New anticoagulants for treatment of venous thromboembolism.

Anticoagulant therapy is the cornerstone of treatment of venous thromboembolism (VTE). Such treatment is divided into 2 stages: Rapid initial anticoagulation is given to minimize the risk of thrombus extension and fatal pulmonary embolism, whereas extended anticoagulation is aimed at preventing recurrent VTE, thereby reducing the risk of postphlebitic syndrome. With currently available drugs, immediate anticoagulation can only be achieved with parenteral agents, such as heparin, low-molecular-weight heparin, or fondaparinux. Extended treatment usually involves the administration of vitamin K antagonists, such as warfarin. Emerging anticoagulants have the potential to streamline VTE treatment. These agents include idraparinux, a long-acting synthetic pentasaccharide that is given subcutaneously on a once-weekly basis, and new oral anticoagulants that target thrombin or factor Xa. This article (1) reviews the pharmacology of these agents, (2) outlines their potential strengths and weaknesses, (3) describes the results of clinical trials with these new drugs, and (4) identifies the evolving role of new anticoagulants in the management of VTE.

Contemporary issues in the prevention and management of postthrombotic syndrome.

OBJECTIVE: To provide an evidence-based review and clinical summary of postthrombotic syndrome (PTS). DATA SOURCES: A literature review was performed via MEDLINE (1950-July 1, 2009) and International Pharmaceutical Abstracts (1970-June 2009) searches using the terms post-thrombotic syndrome, post-phlebitic syndrome, deep vein thrombosis, and compression stockings. DATA SYNTHESIS: PTS is best characterized as a chronic syndrome of clinical signs and symptoms including pain, swelling, parasthesias, and ulceration in the affected limb following deep vein thrombosis (DVT). It occurs in up to half of patients with symptomatic DVT, usually within the first 2 years. Although the pathophysiology of PTS is not well understood, a thrombus may cause venous hypertension and valvular incompetence resulting in edema, tissue hypoxia, and in severe cases, ulceration. Risk factors for PTS include recurrent ipsilateral DVT, obesity, and poor quality of anticoagulant therapy. PTS diagnosis is based on the presence of typical signs and symptoms and may be made using one of several clinical scoring systems. Prevention of PTS should focus on DVT prevention and the use of elastic compression stockings following DVT, while fibrinolysis remains under investigation as an effective method for PTS prevention. The treatment of PTS may include either pharmacologic or mechanical modalities, although none of these regimens has been rigorously tested. Pharmacists have the opportunity to provide more comprehensive antithrombotic management by educating patients and providers on PTS, recommending appropriate preventive therapy, assisting patients in obtaining and adhering to this therapy, and assisting providers with the management of PTS. CONCLUSIONS: Providers should be proactive in preventing PTS, with pharmacists taking an active role in optimal DVT prevention, identifying patients at risk for PTS, and counseling and directing preventive therapies.

[Treatment of postoperative thrombosis]. / Therapie der postoperativen Thrombose.

For the treatment of deep vein thrombosis (DVT), rapid diagnosis and prompt therapy are crucial to minimize the risk of fatal pulmonary embolism and long-term complications, including the postthrombotic syndrome and recurrent thromboembolism. The treatment of acute DVT remains controversial. In this review, treatment options in relation to exposing and predisposing risk factors are discussed. Evidence-based data and recommendations from official guidelines are presented.

Post-thrombotic syndrome after total hip arthroplasty is uncommon.

BACKGROUND: Deep vein thrombosis (DVT), usually asymptomatic, is common after total hip arthroplasty (THA). Post-thrombotic syndrome (PTS) is a potential late complication of DVT, but there is limited data on its occurrence. PATIENTS AND METHODS: This was a prospective cohort study of subjects at one hospital who had participated in a trial of thromboprophylaxis for THA and who had postoperative venography. Data were collected at baseline and 2-4 years later to ascertain symptoms of PTS using a modification of a validated scoring system. Outcomes were collected without knowledge of baseline characteristics or venogram results. Potential predictors of PTS were explored using exact logistic regression analyses. RESULTS: The cohort (n=188) had a mean age of 63 years, 51% were male, 35% had a BMI of>30, and 4% had a prior history of DVT. 25 patients (13%) had DVTs on venography. 12 patients (6%, 95% CI: 3-11) subsequently developed symptoms consistent with PTS, 7 with bilateral symptoms. Most affected limbs (15 of 19) had no postoperative DVT. No statistically significant predictors of PTS were found. INTERPRETATION: Symptoms of PTS are infrequent after THA in patients who receive some form of thromboprophylaxis. Our findings, which are consistent with the existing literature, suggest that there is a potential benefit to giving thromboprophylaxis for reduction of symptomatic PTS.

Effectiveness of compression stockings to prevent the post-thrombotic syndrome (the SOX Trial and Bio-SOX biomarker substudy): a randomized controlled trial.

BACKGROUND: Post thrombotic syndrome (PTS) is a burdensome and costly complication of deep venous thrombosis (DVT) that develops in 20-40% of patients within 1-2 years after symptomatic DVT. Affected patients have chronic leg pain and swelling and may develop ulcers. Venous valve disruption from the thrombus itself or thrombus-associated mediators of inflammation is considered to be a key initiating event for the development of venous hypertension that often underlies PTS. As existing treatments for PTS are extremely limited, strategies that focus on preventing the development of PTS in patients with DVT are more likely to be effective and cost-effective in reducing its burden. Elastic compression stockings (ECS) could be helpful in preventing PTS; however, data on their effectiveness are scarce and conflicting. METHODS/DESIGN: The SOX Trial is a randomized, allocation concealed, double-blind multicenter clinical trial. The objective of the study is to evaluate ECS to prevent PTS. A total of 800 patients with proximal DVT will be randomized to one of 2 treatment groups: ECS or placebo (inactive) stockings worn on the DVT-affected leg daily for 2 years. The primary outcome is the incidence of PTS during follow-up. Secondary outcomes are severity of PTS, venous thromboembolism (VTE) recurrence, death from VTE, quality of life and cost-effectiveness. Outcomes will be evaluated during 6 clinic visits and 2 telephone follow ups. At baseline, 1 and 6 months, blood samples will be obtained to evaluate the role of inflammatory mediators and genetic markers of thrombophilia in the development of PTS (Bio-SOX substudy). DISCUSSION: The SOX Trial will be the largest study and the first with a placebo control to evaluate the effectiveness of ECS to prevent PTS. It is designed to provide definitive data on the effects of ECS on the occurrence and severity of PTS, as well as DVT recurrence, cost-effectiveness and quality of life. This study will also prospectively evaluate the predictive role of biomarkers that are reflective of putative underlying pathophysiological mechanisms in the development of clinical PTS. As such, our results will impact directly on the care of patients with DVT. TRIAL REGISTRATION: NCT00143598 and ISRCTN71334751.

Late results of catheter-directed recombinant tissue plasminogen activator fibrinolytic therapy of iliofemoral deep venous thrombosis.

PURPOSE: To evaluate the efficacy of catheter-directed low-dose recombinant tissue-type plasminogen activator infusion in the treatment of iliofemoral deep venous thrombosis and prevention of post-thrombotic syndrome. METHOD: Eighteen patients (out of 260 evaluated) with acute iliofemoral deep venous thrombosis and no previous evidence of venous insufficiency were prospectively selected for thrombolytic therapy. Catheter-directed low-dose recombinant tissue-type plasminogen activator (1 mg/h) was infused into the thrombotic segments. RESULTS: Effective fibrinolysis was achieved in 14 of 18 cases, with correlation between effective fibrinolysis and major/complete resolution of acute signs and symptoms (P <.01). There were no episodes of major complications. Four patients presented with early rethrombosis (1 to 8 weeks). Individuals were followed for a period up to 131 weeks (average, 85.2). The incidence of clinical signs and symptoms of venous insufficiency and duplex-scan findings of valvular reflux was significantly lower in the patients in which lytic therapy succeeded and patency was kept, compared with patients experiencing acute therapeutic failure or rethrombosis (P <.01). CONCLUSIONS: Low-dose recombinant tissue-type plasminogen activator fibrinolytic therapy is safe and effective in the treatment of acute iliofemoral venous thrombosis. The late evolution as revealed clinically and by ultrasound was superior in patients for whom lytic therapy was effective.

Review on the value of graduated elastic compression stockings after deep vein thrombosis.

Graduated elastic compression stockings (GECS) are commonly used in the primary prevention of deep vein thrombosis (DVT); however, their role in preventing recurrent DVT and also post-thrombotic syndrome is less well established. The aim of this review was to investigate the effect of GECS after DVT. A literature search was performed by two independent searchers in order to identify randomised controlled trials on the effect of GECS in preventing recurrent DVT and post-thrombotic syndrome. Four randomised trials, including 537 patients, were identified. Two of the studies demonstrated that below-knee GECS significantly reduced post-thrombotic syndrome during follow-up, while a smaller study showed equivocal results. GECS reduced the incidence of post-thrombotic syndrome from 54% to 25.2% [relative risk (RR) 0.47, 95% confidence interval (CI) 0.36-0.61] with the number needed to treat (NNT) being 4 (95% CI 2.7-5.0). The rate of recurrent asymptomatic DVT was also significantly reduced by GECS (RR 0.20, 95% CI 0.06-0.64; NNT 5); the reduction in symptomatic DVT was not significant (RR 0.79, 95% CI 0.50-1.26; NNT 34). In conclusion, there is level Ia evidence to suggest that GECS can significantly reduce the incidence of post-thrombotic syndrome (PTS) after DVT, and therefore these should be routinely prescribed. The evidence for recurrent DVT is less conclusive. Further research is needed towards standardising PTS diagnostic criteria and evaluating more effective preventive measures after DVT.

A cost analysis of the treatment of patients with post-thrombotic syndrome in Brazil.

INTRODUCTION: Post-thrombotic syndrome (PTS) occurs in 15-50% of patients with deep vein thrombosis (DVT), and is associated with substantial medical costs. This prospective observational study investigated the costs associated with the treatment of PTS in Brazil. MATERIALS AND METHODS: A total of 157 patients diagnosed with PTS and with a history of DVT were recruited from nine centers in Brazil. The costs of investigations and treatment for PTS over a 1-year follow-up period were analyzed. Ninety patients were available for this analysis. RESULTS: Of the 90 patients, 17 had mild-to-moderate PTS, and 73 had severe PTS. The patients with severe PTS tended to undergo more investigations and hospitalizations for PTS than those with mild-to-moderate PTS, although the differences between the two groups did not reach statistical significance. The mean annual cost of treating PTS in Brazilian Reais was 1214 R dollars (426 US dollars) for mild-to-moderate PTS and 3386 R dollars (1188 US dollars) for severe PTS. The difference was mainly due to significantly higher hospitalization costs in patients with severe PTS (704 R dollars/247 US dollars vs. 0 R dollars; p=0.044). CONCLUSION: These results suggest that PTS imposes substantial demands on health care resources in Brazil. The implementation of effective thromboprophylactic strategies could significantly reduce the incidence of DVT, and hence of PTS, potentially resulting in significant cost savings.

Relation between quality of anticoagulant treatment and the development of the postthrombotic syndrome.

BACKGROUND: About 30% of patients with an episode of adequately treated deep venous thrombosis (DVT) develop the postthrombotic syndrome (PTS) within 2 years. During treatment with vitamin K antagonists (VKA) patients spend only 60% of time between an International Normalized Ratio (INR) of 2.0 and 3.0. We hypothesized that patients who spend a large amount of their time beneath this range will have an increased risk of the PTS. OBJECTIVE: To investigate the relation between the quality of anticoagulant therapy with VKA and the risk of the development of the PTS. METHODS: The time spent beneath the therapeutic range was calculated for patients with a first episode of DVT, who were treated with VKA for at least 3 months. At follow-up assessments for a maximum of 5 years, presence and severity of signs and symptoms of PTS were recorded. RESULTS: A total of 244 patients, with a median duration of follow-up of 4.9 years were included for analysis. Of these, 81 patients (33%) developed the PTS. The multivariate model showed that patients who spend more than 50% of their time beneath an INR level of 2.0 are at higher risk for PTS [odds ratio (OR): 2.71, 95% CI: 1.44-5.10]. CONCLUSIONS: Low quality treatment with VKA, which is a common condition, is related to the occurrence of the PTS in patients with DVT. Strategies aimed at improving the quality of long-term anticoagulation might have the potential to reduce the incidence of this complication.

Prevention and treatment of postphlebitic syndrome: results of a 3-part study.

BACKGROUND: The true incidence of postphlebitic syndrome (PPS) following proximal deep venous thrombosis (DVT) and the efficacy of graduated compression stockings in preventing and treating PPS are unknown. METHODS: A 3-part study of 202 patients evaluated 1 year after proximal DVT: 2 randomized placebo-controlled trials of stockings and 1 prospective cohort of untreated patients. Patients were evaluated for PPS, using a standardized questionnaire, and for venous valvular incompetence, using photoplethysmography and venous Doppler. They were enrolled in study 1 or study 2 if they did not have symptomatic PPS and did not have or had venous valvular incompetence, respectively, and into study 3 if they had symptomatic PPS. Study 1 patients were left untreated and followed up for development of PPS every 6 months for a mean of 55 months. Study 2 patients were randomized to a below-knee stocking (20-30 mm Hg) or a matched placebo stocking, and followed up for development of PPS every 6 months for a mean of 57 months. Study 3 patients were randomized to an active stocking (30-40 mm Hg) or a matched placebo stocking and followed up every 3 months for treatment failure, defined a priori. RESULTS: In study 1, 6 (5.0%) of 120 patients were categorized as treatment failures, a rate similar to placebo-treated study 2 patients (P =.10). In study 2, 0 (0%) of 24 active and 1 (4.3%) of 23 placebo-treated patients were categorized as treatment failures (P =.49). In study 3, 11 (61.1%) of 18 active and 10 (58.8%) of 17 placebo-treated patients were categorized as treatment failures (P>.99). CONCLUSIONS: Most patients do not have PPS 1 year after proximal DVT, and do not require stockings. We failed to show a benefit of stockings in patients with PPS, but the small numbers preclude definitive conclusions.

Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial.

BACKGROUND: Because only limited evidence suggests that elastic stockings prevent the post-thrombotic syndrome in patients with symptomatic deep venous thrombosis (DVT), these stockings are not widely used. OBJECTIVE: To evaluate the efficacy of compression elastic stockings for prevention of the post-thrombotic syndrome in patients with proximal DVT. DESIGN: Randomized, controlled clinical trial. SETTING: University hospital. PATIENTS: 180 consecutive patients with a first episode of symptomatic proximal DVT who received conventional anticoagulant treatment. INTERVENTIONS: Before discharge, patients were randomly assigned to wear or not wear below-knee compression elastic stockings (30 to 40 mm Hg at the ankle) for 2 years. Follow-up was performed for up to 5 years. MEASUREMENTS: The presence and severity of the post-thrombotic syndrome were scored by using a standardized scale. RESULTS: Post-thrombotic sequelae developed in 44 of 90 controls (severe in 10) and in 23 of 90 patients wearing elastic stockings (severe in 3). All but 1 event developed in the first 2 years. The cumulative incidence of the post-thrombotic syndrome in the control group versus the elastic stockings group was 40.0% (95% CI, 29.9% to 50.1%) versus 21.1% (CI, 12.7% to 29.5%) after 6 months, 46.7% (CI, 36.4% to 57.0%) versus 22.2% (CI, 13.8% to 30.7%) after 1 year, and 49.1% (CI, 38.7% to 59.4%) versus 24.5% (CI, 15.6% to 33.4%) after 2 years. After adjustment for baseline characteristics, the hazard ratio for the post-thrombotic syndrome in the elastic stockings group compared with controls was 0.49 (CI, 0.29 to 0.84; P = 0.011). LIMITATIONS: This study lacked a double-blind design. CONCLUSIONS: Post-thrombotic sequelae develop in almost half of patients with proximal DVT. Below-knee compression elastic stockings reduce this rate by approximately 50%.

Thrombolytic therapy for acute deep vein thrombosis and the venous registry.

Randomized clinical trials have defined anticoagulation with unfractionated or low molecular weight heparin followed by warfarin as standard therapy for acute deep venous thrombosis (DVT). Such treatment is highly effective in preventing recurrent venous thromboembolism, but provides imperfect protection against development of the postthrombotic syndrome. By restoring venous patency and preserving valvular function, catheter-directed thrombolytic therapy potentially affords an improved long-term outcome in selected patients with DVT. A national venous registry, compiling data from 63 participating centers, was established to collect data regarding the technical details of the procedure and early outcome. Data from the registry have established the optimal technical approach and patient population. An antegrade catheter-directed approach using urokinase in patients with acute iliofemoral DVT of less than 10 days duration and no prior history of DVT may achieve complete lysis in 65% of patients. Analysis of the clinical outcome is pending, but early results suggest improved valve function and fewer symptoms at 1 year in patients with complete thrombolysis. These promising data should serve as the basis for future randomized trials of catheter-directed thrombolysis for the treatment of acute DVT.

Quality-of-life improvement using thrombolytic therapy for iliofemoral deep venous thrombosis.

Patients with iliofemoral deep venous thrombosis suffer the most severe postthrombotic morbidity. Techniques that effectively remove thrombus from the venous system eliminate venous obstruction and potentially preserve valvular function. This will likely reduce or avoid the postthrombotic syndrome and improve long-term quality of life. To evaluate whether catheter-directed thrombolysis is associated with improved quality of life compared with anticoagulation alone and whether outcome in the thrombolysis group is related to lytic success, 98 patients with iliofemoral deep venous thrombosis who were treated at least 6 months earlier were identified and queried with a validated health-related quality-of-life questionnaire. Sixty-eight patients were identified through the Venous Registry (a national, multicenter venous registry) and were treated with catheter-directed thrombolysis with urokinase, and 30 patients were identified by means of medical record review and were treated with anticoagulation alone. All patients were candidates for thrombolysis; however, the treatment decision was made according to physician preference. The two treatment groups did not differ significantly in average time between the reference hospitalization and first contact. No difference was found in physical functioning and well-being between the groups before the development of deep venous thrombosis. Following treatment, patients receiving catheter-directed thrombolysis reported better overall physical functioning, less stigma, less health distress, and fewer postthrombotic symptoms compared to those patients treated with anticoagulation alone. Within the thrombolysis group, successful lysis correlated with health-related quality of life. Catheter-directed thrombolysis for the management of patients with iliofemoral deep venous thrombosis significantly improves health-related quality of life compared to similar patients treated with anticoagulation alone. Improved quality of life is related to successful thrombolysis. These data offer a compelling argument for a prospective randomized study.

Automated computer interviews to elicit utilities: potential applications in the treatment of deep venous thrombosis.

OBJECTIVE: To assess the practicality of an automated computer interview as a method to assess preferences for use in decision making. To assess preferences for outcomes of deep vein thrombosis (DVT) and its treatment. STUDY DESIGN: A multimedia program was developed to train subjects in the use of different preference assessment methods, presented descriptions of mild post-thrombotic syndrome (PTS), severe PTS and stroke and elicited subject preferences for these health states. This instrument was used to measure preferences in 30 community volunteers and 30 internal medicine physicians. We then assessed the validity of subject responses and calculated the number of quality-adjusted life years (QALYs) for each individual for each alternative. RESULTS: All subjects completed the computerized survey instrument without assistance. Subjects generally responded positively to the program, with volunteers and physicians reporting similar preferences. Approximately 26.5% of volunteers and physicians had preferences that would be consistent with the use of thrombolysis. Individualization of therapy would lead to the most QALYs. CONCLUSIONS: Utilization of computerized survey instruments to elicit patient preferences appears to be a practical and valid approach to individualize therapy. Application of this method suggests that there may be many patients with DVT for whom treatment with a thrombolytic drug would be optimal.

Treatment and management of acute venous thromboembolic disease.

Venous thromboembolic (VTE) disease consists of deep vein thrombosis and/or pulmonary embolism. Either low molecular weight heparin given subcutaneously or unfractionated heparin administered intravenously are used for the initial treatment. Simultaneously, warfarin therapy is initiated. Thrombolytic therapy plays a limited role. Following the initial heparin treatment, anticoagulation clinics provide an excellent means of monitoring the oral anticoagulation. Patient education is important and patients should be well versed in the basic features of oral anticoagulation. The duration of oral anticoagulation is dependent on a number of factors including the presence of inherited risk factors, bleeding risk and patient reliability. Residual thrombus in the affected vein may indicate the need for prolonged anticoagulation. The low intensity oral anticoagulation (INR 1.5-2.0) is useful in preventing recurrent thrombosis following the initial treatment period with full intensity oral anticoagulation.

Non-pharmaceutical measures for prevention of post-thrombotic syndrome.

BACKGROUND: Post-thrombotic syndrome (PTS) is a long-term complication of deep vein thrombosis (DVT) characterised by chronic pain, swelling and skin changes in the affected limb. One in every three patients with DVT will develop post-thrombotic complications within five years. OBJECTIVES: To determine the relative effectiveness of, and the rate of complications using non-pharmaceutical interventions in patients with DVT in the prevention of PTS. SEARCH STRATEGY: The reviewers searched the Cochrane Peripheral Vascular Diseases Group Specialised Trials Register (last searched January 2003), and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 4, 2002). In addition, hand searching of non-listed journals and personal communications with researchers was undertaken. SELECTION CRITERIA: Randomised controlled trials (RCTs) of non-pharmaceutical interventions, such as bandaging and elastic stockings in patients with clinically confirmed DVT. The primary outcome was the occurrence of PTS. There was no restriction on date or language. One reviewer (DNK) identified and assessed titles and abstracts for relevance. This was verified independently by a second reviewer (RS). DATA COLLECTION AND ANALYSIS: Data extraction was undertaken independently by two reviewers (DNK, RS), using data extraction sheets. MAIN RESULTS: Three RCTs that evaluated compression therapy were identified. Two studies compared elastic compression stockings with a pressure of 30-40 mm Hg at the ankle with no intervention applied directly after an episode of DVT. The other small study compared elastic compression stockings (pressure 20-30 mm Hg) with stockings that were one to two sizes too large in patients one year after DVT. Overall, in the treatment group at two years, the use of elastic compression stockings was associated with a highly statistically significant reduction in the incidence of PTS with odds ratio (OR) 0.31 (95% confidence interval (CI) 0.20 to 0.48). In addition, the incidence of severe PTS was reduced from OR 0.39 (95% CI 0.20 to 0.76). In another RCT that considered the first nine days post DVT, no difference in the incidence of pulmonary embolism and size of thrombus in the femoral vein was found. A statistically significant reduction (p <0.05) was found in pain, swelling and clinical scores, favouring the compression group. REVIEWER'S CONCLUSIONS: There is substantial evidence that elastic compression stockings reduce the occurrence of PTS after DVT. No serious adverse effects were mentioned in the studies. Hence, elastic compression stockings should be added to the treatment of DVT to prevent the development of post-thrombotic syndrome.

Thrombectomy for acute deep vein thrombosis: prevention of postthrombotic syndrome.

Ninety-six limbs of 89 patients with acute deep vein thrombosis of the lower extremity were followed for 1 to 18 years. In the thrombectomy group (43 limbs), the cumulative incidence of pigmentation at the 15th year was 15%, but no stasis ulcers occurred throughout the follow-up period. In the conservative treatment group (53 limbs), the cumulative incidence of pigmentation at the 15th year was 41%, and that of stasis ulceration was 27%. Fogarty thrombectomy restricted below the pelvic vein spur and removal of thrombi in the leg veins by manual milking is sufficient to relieve early morbidity, preserve venous valve function, and promote intrapelvic collateral circulation. Preservation of venous valves in the femoropopliteal region is a key to the prevention of postthrombotic syndrome. Thrombectomy within 5 days of the onset of symptoms is recommended for patients with iliofemoropopliteal venous thrombosis.

[Role of plasminogen activators in the treatment of deep venous thrombosis]. / Place des activateurs du plasminogène dans le traitement de la thrombose veineuse profonde.

In deep vein thrombosis, thrombolytic agents can improve vein patency more rapidly than conventional anticoagulant therapy. The clinical benefit of thrombolytic use would be a reduction in the incidence and severity of the postthrombotic syndrome and limb salvage in "phlegmatia caerulea". A literature review suggests that streptokinase and rt-PA do better than heparin regarding vein patency. A clinical benefit on postthrombotic syndrome can only be suggested by available evidence. The risk of major bleeding is increased by thrombolytic agents as compared with heparin. Mortality for cerebral bleeding is about 0.5%. Currently, thrombolytic therapy is only recommended for limb salvage in phlegmatia caerulea.

[Thrombolysis in deep venous thrombosis: critical review]. / Thrombolyse bei tiefer Venenthrombose: kritische Ubersicht.

Thrombolytic treatment of deep vein thrombosis remains controversial. It has never been demonstrated that the late postthrombotic syndrome may be diminished by the faster dissolution of the clots induced by streptokinase or urokinase. On the other hand are the hemorrhagic side effects associated with thrombolysis well described (lethality of 0.6%). Thrombolysis should be performed preferably under controlled conditions of a clinical study. It is indicated only in young patients with symptoms for less than 7 days of a first thrombosis. Initial results from second generation fibrinolytic substances such as rt-PA (alteplase) do not change this view drastically.

[Venous thromboembolic disease]. / La maladie veineuse thrombo-embolique.

Prevention and treatment of venous thrombosis and pulmonary embolism have improved dramatically in the last few years owing to: 1) better control of the coumarin activity with the International Normalized Ratio system; 2) appearance on the market of the low-weight molecular heparins and enlargement of their field of prescription; 3) indications of thrombolysis in severe pulmonary embolism; 4) availability of inferior vena cava filters, effective in preventing recurrent pulmonary embolism.