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Better Catheter-Directed Thrombolysis Outcomes at Higher-Volume Institutions


NEW YORK - In-hospital mortality and bleeding rates after catheter-directed thrombolysis (CDT) of lower extremity proximal deep vein thrombosis are lower in institutions that perform more procedures than in those with fewer procedures, according to a new study.

"As utilization of CDT continues to increase, we propose that institutions follow a standardized CDT protocol that includes careful patient selection as well as patient monitoring," Dr. Riyaz Bashir from Temple University School of Medicine in Philadelphia, Pennsylvania, told Reuters Health by email. "In addition, establishment of centers of excellence in treating venous thromboembolic disease may provide the necessary framework within which bleeding risk to the patient can be minimized."

CDT is increasingly favored over anticoagulation for patients with lower extremity proximal deep vein thrombosis (LE-DVT), but it has been associated with increased bleeding rates and procedure-related complications, Dr. Bashir and colleagues note in Circulation, online July 21.

In light of literature implicating institutional volume as a significant factor in patient outcomes, the team used the Nationwide Inpatient Sample database to investigate the relationship between annual institutional procedure volume and adverse in-hospital patient outcomes in patients receiving CDT for acute proximal LE-DVT.

Just over half the 3,649 procedures were performed at high-volume centers (six or more procedures per year), with the remainder (43%) done at low-volume centers (less than six procedures per year).

In a propensity-matched comparison of 1,310 patients from each group, in-hospital mortality was significantly lower at high-volume centers than at low-volume centers (0.6% vs. 1.5%, p=0.04), the researchers found.

Intracranial hemorrhage rates tended to be lower at high-volume centers (0.4% vs. 1.0%, p=0.07), while inferior vena cava filter placement rates were significantly higher at high-volume centers (37.0% vs. 32.8%; p=0.03).

Institutional volume did not influence blood transfusion, GI bleeding, or pulmonary embolism rates or hospital length of stay. Median hospital charges were higher at high-volume centers ($75,870) than at low-volume centers ($65,500).

At low-volume centers, outcomes tended to be worse for CDT plus anticoagulation than for anticoagulation alone, whereas outcomes were similar for CDT plus anticoagulation and for anticoagulation alone at high-volume centers.

On multiple regression analysis, there was a significant inverse relationship between institutional volume and in-hospital mortality.

"Our observation that the major safety outcomes (death and intracranial hemorrhage) were not significantly different between patients undergoing CDT as compared to patients undergoing anticoagulation therapy alone at high volume centers suggests that these complications can be minimized," Dr. Bashir concluded. "Patients with leg DVT - especially young patients - should feel comfortable considering clot removal, particularly at a high volume center, as a viable option to prevent post-thrombotic syndrome."

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