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Referral patterns for catheter-directed thrombolysis for iliofemoral deep venous thrombosis
Kirtan D Patel1, Alison Yy Tang1, Ashik Dj Zala1
1Education Department, The Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK.
Insights
Catheter directed thrombolysis (CDT) for iliofemoral deep venous thrombosis (DVT) can improve outcomes, but awareness and referral rates are low. Improved collaboration and clear guidelines are needed for better patient management and reduced post-thrombotic syndrome.
Area of Science:
- Vascular Medicine
- Interventional Radiology
- Thrombosis Management
Background:
- Post-thrombotic syndrome (PTS) is a significant complication following deep venous thrombosis (DVT), particularly iliofemoral DVT.
- Catheter directed thrombolysis (CDT) offers a potential treatment to reduce the incidence and severity of PTS after iliofemoral DVT.
Purpose of the Study:
- To determine the incidence of iliofemoral DVT at the institution.
- To assess the management of these cases and adherence to National Institute for Health and Care Excellence (NICE) guidelines.
- To evaluate clinician awareness of CDT as a treatment option for iliofemoral DVT.
Main Methods:
- Retrospective review of 225 lower limb DVT cases over three years.
- Identification of 96 iliofemoral DVTs using ICD-10 codes and duplex scan reports.
- Survey of clinicians regarding CDT awareness and local management guidelines for iliofemoral DVT.
Main Results:
- 96 cases of iliofemoral DVT were identified, with a median age of 77; 67.7% affected the left leg.
- Only 21 of 96 iliofemoral DVTs were eligible for CDT, with only 3 patients referred to vascular services and 3 receiving thrombolysis.
- A significant knowledge gap was observed, with 95.5% of clinicians favoring anticoagulation alone and limited awareness of venous anatomy.
Conclusions:
- Underutilization of CDT for iliofemoral DVT is linked to a lack of awareness among clinicians.
- Improved collaboration between vascular services and DVT clinics, alongside guideline development, is crucial.
- Establishing robust care pathways can enhance management of iliofemoral DVT and potentially reduce PTS.
Objectives:
Post thrombotic syndrome (PTS) is a serious complication of deep venous thromboses (DVTs). PTS occurs more frequently and severely following iliofemoral DVT compared to distal DVTs. Catheter directed thrombolysis (CDT) of iliofemoral DVTs may reduce PTS incidence and severity.We aimed to determine the rate of iliofemoral DVT within our institution, their subsequent management, and compliance with NICE guidelines.
Methods:
Retrospective review of all DVTs diagnosed over a 3-year period was conducted. Cases of iliofemoral DVT were identified using ICD-10 codes from patient notes, and radiology reports of Duplex scans. Further details were retrieved, such as patient demographics and referrals to vascular services. NICE guidance was applied to determine if patients would have been suitable for CDT. A survey was sent to clinicians within medicine to identify awareness of CDT and local guidelines for iliofemoral DVT management.
Results:
225 patients with lower limb DVTs were identified. Of these, 96 were radiographically confirmed as iliofemoral DVTs. The median age was 77. 67.7% of iliofemoral DVTs affected the left leg. Right leg DVTs made up 30.2% and 2.1% were bilateral DVTs. Of the 96 iliofemoral DVTs, 21 were deemed eligible for CDT. Only 3 patients (14.3%) were referred to vascular services, and 3 received thrombolysis.From our survey, 95.5% of respondents suggested anticoagulation alone as management for iliofemoral DVT. Only one respondent recommended referral to vascular services. There was a knowledge deficiency regarding venous anatomy, including superficial versus deep veins.
Conclusions:
CDT and other mechanochemical procedures have been shown to improve outcomes of patients post-iliofemoral DVT, however a lack of awareness regarding CDT as a management option results in under-referral to vascular services. We suggest closer relations between vascular services and their "tributary" DVT clinics, development of guidelines and robust care pathways in the management of iliofemoral DVT.
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