Step 1 :Confirm PTE or DVT diagnosis
Step 2: Look for contraindications for full dose anticoagulation. If contraindications exist then insert IVC filter.
Step 3 : If no contraindication then look for impending venous gangrene (in case of DVT) or cardiopulmonary collapse (cardiogenic shock/ RV dysfunction in case of PTE). If yes then start thrombolysis
Thrombolysis for DVT:
Indications : Impending venous gangrene, symptom duration < 14 days and low risk of bleeding
Mode : a)Catheter directed thrombolysis (CDT) : Fluroscopy guided placement of multiside holed catheter (pigtail) into the thrombus segment and infusing alteplase for 1-3 days at a rate of 0.5 mg to 3 mg/hour (50 mg diluted in 50 ml of NS). CDT is superior to systemic anticoagulation alone because of reduced post thrombotic syndrome and reduced bleeding complications
b)Pharmacomechanical Catheter directed thrombolysis (PCDT)
PCDT uses either the “Power Pulse” or “isolated thrombolysis” techniques. Power Pulse employs the AngioJet rheolytic thrombectomy system (Bayer, Warrendale, PA) to deliver and disperse the thrombolytic agent by a powerful pulse-spray injection. After bathing the clot in the thrombolytic agent, the AngioJet catheter aspirates the softened thrombus fragments. Isolated thrombolysis uses the Trellis peripheral infusion system (Covidien, Mansfield, MA) to deliver the thrombolytic agent directly into the clot. The agent is then circulated within the clot by an oscillating wire.
Advantage of PCDT over CDT : Reduced dose and infusion duration of alteplase thereby reducing bleeding complications and better efficacy
Thrombolysis for PTE :
For PTE there is insufficient evidence to recommend thrombolysis via a pulmonary artery catheter rather than systemic thrombolysis
Systemic thrombolysis dose: Alteplase 100 mg (10 mg as iv bolus over 10 min f/b 90 mg in 100 ml of NS infused over 2 hours)
Step 4
If there is no evidence of impending gangrene or cardiopulmonary collapse then initiate systemic anticoagulation
Phases of anticoagulation treatment:
Initial phase– 0 to 10 days:
IV or SC unfractionated heparin/LMWH/Fondaparinux/Rivaroxaban/Apixaban
Long term phase- 10 days to 3 months
Vitamin K antagonist – warfarin/acitrom (target INR: 2-3.5)
Rivaroxaban/Apixaban/Edoxaban/Dabigatran/LMWH
Extended phase-3 months to indefinite
Indictions for extended therapy- 1.unprovoked/recurrent VTE 2. Malignancy related VTE
Drugs :
Vitamin K antagonist – warfarin/acitrom (target INR: 2-3.5)
Rivaroxaban/Apixaban/Edoxaban/Dabigatran/LMWH
Newer agents : Rivaroxaban(15 mg bd)/Apixaban(10 mg bd)/Edoxaban/Dabigatran(110 or 150 mg bd)
Pros- No need for INR monitoring, non-inferior or slightly efficacious then warfarin/acitrom, lesser major bleeding rates
cons- costlier, lesser availability especially in developing countries and no specific reversal agents
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