those patients most likely to benefit from this intervention; that is, those who have limb-threatening thrombosis with a short duration of symptoms and a low risk of bleeding.1
Dr. Vedantham and colleagues suggest that this recommendation is overly conservative. However, there have been no randomized trials comparing catheter-directed thrombolytic therapy with anticoagulation, and the true benefits, risks, and economic costs, as compared with those of traditional therapy, are unknown. The results of the cited studies are interesting, but both studies had methodologic shortcomings. Specifically, bias in patient selection was probable in the National Venous Thrombosis Registry,2 given that only 473 patients were enrolled at 63 centers in one year.3 Treatment was not randomly assigned in the study by Comerota and colleagues4 and, as acknowledged by the authors, patients treated with anticoagulants may have been more likely to have coexisting conditions and, thus, a lower quality of life. Furthermore, it is not clear that consecutive patients were invited to participate in the study, and although Vedantham et al. state that the treatment cohorts were matched, there was a significant difference in age, suggesting that patients were not similar at baseline. A systematic review suggests that catheter-directed thrombolysis is more hazardous than anticoagulant therapy, on the basis of an increased risk of major hemorrhage (11.3 percent vs. 5.9 percent),2 and a decision analysis suggests that patients are not willing to risk potential adverse outcomes associated with thrombolytic therapy to prevent the post-thrombotic syndrome.5
Until properly designed studies show a benefit, thrombolytic therapy, which is more expensive and associated with a greater risk of serious complications, should be reserved for patients who are most likely to benefit and least likely to be harmed by the intervention. We agree that this decision should be made on an individual basis. However, all the risks, the possible lack of long-term benefits, and acknowledgment of the absence of high-quality supportive data must be discussed with the patient.
Shannon M. Bates, M.D.C.M.
Jeffrey S. Ginsberg, M.D.
McMaster University
Hamilton, ON L8N 3Z5, Canada
batesm@mcmaster.ca
References
Hyers TM, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease. Chest 2001;119:Suppl:176S-193S.
Wells PS, Forster AJ. Thrombolysis in deep vein thrombosis: is there still an indication? Thromb Haemost 2001;86:499-508.
Mewissen MW, Seabrook GR, Meissner MH, Cynamon J, Labropoulos N, Haughton SH. Catheter-directed thrombolysis for lower extremity deep vein thrombosis: report of a national multicenter registry. Radiology 1999;211:39-49.
Comerota AJ, Throm RD, Mathias SD, Haughton S, Mewissen M. Catheter-directed thrombolysis for iliofemoral deep venous thrombosis improves health-related quality of life. J Vasc Surg 2000;132:130-137.
O'Meara JJ III, McNutt RA, Evans AT, Moore SW, Downs SM. A decision analysis of streptokinase plus heparin compared with heparin alone for deep-vein thrombosis. N Engl J Med 1994;330:1865-1869.