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Treating Deep Venous Thrombosis with Thrombolysis

Am Fam Physician. 2000 May 1;61(9):2820.

Horne and Chang present the case of a young man with metastatic colon cancer who developed an acute deep venous thrombosis (DVT) of the lower extremity. Symptoms from the DVT were severe enough that the patient was bed-bound and were not improved with heparinization. Recombinant tissue-type plasminogen activator (rtPA) was injected along the course of the thrombus, with partial relief of symptoms. A second dosage of rtPA was injected in a similar manner, with marked improvement of symptoms. Subsequent anticoagulation with warfarin was accomplished.

Since the early 1990s, catheter-directed infusion of rtPA has become a typical method of thrombolysis. A four-day infusion of urokinase has been an accepted treatment, and most (80 percent) of the patients who receive this treatment are found to have at least a 50 percent resolution of the thrombus. The cost of urokinase therapy, however, is quite high, and justifying its use (instead of low-molecular-weight heparin therapy, another standard treatment for acute DVT), is difficult. Heparin or low-molecular-weight heparin gives adequate results (e.g., symptomatic relief and decreased risk of pulmonary embolism), but recurrent DVT is not uncommon. Also, DVT complications, which may be caused by systemic hypercoagulability and damage to the venous valves, may occur.

In the case presented, an immediate benefit from thrombolytic therapy was seen. The authors question whether rtPA can reduce the risk of the development of chronic complications of acute DVT. Rapid thrombolysis seems to preserve the function of the venous valves; this is not always the case when traditional anticoagulant therapy is used. The question then becomes, “Which patients will benefit most from thrombolytic therapy without suffering undue risk or cost?” The answers to this question will be based on the factors such as the patient's prognosis, underlying diseases, concomitant symptoms, risk of hemorrhage and age of the DVT.

The authors conclude that there is insufficient evidence to recommend use of thrombolytic therapy for treatment of acute DVT, although they pose questions to help guide this decision (see the accompanying table). Randomized clinical trials are clearly needed to help physicians decide whether to use thrombolysis instead of anticoagulation alone.

Questions for Deciding Whether to Give Thrombolytic Therapy for Acute DVT

Questions with answers

What is the patient's prognosis from the DVT?

How severe are the patient's symptoms?

Is there evidence of limb ischemia?

Can the symptoms of ischemia be relieved with heparinization alone?

Are resources available to pay for thrombolytic therapy?

Is there sufficient local expertise with catheter-directed thrombolytic drugs?

Is the DVT idiopathic (worse prognosis) or secondary (better prognosis) to a specific insult?

What is the risk of hemorrhage?

How old is the DVT?

How significantly would even a mild postthrombotic syndrome affect the patient's lifestyle and occupation?

Question without an answer

Will thrombolytic therapy reduce the patient's morbidity from late complications of DVT and the costs for treating those complications?


DVT = deep venous thrombosis.

Adapted with permission from Horne MK 3d, Chang R. Thrombolytic therapy for deep venous thrombosis? JAMA 1999;282:2166.

Questions for Deciding Whether to Give Thrombolytic Therapy for Acute DVT

View Table

Questions for Deciding Whether to Give Thrombolytic Therapy for Acute DVT

Questions with answers

What is the patient's prognosis from the DVT?

How severe are the patient's symptoms?

Is there evidence of limb ischemia?

Can the symptoms of ischemia be relieved with heparinization alone?

Are resources available to pay for thrombolytic therapy?

Is there sufficient local expertise with catheter-directed thrombolytic drugs?

Is the DVT idiopathic (worse prognosis) or secondary (better prognosis) to a specific insult?

What is the risk of hemorrhage?

How old is the DVT?

How significantly would even a mild postthrombotic syndrome affect the patient's lifestyle and occupation?

Question without an answer

Will thrombolytic therapy reduce the patient's morbidity from late complications of DVT and the costs for treating those complications?


DVT = deep venous thrombosis.

Adapted with permission from Horne MK 3d, Chang R. Thrombolytic therapy for deep venous thrombosis? JAMA 1999;282:2166.

Horne MK 3d, Chang R. Thrombolytic therapy for deep venous thrombosis? JAMA. December 8, 1999;282: 2164–6.


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