Thromboses veineuses profondes aiguës : un nouveau champ d’application pour les techniques endovasculaires

Acute deep venous thrombosis: a new field for endovascular techniques Acute deep venous thrombosis (DVT) therapies have been judged primarily on their ability to prevent symptomatic pulmonary embolism, early thrombus progression, and recurrent venous thromboembolism (VTE). The cornerstones of current management of DVT, supported by the 2008 American College of Chest Physicians (ACCP) guidelines, are the routine use of anticoagulant therapy, graduated elastic compression stockings, and early ambulation. In selected patients with extensive acute proximal DVT, despite the fact that the French guidelines (Afssaps 2009) still consider thrombolysis not to be indicated, ACCP now recommends in-situ thrombolysis in addition to anticoagulation to reduce the risk of subsequent post-thrombotic syndrome (PTS) and recurrent DVT(Grade 2 B recommendation). The PTS has been increasingly recognized as a frequent and serious long-term complication of DVT. Its risk is thought to be higher when DVT is not managed aggressively and this concern has contributed to the greater emphasis on early thrombolytic management in extensive proximal DVT. Contemporary invasive endovascular treatments, so-called pharmaco-mechanical treatment, mitigate the drawbacks (major bleeding) historically associated with thrombolytic approaches, by means of intra-thrombus delivery of drugs followed by mechanical dispersion to accelerate lysis and then aspiration of remaining drug and clot debris. Evidence in favour of the concept of the "open vein hypothesis", that a strategy of early thrombus removal can reduce the incidence of PIS in the long term, has been reported progressively. Randomized trials (ATTRACT trial with a 2016 target completion date) are currently under way and could lead to a paradigm shift in the management of acute DVT focused on active thrombus removal.