A pain in the leg and breathlessnessBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c925 (Published 11 March 2010) Cite this as: BMJ 2010;340:c925
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Dear Prof Madden,
I read your 'Endgame' in this week's BMJ with interest. Venous
thromboembolic (VTE) disease is a source of considerable morbidity and
mortality worldwide. The management of these patients is however changing
rapidly, and it is with this in mind that I would challenge your
The case is that of a young man with an acute proximal DVT of the leg
with pulmonary embolus. The management plan for this patient was to
provide anticoagualtion. You stated that systemic thrombolysis should not
be considered due to a lack of haemodynamic compromise.
The modern management of acute proximal DVT is using catheter-
directed thrombolysis (CDT), with or without adjunctive mechanical
percutaneous thrombectomy, followed by both anticoagulation and elastic
compression stockings for six-months. Systemic thrombolysis, as suggested
in your article, is associated with high complication rates and relatively
The more appropriate management for this gentleman would have been an
urgent referral to a DVT specialist team containing haematologists,
vascular surgeons and interventional radiologists who would have assessed
him for CDT. The modern management of DVT is both multi-disciplinary and
CDT has been shown to increase the rate and volume of thrombus lysis
when compared to anticoagulation alone with a comparable risk profile.
This leads to a significantly reduced incidence of the post-thrombotic
syndrome and subsequent venous ulceration as well as lower rates of DVT
recurrence. The quality of life of patients post-CDT has been shown to be
better than patients treated with anticoagulation alone.
Two large clinical trials are underway in the USA and Norway to
further evaluate CDT at present and funding is pending for a UK-based
trial. Early reports have been positive, but further evidence is needed to
drive this important agenda forward.
The management of DVT is undergoing a major change, both in terms of
the immediate management and the subsequent management with modern oral
anticoagulants. The BMJ readers should be aware that all patients with an
acute proximal DVT must be referred to DVT specialists or vascular
surgeons for consideration for urgent thrombolysis.
Competing interests: No competing interests