Fibrinolytic therapy for venous thrombosis

In the treatment of DVT fibrinolytic therapy offers the possibility of rapid clot dissolution resulting in symptomatic relief of the acute episode as well as preservation of venous valve function and prevention of long-term disability from chronic venous insufficiency. A review of published studies comparing fibrinolytic therapy with SK to anticoagulation alone indicates that substantial venographic improvement occurs in 45% of SK treated patients compared with only 5% receiving only anticoagulation. Substantial data indicate a high incidence of venous valvular dysfunction and eventual development of chronic venous insufficiency in patients with extensive leg DVT treated with anticoagulants alone. The available data on the long-term benefits of thrombolytic therapy in preventing chronic venous insufficiency suggest that fibrinolytic therapy reduces long-term morbidity. Because best results are obtained by treatment soon after the onset of symptoms, it follows that the postphlebitic syndrome can be best avoided by prompt thrombolytic therapy of patients with acute DVT. Bleeding complications are more frequent after thrombolytic therapy than anticoagulant therapy, but most are related to invasive vascular procedures and can be minimized by proper patient selection and management. Available studies of rt-PA in treatment of DVT indicate that infusion durations of 24 hours or more may be required; further studies will be needed to evaluate the response to rt-PA compared with those of SK or UK. Thrombosis of the axillary/subclavian veins of the upper extremity, occurring spontaneously or in association with indwelling venous catheters, also respond well to regional or systemic fibrinolytic therapy, which may reduce the likelihood of developing chronic arm symptoms related to venous insufficiency.