title: Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  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).
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA. meissner@u.washington.edu
authors.forename: Mark H
authors.initials: MH
authors.lastname: Meissner
authors.forename: Peter
authors.initials: P
authors.lastname: Gloviczki
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Comerota
authors.forename: Michael C
authors.initials: MC
authors.lastname: Dalsing
authors.forename: Bo G
authors.initials: BG
authors.lastname: Eklof
authors.forename: David L
authors.initials: DL
authors.lastname: Gillespie
authors.forename: Joann M
authors.initials: JM
authors.lastname: Lohr
authors.forename: Robert B
authors.initials: RB
authors.lastname: McLafferty
authors.forename: M Hassan
authors.initials: MH
authors.lastname: Murad
authors.forename: Frank
authors.initials: F
authors.lastname: Padberg
authors.forename: Peter
authors.initials: P
authors.lastname: Pappas
authors.forename: Joseph D
authors.initials: JD
authors.lastname: Raffetto
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Wakefield
mesh_terms: D000208:Acute Disease; D019317:Evidence-Based Medicine / Q000592:standards; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D018579:Patient Selection; D054070:Postthrombotic Syndrome / Q000209:etiology / Q000517:prevention & control; D018570:Risk Assessment; D012307:Risk Factors; D017131:Thrombectomy / Q000009:adverse effects / Q000592:standards*; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000592:standards*; D016896:Treatment Outcome; D020246:Venous Thrombosis / Q000145:classification / Q000150:complications / Q000175:diagnosis / Q000628:therapy*
chemical_list: D005343:Fibrinolytic Agents