Cardiovascular Interventional Department of the Antony Private Hospital, Antony, France.
Diagn Interv Imaging. 2012 Oct;93(10):725-33. doi: 10.1016/j.diii.2012.07.014. Epub 2012 Sep 18.
The stated aims of treating acute deep vein thrombosis (DVT) are to prevent a pulmonary embolism, stop the clot from spreading, reduce the risk of a recurrence; they are less concerned with the late morbidity associated with post-thrombotic syndrome (PTS). In accordance with the French (Afssaps, 2009) and North American (ACCP, 2008) recommendations, anticoagulants (LMWH, heparin, AVK) form the cornerstone for treating DVT. These treatments appear to be far less effective in preventing post-thrombotic syndrome (PTS), associated with venous hypertension, residual occlusion, and with reflux caused by valve incompetence. Given that, the new aim is to optimise the prevention of PTS, the ACCP guidelines, unlike those of Afssaps, "suggest" for selected patients suffering from acute iliofemoral DVT, the use of both classic anticoagulants, and in situ percutaneous administration of thrombolytic drugs (recommendation grade 2B) and simultaneous correction of any underlying anatomical anomalies using angioplasty and stenting (recommendation 2C). Contemporary endovascular methods, referred to collectively as "facilitated" thrombolysis, combine low doses of rtPa or Urokinase administered locally, and the removal of the clot using various mechanical, rotating, rheolytic systems, or using ultrasound. The results of non-randomised, heterogeneous studies objectivised a lysis rate of 80%, a 50% lower risk of haemorrhage complications compared with systemic thrombolysis (<4%), and a clear reduction in treatment time (one-shot methods possible for procedures lasting less than 2 hours). This data ties in with the modern "open vein" concept which underpins the hope of an improvement in the late prognosis of acute DVT, through the removal of a clot, thereby improving permeability and valve integrity; this hypothesis is supported by the results at 24 months of a randomised CaVent objectifying absolute risk reduction of 15% in the thrombolysis in situ. The current randomised study (ATTRACT trial) comparing the combination of "facilitated thrombolysis" in addition to the usual treatment with the traditional treatment alone for acute iliofemoral DVT, the statistical power of which has been established (600 patients) to authenticate a reduction by a third in the number of PTS (CaVent trial, showing a 15% reduction rate of 24 months PTS in the thrombolysed group results expected in 2016), might, if the results are positive, lead to a profound change in the paradigms for the treatment of acute iliofemoral DVT.
治疗急性深静脉血栓形成（DVT）的既定目标是预防肺栓塞，阻止血栓扩散，降低复发风险；它们较少关注与血栓后综合征（PTS）相关的晚期发病率。根据法国（Afssaps，2009 年）和北美（ACCP，2008 年）的建议，抗凝剂（LMWH、肝素、AVK）是治疗 DVT 的基石。这些治疗方法在预防血栓后综合征（PTS）方面似乎效果较差，PTS 与静脉高压、残余闭塞以及瓣膜功能不全引起的反流有关。鉴于此，新的目标是优化 PTS 的预防，ACCP 指南与 Afssaps 指南不同，“建议”对患有急性髂股 DVT 的选定患者，同时使用经典抗凝剂，并原位经皮给予溶栓药物（推荐等级 2B），并使用血管成形术和支架同时纠正任何潜在的解剖异常（推荐 2C）。将各种机械、旋转、溶纤系统或使用超声波清除血栓的现代腔内方法统称为“辅助”溶栓。局部给予低剂量的 rtPa 或尿激酶，并结合各种机械、旋转、溶纤系统或使用超声波清除血栓。非随机、异质研究的结果客观地显示出 80%的溶解率、出血并发症风险降低 50%（与系统性溶栓相比<4%），以及治疗时间明显缩短（对于持续时间小于 2 小时的单次操作方法是可能的）。这一数据与现代“开放静脉”的概念相吻合，该概念是通过清除血栓，从而改善通透性和瓣膜完整性，来改善急性 DVT 晚期预后的希望。这一假设得到了随机 CaVent 研究的结果支持，该研究在 24 个月时客观地证明了局部溶栓的绝对风险降低了 15%。目前正在进行一项随机对照研究（ATTRACT 试验），比较在急性髂股 DVT 患者中常规治疗的基础上联合使用“辅助溶栓”与单独使用传统治疗的效果，该研究的统计效力（600 例患者）已建立，以验证血栓后综合征（PTS）数量减少三分之一（CaVent 试验，溶栓组 24 个月的 PTS 降低率为 15%，预计在 2016 年得到证实）的可能性，如果结果为阳性，可能会导致急性髂股 DVT 治疗模式发生深刻变化。
