Thrombolysis for acute lower extremity deep venous thrombosis in a tertiary care setting.
BACKGROUND
In 2008, the Surgeon General made a Call to Action for the prevention of deep venous thrombosis (DVT), and for the first time, the 2008 American College of Chest Physicians guidelines for treatment of acute lower extremity DVT (ALE DVT) were revised to include thrombolysis as a grade 2B recommendation. Catheter-directed thrombolysis (CDT) therapy for patients with ALE DVT without contraindications can result in more complete clot dissolution than anticoagulation alone and may prevent the long-term sequelae of DVT. We sought to determine the percentage of inpatients with ALE DVT at a tertiary medical center who were candidates for CDT therapy and whether these patients were appropriately offered such treatment.


METHODS
A hospital administrative database search from a tertiary medical center between January 2007 and December 2007 revealed 667 patient admissions associated with a diagnosis of DVT by International Classification of Diseases, Ninth Revision diagnosis codes (451-451.99, 453-453.99). Computerized hospital records were then searched for information regarding medical history, comorbidities, contraindications to thrombolysis, symptoms, imaging findings, and treatment.


RESULTS
Of the 667 patient admissions, 157 (24%) had ALE DVT, 31% had upper extremity DVT, 17% carried an old diagnosis DVT, and 28% had venous thromboses in other vessels. Of those 157 patients with ALE DVT, 60 (38%) had proximal iliofemoral or extensive femoral DVT that would be candidates for thrombolysis. Of the 60 patients, only 10 (17%) had no major contraindication thrombolysis. Of these, one was offered CDT but refused treatment, four did not receive consults for thrombolysis; five (9%) were offered CDT and were treated. However, of these 60 patients, 50 (83%) patients had severe illness and major and often multiple contraindications to thrombolysis.


CONCLUSIONS
Although the majority of patients identified in the 2007 inpatient database with ALE DVT and an absence of contraindications to thrombolysis were appropriately offered CDT therapy, patients in such a tertiary inpatient setting typically have severe medical comorbidities that precluded the use of thrombolysis. Future studies assessing the expanding role of CDT in patients with ALE DVT should focus on outpatient settings or nontertiary care hospitals, where patients are likely to have fewer contraindications to thrombolytic therapy.
O'Connell
Jessica B
JB
UCLA Gonda (Goldschmied) Vascular Center, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA 90095-6908, USA. jbocjboc@hotmail.com
Chandra
Ankur
A
Russell
Marcia M
MM
Davis
Gavin
G
Sanchez
Ivan
I
Lawrence
Peter F
PF
Derubertis
Brian G
BG
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D000075202:Contraindications; D019992:Databases as Topic; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D019983:Guideline Adherence; D006297:Health Services Accessibility; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007297:Inpatients; D015141:Los Angeles; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D015912:Thrombolytic Therapy; D016896:Treatment Outcome; D016312:Treatment Refusal; D020246:Venous Thrombosis / Q000175:diagnosis / Q000188:drug therapy*
D005343:Fibrinolytic Agents