The situation is a bit counter intuitive, but probably not unique: widely-acknowledged progress in diagnostic methodology, leading to…less than optimal management for some patients! Can this be true?
Consider the following: patients with acute deep vein thrombosis (DVT) most often present to the emergency department, or other medical/surgical services, that have in place sophisticated and well-validated protocols and guidelines to determine whether the patient should be classified at a high or low suspicion. The physician can then (easily) obtain confirmation (or exclusion) of the diagnosis by obtaining a non-invasive duplex ultrasound test. The latter is very accurate and widely available. If such a scenario occurs during a weekend or when testing may not be available, the patient is often treated provisionally with anticoagulants for 12–24 hours until such objective diagnostic scan can be performed. Ultimately, a decision is made on whether to continue “blood thinners” (and for how long) or stop the therapy altogether if the diagnosis can be ruled out. And all of that without need for admission to the hospital…
It sounds good and desirable, doesn’t it? Well, yes, but not always.
The above-described scenario carries with it the implicit notion that consultation with or referral to a vascular specialist is no longer necessary. The reason why this is wrong is provided powerfully and with clarity in the nice review article by Comerota and Grewal appearing in this issue of VDM.1 The authors examine currently available evidence in support of clot removal as a worthy therapeutic objective that offers potential significant benefit, as it can prevent or minimize post-DVT morbidity (post-thrombotic syndrome). The latter can become a progressive and most incapacitating life-long disease that is particularly prevalent after one or more episodes of proximal (iliofemoral) acute DVT. Use of anticoagulants alone in this setting, while capable of stabilizing the clot and add a measure of prevention for thrombus propagation and pulmonary embolism, would achieve absolutely nothing in the all-important area of protecting veins and valves from the clot-mediated damage that tends to be extensive and irreversible. Clot removal, on the other hand, offers much greater hope of an improved long-term outlook for many such patients.
Clot removal is definitely back “on the table” today thanks to the technological developments of the recent past with approaches that use thrombolytics and/or percutaneous mechanical thrombectomy devices — often, a combination of both (pharmaco-mechanical). More importantly, in the context of this editorial, the procedure involves a catheter-based approach that is performed by a vascular specialist (surgeon or not) who has a strong interest in DVT treatment and percutaneous vascular intervention. The same specialized physician can appropriately select patients for such treatment and also provide follow-up care — a most important component in the overall management of DVT.
VDM readers will immediately understand that the situation described above will not happen in the absence of participation from a vascular specialist, possibly “condemning” many DVT patients unnecessarily to the life-long consequences of severe progressive venous insufficiency. We can do much to improve on this predicament through education and the dissemination of information on the present-day interventional capabilities and scientific evidence in support of a tailored modern approach to patient treatment, where “anticoagulation alone for everyone” is no longer good enough. More than any, vascular surgeons find themselves in the eye of the storm on the subject, as they have been perceived (in the recent past) to “send the message” that a consultation may no longer be necessary for patients suspected of suffering from acute DVT, since diagnosis and therapy no longer require their participation… Wrong! It is only through the proactive involvement of vascular surgeons and other vascular specialists that patients at risk for severe post-DVT sequelae can be offered the best and latest for an optimal outcome.
1. Comerota AJ and Grewal N. Catheter-directed and pharmacomechanical thrombolysis for the treatment of acute iliofemoral deep venous thrombosis. Vascular Disease Management 2009;6:74–80.