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Original Investigation |

Comparative Outcomes of Catheter-Directed Thrombolysis Plus Anticoagulation vs Anticoagulation Alone to Treat Lower-Extremity Proximal Deep Vein Thrombosis

Riyaz Bashir, MD1; Chad J. Zack, MD2; Huaqing Zhao, PhD3; Anthony J. Comerota, MD4; Alfred A. Bove, MD1
[+] Author Affiliations
1Division of Cardiovascular Diseases, Temple University School of Medicine, Philadelphia, Pennsylvania
2Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
3Department of Clinical Sciences, Temple University School of Medicine, Philadelphia, Pennsylvania
4Department of Vascular Surgery, ProMedica Toledo Hospital, Toledo, Ohio
JAMA Intern Med. 2014;174(9):1494-1501. doi:10.1001/jamainternmed.2014.3415.
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Importance  The role of catheter-directed thrombolysis (CDT) in the treatment of acute proximal deep vein thrombosis (DVT) is controversial, and the nationwide safety outcomes are unknown.

Objectives  The primary objective was to compare in-hospital outcomes of CDT plus anticoagulation with those of anticoagulation alone. The secondary objective was to evaluate the temporal trends in the utilization and outcomes of CDT in the treatment of proximal DVT.

Design, Setting, and Participants  Observational study of patients with a principal discharge diagnosis of proximal or caval DVT from 2005 to 2010 in the Nationwide Inpatient Sample (NIS) database. We compared patients treated with CDT plus anticoagulation with the patients treated with anticoagulation alone. We used propensity scores to construct 2 matched groups of 3594 patients in each group for comparative outcomes analysis.

Main Outcomes and Measures  The primary study outcome was in-hospital mortality. The secondary outcomes included bleeding complications, length of stay, and hospital charges.

Results  Among a total of 90 618 patients hospitalized for DVT (national estimate of 449 200 hospitalizations), 3649 (4.1%) underwent CDT. The CDT utilization rates increased from 2.3% in 2005 to 5.9% in 2010. Based on the propensity-matched comparison, the in-hospital mortality was not significantly different between the CDT and the anticoagulation groups (1.2% vs 0.9%) (OR, 1.40 [95% CI, 0.88-2.25]) (P = .15). The rates of blood transfusion (11.1% vs 6.5%) (OR, 1.85 [95% CI, 1.57-2.20]) (P < .001), pulmonary embolism (17.9% vs 11.4%) (OR, 1.69 [95% CI, 1.49-1.94]) (P < .001), intracranial hemorrhage (0.9% vs 0.3%) (OR, 2.72 [95% CI, 1.40-5.30]) (P = .03), and vena cava filter placement (34.8% vs 15.6%) (OR, 2.89 [95% CI, 2.58-3.23]) (P < .001) were significantly higher in the CDT group. The CDT group had longer mean (SD) length of stay (7.2 [5.8] vs 5.0 [4.7] days) (OR, 2.27 [95% CI, 1.49-1.94]) (P < .001) and higher hospital charges ($85 094 [$69 121] vs $28 164 [$42 067]) (P < .001) compared with the anticoagulation group.

Conclusions and Relevance  In this study, we did not find any difference in the mortality between the CDT and the anticoagulation groups, but evidence of higher adverse events was noted in the CDT group. In the context of this observational data and continued improvements in technology, a randomized trial with outcomes such as mortality and postthrombotic syndrome is needed to definitively address this comparative effectiveness.

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Figure 1.
Rates of CDT in the United States, 2005-2010

The trend of rate increase is significant (P < .001). CDT indicates catheter-directed thrombolysis.

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Figure 2.
Graphic Respresentations of Temporal Trends in the 2 Study Groups in the United States, 2005-2010

A, In-hospital mortality rates. B, IVC filter placement rates. C, Hospital lengths of stay. D, Hospital charges. CDT indicates catheter-directed thrombolysis; IVC, inferior vena cava. The dotted lines underlying each group line represent trends.

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