Zusammenfassung
Die akute tiefe Becken-Bein-Venenthrombose (TVT) ist eine in der Regel nicht tödlich verlaufende Erkrankung, die einen lebenslangen Schaden im Sinne eines postthrombotischen Syndroms (PTS) hinterlassen kann. Im Moment steht die konservative Therapie mit Antikoagulation und Kompression und Mobilisation als sicherste Therapieform im Mittelpunkt aller Empfehlungen. Das Ausmaß der Thrombose und die Thrombuslokalisation werden dabei einfach ignoriert. Die systemische und die katheterbasierte fibrinolytische Therapie einer akuten proximalen TVT mit und ohne mechanische Unterstützung ist möglich, wird aber in den nationalen und internationalen Leitlinien nicht als Therapie der Wahl beschrieben. Die Anzahl randomisierter kontrollierter Studien ist begrenzt. Die zuletzt publizierte ATTRACT-Studie („Adjunctive Catheter-Directed Thrombolysis“) mit 692 Patienten aus 56 Zentren zum Nutzen der „pharmacomechanical catheter-directed thrombolysis“ (PCDT) zeigt ein negatives Ergebnis. Der primäre Endpunkt der Studie war das Auftreten eines PTS nach 2 Jahren und wurde bei 47 % in der PCDT-Gruppe + Antikoagulation und 48 % in der Kontrollgruppe mit alleiniger Antikoagulation beobachtet (Risikoverhältnis, 0,96; 95 %-Konfidenzintervalll 0,82–1,11; p = 0,56). Andererseits war die PCDT mit signifikant mehr größeren Blutungen innerhalb der ersten 10 Tage verbunden (1,7 % vs. 0,3 % der Patienten, p = 0,049). Zusammenfassend lässt sich daher sagen, auch wenn die fibrinolytische Therapie der akuten Beckenvenenthrombosen ein vielversprechender Ansatz zur Vermeidung eines PTS ist, ist dies eine Therapie, die mit einem signifikant erhöhten Blutungsrisiko einen Teil der Vene rekanalisiert, ohne dass der Mehrwert dieser Rekanalisation für den Patienten im Sinne einer Verbesserung der langfristigen Lebensqualität wissenschaftlich belegt ist.
Abstract
Acute deep pelvic vein thrombosis (DVT) usually is a non-fatal disease that can cause a post-thrombotic syndrome (PTS) as a lifelong damage. All recommendations currently focus on conservative therapy including anticoagulation, compression and mobilization as the safest form of therapy. The extent of the thrombosis and its localization are simply ignored. Systemic and catheter-directed thrombolysis of acute proximal DVT with and without mechanical support is possible but is not the therapy of choice in national and international guidelines. The number of randomized controlled studies are limited. The recently published ATTRACT study (Adjunctive Catheter-Directed Thrombolysis) including 692 patients from 56 centers was performed to show the benefits of pharmacomechanical catheter-directed thrombolysis (PCDT) but the results were negative. The primary endpoint of the study was the occurrence of PTS after 2 years and was observed in 47% of the PCDT group + anticoagulation and 48% in the control group with anticoagulation alone (risk ratio, 0.96, 95% confidence interval 0.82–1.11, p = 0.56). On the other hand, PCDT was associated with significantly more major bleedings within the first 10 days (1.7% vs. 0.3% of patients, p = 0.049). In summary, even if fibrinolytic therapy for acute pelvic vein thrombosis is a promising approach to avoid PTS, it is a therapy that while associated with a significantly increased risk of bleeding can recanalize some of the veins, but without the value that this recanalization has any scientifically proven impact on the long-term quality of life for patients.
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K. Kröger hat bezahlte Vorträge für Bayer, Sanofi, Pfizer, GSK und Aspen gehalten. G. Gäbel gibt an, dass kein Interessenkonflikt besteht.
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Kröger, K., Gäbel, G. Katheterbasierte Fibrinolysetherapie bei tiefer Beinvenenthrombose. Gefässchirurgie 23, 225–230 (2018). https://doi.org/10.1007/s00772-018-0394-8
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DOI: https://doi.org/10.1007/s00772-018-0394-8
Schlüsselwörter
- Postthrombotisches Syndrom
- Venöse Thrombose
- Thrombolytische Therapie
- Katheterbasierte Fibrinolyse
- Pharmakomechanische katheterbasierte Fibrinolyse