Percutaneous endovenous intervention versus anticoagulation in the treatment of lower extremity deep vein thrombosis: a systematic review and meta-analysis

Background: Deep vein thrombosis (DVT) of the lower extremity (LE) might lead to pulmonary embolism ( PE) and post-thrombolytic syndrome (PTS). Recently, percutaneous endovenous intervention (PEVI) has been advocated for early removal of thrombus clot and restoration of venous patency. This study aims to review the safety and efficacy outcomes of PEVI versus anticoagulation in the treatment of acute LE-DVT. Methods: We searched the databases of PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) comparing catheter-directed thrombolysis (CDT) and/or pharmacomechanical thrombectomy (PMT) versus anticoagulation for acute proximal LE-DVT, published before August 2022. Efficacy outcomes were PTS and venous patency. Safety outcomes included recurrent thromboembolism, bleeding complications, and PE. Results: Overall, 1,266 patients were included from 6 RCTs. The overall risk of bias was small due to enrolled high-quality RCTs. Compared to anticoagulation, PEVI moderately reduced PTS incidence [odds ratio (OR) 0.47, 95% confidence interval (CI) 0.23-0.99], obviously inhibited moderate-to-severe PTS (OR 0.60, 95% CI: 0.40-0.88), significantly decreased PE (OR 0.16, 95% CI: 0.05-0.48), and substantially increased venous patency (OR 7.95, 95% CI: 1.00-63.16). There was no significant difference in recurrent thromboembolism between PEVI and anticoagulation (OR 0.76, 95% CI: 0.34-1.73). Bleeding events did not differ statistically between PEVI and anticoagulation (OR 1.36, 95% CI: 0.87-2.11). We conducted single-arm meta-analysis of the PEVI or anticoagulation. Pooled proportion of PTS was less after PEVI (0.295, 95% CI: 0.123-0.505) than after anticoagulation (0.459, 95% CI: 0.306-0.616). Pooled proportion of moderate-to-severe PTS was lower after PEVI (0.098, 95% CI: 0.033-0.191) than after anticoagulation (0.183, 95% CI: 0.126-0.247). Pooled proportion of PE was smaller after PEVI (0.006, 95% CI: 0.00-0.020) as compared to anticoagulation (0.075, 95% CI: 0.038-0.122). Pooled proportion of recurrent thromboembolism was similar between PEVI (0.095, 95% CI: 0.054-0.146) and anticoagulation (0.124, 95% CI: 0.061-0.206). Pooled proportion of bleeding was not different statistically between PEVI (0.026, 95% CI: 0.00-0.131) and anticoagulation (0.008, 95% CI: 0.00-0.094). Conclusions: PEVI, consisting of PMT and/or CDT, is an extremely effective and feasible approach for patients with acute LE-DVT. In comparison to therapeutic anticoagulation, PEVI restores venous patency, inhibits the PTS development, reduces the PE occurrence, does not markedly increase the bleeding risk, but does not reduce recurrent thromboembolism.