Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA.
J Vasc Surg. 2012 May;55(5):1449-62. doi: 10.1016/j.jvs.2011.12.081. Epub 2012 Apr 1.
The anticoagulant treatment of acute deep venous thrombosis (DVT) has been historically directed toward the prevention of recurrent venous thromboembolism. However, such treatment imperfectly protects against late manifestations of the postthrombotic syndrome. By restoring venous patency and preserving valvular function, early thrombus removal strategies can potentially decrease postthrombotic morbidity.
A committee of experts in venous disease was charged by the Society for Vascular Surgery and the American Venous Forum to develop evidence-based practice guidelines for early thrombus removal strategies, including catheter-directed pharmacologic thrombolysis, pharmacomechanical thrombolysis, and surgical thrombectomy.
Evidence-based recommendations are based on a systematic review and meta-analysis of the relevant literature, supplemented when necessary by less rigorous data. Recommendations are made according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, incorporating the strength of the recommendation (strong: 1; weak: 2) and an evaluation of the level of the evidence (A to C).
On the basis of the best evidence currently available, we recommend against routine use of the term "proximal venous thrombosis" in favor of more precise characterization of thrombi as involving the iliofemoral or femoropopliteal venous segments (Grade 1A). We further suggest the use of early thrombus removal strategies in ambulatory patients with good functional capacity and a first episode of iliofemoral DVT of <14 days in duration (Grade 2C) and strongly recommend their use in patients with limb-threatening ischemia due to iliofemoral venous outflow obstruction (Grade 1A). We suggest pharmacomechanical strategies over catheter-directed pharmacologic thrombolysis alone if resources are available and that surgical thrombectomy be considered if thrombolytic therapy is contraindicated (Grade 2C).
Most data regarding early thrombus removal strategies are of low quality but do suggest patient-important benefits with respect to reducing postthrombotic morbidity. We anticipate revision of these guidelines as additional evidence becomes available.
急性深静脉血栓形成（DVT）的抗凝治疗历史上一直针对预防静脉血栓栓塞复发。然而，这种治疗并不能完全预防血栓后综合征的晚期表现。通过恢复静脉通畅并保留瓣膜功能，早期血栓清除策略有可能降低血栓后发病率。
由血管外科学会和美国静脉论坛的专家委员会负责制定早期血栓清除策略的循证实践指南，包括导管定向药物溶栓、药物机械溶栓和手术血栓切除术。
循证建议基于对相关文献的系统回顾和荟萃分析，必要时辅以不太严格的数据。建议根据推荐评估、制定和评估（GRADE）方法进行推荐，包括推荐的强度（强：1；弱：2）和证据水平的评估（A 至 C）。
根据目前可获得的最佳证据，我们建议不常规使用“近端静脉血栓形成”这一术语，而是更准确地描述血栓位于髂股或股腘静脉段（1A 级）。我们进一步建议在活动能力良好且首次出现髂股 DVT 持续时间<14 天的门诊患者中使用早期血栓清除策略（2C 级），并强烈建议在因髂股静脉流出阻塞而导致肢体威胁性缺血的患者中使用（1A 级）。如果资源允许，我们建议使用药物机械策略代替单独的导管定向药物溶栓，如果溶栓治疗禁忌，则考虑手术血栓切除术（2C 级）。
大多数关于早期血栓清除策略的数据质量较低，但确实表明在降低血栓后发病率方面具有重要的患者获益。我们预计随着更多证据的出现，这些指南将进行修订。
