1

Practice Guideline

2025 ESVM Guidelines on

interventional treatment of
venous thromboembolism
Oliver Schlager1 , Elena Campello2, Juraj Madaric3 , Jill Belch4 , Lucia Mazzolai5 ,
https://econtent.hogrefe.com/doi/pdf/10.1024/0301-1526/a001211 - Wednesday, July 02, 2025 7:42:19 AM - IP Address:177.53.49.22

Marianne Brodmann6, Michael Lichtenberg7 , Domenico Baccellieri8 ,

Christos Rammos9 , Christine Espinola-Klein10, Christian Heiss11, and Markus Theurl12
1
Division of Angiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
2
Internal Medicine, Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
3
Department of Angiology, Faculty of Medicine, Comenius University and National Institute of Cardiovascular Disease,
Bratislava, Slovakia
4
Division of Molecular and Clinical Medicine, Institute of Cardiovascular Research, Ninewells Hospital and Medical School, Dundee,
United Kingdom
5
Angiology Division, Heart and Vessel Department, Lausanne University Hospital, University of Lausanne, Switzerland
6
Division of Angiology, Medical University of Graz, Graz, Austria
7
Vascular Center, Klinikum Hochsauerland GmbH, Arnsberg, Germany
8
Vein Center, Vascular Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
9
Department of Cardiology and Vascular Medicine, University of Duisburg-Essen, Essen, Germany
10
Department of Angiology, Centre of Cardiology, University Medical Centre of the Johannes Gutenberg-University Mainz,
Mainz, Germany
11
Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey,
Guildford & Vascular Department, Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Redhill, United Kingdom
12
Department of Internal Medicine III – Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria

Summary: The number of endovascular interventional procedures for catheter-based therapy (CBT) of acute venous
thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), has been increasing over the
past years. The development of more efficient thrombectomy systems for CBT of VTE has potentially enhanced the efficacy of
interventional treatment of VTE. Nevertheless, indications for CBT of VTE, i.e. catheter-directed thrombolysis (CDT) or
catheter-based mechanical thrombus removal, need to be established based on existing data and expert consensus. Vascular
experts should be involved in the decision-making process on CBTs in patients with acute VTE, and thrombus removal
procedures should be performed in centers with experience in interventional treatment of VTE. This guideline document of the
European Society of Vascular Medicine (ESVM) provides recommendations on indications and management of CBT in acute
VTE and is endorsed by the European national societies of Vascular Medicine.

Keywords: Thrombus removal, catheter-based treatment, catheter directed thrombolysis, venous thromboembolism, deep
vein thrombosis, pulmonary embolism, guidelines

National reviewers (in alphabetical order as nomi- Abbreviations

nated by the National Vascular Medicine Society)
Leyla Schweiger (Austria), Tine De Backer (Belgium), CBT Catheter-based therapy
Mislav Vrsalovic (Croatia), Petr Varejka (Czech CDT Catheter-directed thrombolysis
Republic), Sophie Blaise (France), Nikolaos Ptohis CPES Composite Pulmonary Embolism Shock Score
(Greece), Balasz Nemes (Hungary), Marzia Lugli CT Conservative therapy
(Italy), Agata Stanek (Poland), Dan Olinic (Romania), CTEPH Chronic thrombo-embolic pulmonary
Ivar Vacula (Slovakia), Vinko Boc (Slovenia), Pablo hypertension
Demelo Rodríguez (Spain), Moncef Zarrouk CTPA Computed tomography pulmonary angiography
(Sweden), Marc Righini (Switzerland) DVT Deep vein thrombosis

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 2 O. Schlager et al., ESVM Guidelines intervention in VTE

ICU Intensive care unit

IVC Inferior vena cava Class of Definition Proposal
LV Left ventricular recommendation

NEWS National Early Warning Score Conflicting evidence and/or divergence of opinion
Class II
NYHA New York Heart Association about usefulness/efficacy of the treatment or
procedure
PE Pulmonary embolism
PERT Pulmonary embolism response team Weight of evidence/ Should be
PTS Postthrombotic syndrome opinion in favour of considered
usefulness/efficacy
RCT Randomized controlled trial
rt-PA Recombinant tissue plasminogen activator Usefulness/efficacy is May be considered
RV Right ventricular less well established by
TAPSE Tricuspid annular plane systolic excursion evidence/opinion
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UFH Unfractionated heparin Class III Evidence or general Not recommended

agreement that the
USAT Ultrasound assisted thrombolysis
given treatment or
VTE Venous thromboembolism procedure is not
useful/effective and in
some cases may be
harmful
1. The process of compilation of
these guidelines
Levels of evidence
1.1 Timeline of work Levels of evidence
 Approval of the Guideline committee of the European Level of evidence A Data derived from multiple randomized
Society of Vascular Medicine (ESVM) 1.9.2023 clinical trials or meta-analysis
 Finalization of first draft 31.7.2024 Level of evidence B Data derived from a single randomized clinical
 Finalization of first round of internal review 31.7.2024 trial or large non-randomized studies
 Finalization of first round of patients’ and nurse’s Level of evidence C Consensus of opinion of experts and/or small
review 30.8.2024 studies, retrospective studies, registries
 Finalization of second round of internal and review
17.3.2025 1.3 Review process and involvement of
 External review by European national societies of vas-
stakeholders
cular medicine (reviewer assignments through presi-
dents of national societies of vascular medicine) This ESVM guideline document underwent a review pro-
24.3.2025 cess involving European national Vascular Medicine soci-
 Completion of second round of patients’ and nurse’s eties. Each European national society of Vascular
review, and of external review process 13.5.2025 Medicine was invited to nominate reviewers.
Regarding this review process, the following medical dis-
ciplines were represented among the reviewers, which
1:2 Recommendations and levels of were nominated by the European national society of Vascu-
lar Medicine: Vascular Medicine/Angiology, Cardiology,
evidence
Vascular Surgery, Interventional Radiology, and Internal
For the grading of recommendations and of the supporting Medicine.
evidence of this guideline document we refer to the recom- In addition, this ESVM guideline document was sent for
mendations as provided by the European Society of Cardi- review to 2 laypersons (patients) with a personal history and
ology (ESC) [1]. The strengths of recommendations were experience with interventional treatment of venous throm-
classified into Class I, II, or III, and the levels of evidence boembolism (VTE), and to a vascular nurse. Standardized
were graded A, B, or C. review forms were used to collect comments of the respec-
tive stakeholders through the review process and the com-
Classes of recommendation used in these guidelines ments were implemented whenever possible.

Class of Definition Proposal

recommendation
2. Background and purpose
Class I Evidence and/or general Recommended/
agreement, that a given indicated VTE most commonly comprises deep vein thrombosis
treatment or procedure
is beneficial, useful,
(DVT) and/or pulmonary embolism (PE) and has an esti-
effective mated global incidence of approximately 1 per 1,000 adults
annually [2]. The incidence rates of VTE increase by age

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 O. Schlager et al., ESVM Guidelines intervention in VTE 3

and are higher in men than women with a sex ratio of 1.2:1
[3, 4, 5].
In patients with first-time DVT or PE an estimated 30-day
case fatality of 4.6% or 9.7% (DVT/PE) was reported, while in
recent years a decline in mortality rates has been observed [5,
6, 7]. According to a recent European analysis, PE accounted
for 6.5 deaths per 100,000 population in 2015, a decline com-
pared to 12.8 deaths per 100,000 population in 2000 [8].
Among PE-related deaths, 34% of patients with acute PE died
suddenly or within a few hours of the event, before therapy
could be initiated or take effect [9]. Regarding the distribution
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of different risk categories among patients with PE, recent

observational data found a prevalence of 3.4% of patients
with PE categorized as high-risk, 63.6% as intermediate risk
and 33% as low-risk PE (PE risk categorization according to
2019 Guidelines for the diagnosis and management of acute
pulmonary embolism of the European Society of Cardiology,
developed in collaboration with the European Respiratory
Society) [10, 11]. Beyond the mortality risk and despite timely
initiation of anticoagulation, VTE may be regarded as chronic
condition (especially in cases without identifiable risk-factor),
Figure 1. Multidisciplinary management of acute venous thromboem-
as approximately 30% of patients experience recurrence bolism (VTE): acute deep vein thrombosis (DVT) and/or pulmonary
within 10 years [2]. Importantly, VTE can be severely dis- embolism (PE).
abling, the most important long-term sequelae are the post-
thrombotic syndrome (PTS) in DVT and chronic thrombo-
embolic pulmonary hypertension (CTEPH) or post pulmonary 3. Interventional therapy of acute
embolism syndrome (PPS) in PE patients [2, 3].
The development of interventional thrombus removal
deep vein thrombosis (DVT)
strategies has expanded the treatment options for patients
3.1 Therapeutic aims
with acute DVT and PE, however, therapeutic aims of
thrombus removal differ between DVT and PE. In acute CBT of acute DVT yields at thrombus removal and restora-
DVT catheter-based therapy (CBT), i.e. catheter-directed tion of venous drainage of the affected limb. The main short-
thrombolysis (CDT) or catheter-based mechanical term aim of CBT of acute DVT is to rapidly reduce DVT-
thrombectomy, primarily targets the reduction of pain symptoms, such as pain and leg swelling, by reducing
and swelling and the prevention of the occurrence of the venous pressure, venous distension, and local inflammation.
PTS as long-term complication. In PE early thrombus The major long-term aim is the prevention of the develop-
removal primarily aims at a prompt, short-term reduction ment of a clinically-relevant PTS. This approach is based
of pulmonary artery pressure, right ventricular strain and on the “open-vein hypothesis”, which proposes a reduction
the occurrence of shock and cardiac arrest. of the risk of venous lesion chronification by early thrombus
In recent years, the numbers of interventional proce- removal. Chronic thrombus potentially causes venous wall
dures performed in patients with acute DVT, and acute and valve damage, and impairs venous drainage of the legs,
PE have substantially increased. This can be attributed to which subsequently leads to venous hypertension. Venous
an increasing awareness of the diseases, but also to the hypertension is the pathophysiological correlate underlying
development of more efficient and safer thrombectomy the PTS, which comprises a broad spectrum of different clin-
devices for treatment of both entities, DVT and PE. ical signs and symptoms. Depending on its severity, the PTS
Nevertheless, not all patients diagnosed with acute may affect up to 50% of patients after acute DVT [12]. The
DVT or PE benefit from interventional treatment. A multi- clinical severity of the PTS can be assessed by using clinical
disciplinary team involving vascular medicine specialists scores, such as the Villalta score or the revised venous clin-
should be responsible for patient selection, periinterven- ical severity score [13]. However, it needs to be acknowl-
tional decision making, and structured clinical pathways edged that both scores do not capture the whole spectrum
to maximize the potentially positive effects of this thera- of symptoms of the PTS: e.g. venous claudication, which is
peutic approach and to minimize procedure-related risks commonly observed in patients with chronic iliofemoral
(Figure 1). venous obstructions, potentially affects patients’ walking
The purpose of this practice guideline document of the capacity and quality of life.
European Society of Vascular Medicine is to provide recom- Referring to the location of DVT, iliofemoral location of
mendations for the decision process on interventional thrombosis might potentially be associated with a higher
treatment of acute DVT and PE and the related periinter- impact on venous pressure. Moreover, the risk of the devel-
ventional patient-management. opment of a clinically relevant PTS is higher in patients

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Table I. Published randomized controlled trials (RCT) comparing catheter-based therapy (CBT) on top of anticoagulation versus conservative therapy (anticoagulation alone) in patients with acute deep vein
thrombosis (DVT) with the primary aim to prevent the development of the postthrombotic syndrome (PTS). Table shows primary endpoint data not including post-hoc and additional long-term outcome analyses

Study Type Patients Indication Experimental arm Comparator arm Primary endpoint(s) Follow-up Main hypothesis validated
randomized duration

CaVenT [14] Multicenter 209  DVT in upper half of Catheter-directed Anticoagulation  Iliofemoral 5 years Yes: Patency at 6 months (CBT
RCT (20 sites) the thigh, common thrombolysis on top of patency at 6 vs. anticoagulation alone:
iliac vein, or com- anticoagulation months 65.9% (95% CI 55.5–75%) vs.
bined iliofemoral  Frequency of PTS 47.4% (95% CI 37.6–57.3%),
segment at 24 months p=0.012)
 Onset within past 21 PTS at 24 months (CBT vs.
days anticoagulation alone: 41.1%
(95% CI 31.5–51.4%) vs. 55.6%
(95% CI 45.7–65%), p=0.047)

TORPEDO [18] Singlecenter 183  DVT of popliteal vein Pharmacomechanical Anticoagulation  Frequency of PTS 6 months Yes: PTS at 6 months (CBT vs.
RCT or more proximal thrombolysis on top of at 6 months anticoagulation alone: 3.4% vs.
veins anticoagulation  Frequency of 27.2%, p<0.001)
recurrent VTE at Recurrent VTE at 6 months (CBT
6 months vs. anticoagulation alone: 2.3%
vs. 14.8%, p=0.003)

ATTRACT [20] Multicenter 692  DVT in femoral vein, Pharmacomechanical Anticoagulation  Frequency of PTS 24 months No: PTS between 6 and 24
RCT (56 sites) common femoral, or thrombolysis on top of between 6 and months, CBT vs.
iliac vein anticoagulation 24 months anticoagulation alone: 47% vs.
 Onset within past 14 48% (risk ratio 0.96; 95% CI
days 0.82–1.11, p=0.56)

CAVA [24] Multicenter 120  Iliofemoral DVT Pharmacomechanical Anticoagulation  Frequency of PTS 39 months No: PTS at 12 months (CBT vs.
RCT (15 sites)  Onset within past 14 thrombolysis on top of at 12 months anticoagulation alone: 12.9%
days anticoagulation vs. 10.3% (OR 1.28; 95% CI
0.42-3.96)
Abbreviations. CBT – catheter-based therapy, CDT – catheter-directed thrombolysis, CT – computed tomography, CTA – computed tomography angiography, DVT – deep vein thrombosis, PTS – postthrombotic
syndrome, RCT – randomized controlled trial, RV/LV – right ventricle/left ventricle, tPA – tissue plasminogen activator, USAT – ultrasound assisted thrombolysis.

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 O. Schlager et al., ESVM Guidelines intervention in VTE 5

with more proximal location of DVT than in patients with recurrence of VTE at 6 months CT vs. CBT 14.8% vs.
further distal manifestations of DVT [12]. 2.3%, p=0.003) [18, 19]. The main limitation of this study
is the missing implementation of an established evaluation
method of the PTS, which was the primary endpoint.
3.2 Available data
Instead, the authors relied on their own definition of the
So far, four randomized controlled trials (RCT) compared presence or absence of the PTS.
CBT of acute DVT with CT (Table I). The Catheter-directed The largest RCT, the Acute Venous Thrombosis: Thrombus
Venous Thrombolysis (CaVenT) study was a Norwegian mul- Removal with Adjunctive Catheter-Directed Thrombolysis
ticentre RCT, in which patients with acute DVT above mid- (ATTRACT) trial, randomly assigned patients with acute
thigh level were included across 20 participating hospitals DVT to either CBT by pharmacomechanical thrombolysis
[14]. Patients with phlegmasia cerulea dolens or isolated or – in case of involvement of the popliteal vein or IVC –
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inferior vena cava (IVC) thrombosis were not included in a combination of CDT and pharmacomechanical throm-
this trial. Included patients were randomly assigned to bolysis versus to CT (i.e. anticoagulation alone) [20]. In
either CBT with CDT in addition to anticoagulation (CBT summary, this large RCT failed to demonstrate a signifi-
group: n=90) or to conservative therapy (CT) by anticoag- cant benefit of CBT of acute DVT: the prevalence of the
ulation with vitamin K antagonists (CT group: n=99) [14]. PTS, defined as combination of a Villalta score of 5 points
In addition, all patients were advised to use knee-high elas- or an ulcer of the index limb after 6 to 24 months of follow
tic compression stockings (class II) for 24 months. up, did not differ between CBT and CT (risk ratio 0.96,
CDT was performed by inserting an infusion catheter 95% CI 0.82-1.11). However, interventional treatment led
with multiple side-holes into the thrombosed segment, to a reduction in leg symptoms, PTS severity scores, and
mostly via an antegrade popliteal access. Recombinant tis- the proportion of patients with moderate-to-severe PTS
sue plasminogen activator (rt-PA) was administered with over a period of 24 months [21].
the side-hole catheter with an infusion rate of 0.01 mg/ Apart from RCTs, which compared CBT with CT, the
kg per hour for a maximum 96 hours and a maximum dose BERN Ultrasound-Assisted Thrombolysis for Ilio-Femoral
of 20 mg/24h [14]. Deep Vein Thrombosis Versus Standard Catheter Directed
Regarding the primary study endpoint, CBT was associ- Thrombolysis (BERNUTIFUL) RCT compared the applica-
ated with a reduction of PTS, as assessed by determining tion of ultrasound assisted catheter directed thrombolysis
the Villalta scale, after 2 years, which further improved (USAT) as pharmacomechanical approach with conven-
after 5 years (CBT vs. CT: 43%, 95% CI 33%–53% vs. tional CDT in patients with acute iliofemoral DVT. BER-
71%, 95% CI 61%–79%, p<0.0001) [14], 15]. At 6 months, NUTIFUL did not demonstrate superiority of USAT in
iliofemoral venous patency was higher in the CBT group CBT of acute iliofemoral DVT in comparison with CBT
that in the CT group (CBT vs. CT: 65.9%, 95% CI 55.5%– by conventional CDT [22].
75% vs. 47.4%, 95% CI 37.6%–57.3%, p=0.012) [14]. In The efficacy and safety of interventional therapy of acute
the CBT group, 20 bleeding complications (3 major bleed- DVT by USAT in comparison with CT was assessed in the
ings, 5 clinically relevant bleedings) were observed [14]. fourth RCT, which compared CBT with CT, the Ultra-
CBT was not associated with the occurrence of PE, cerebral sound-Accelerated Catheter-Directed Thrombolysis Versus
hemorrhage or death. DVT recurrence did not differ Anticoagulation for the Prevention of Post-Thrombotic Syn-
between groups. Quality of life did not differ between both drome (CAVA) trial [23]. The CAVA trial focused on
treatment arms [16]. In an economic evaluation CBT patients with iliofemoral location of DVT. Patients were
appeared to be a cost-effective alternative to CT [17]. The randomly assigned to CBT by means of pharmacomechni-
main limitation of this study is the use of CDT only which cal thrombolysis with ultrasound-assisted thrombolysis
nowadays is mostly replaced by CBT with catheter-based (USAT), or to CT. USAT combines catheter-directed infu-
mechanical thrombus removal. CDT is potentially related sion of a thrombolytic agent with the local delivery of
to an increased risk of bleeding due to the prolonged appli- high-frequency ultrasound aiming to disaggregate and sep-
cation of thrombolytic agents [14]. arate fibrin fibres, and to further enhance the penetration
In the Thrombus Obliteration by Rapid Percutaneous of the thrombolytic agent into the thrombus.
Endovenous Intervention in Deep Venous Occlusion (TOR- In the CAVA trial, the stent rate was higher than in former
PEDO) trial, patients with acute DVT of the popliteal or studies, which appeared to better reflect daily practice in
more proximal veins were randomly assigned to CBT with CBT of acute DVT patients. Nevertheless, no clinical benefit
mainly pharmacomechanical thrombolysis (combination of of USAT was demonstrated in patients with iliofemoral DVT
mechanical thrombectomy with pharmacological CDT) on in this study. When following patients for >3 years, the
top of anticoagulation or to anticoagulation only [18]. The between-group difference in the prevalence of the PTS
two primary outcome measures, the occurrence of the increased but did not reach statistical significance [24].
PTS and recurrence of VTE after 6 months, were less fre- The above listed trials have to viewed in the light of their
quently observed in the interventional treatment arm than strengths and weaknesses: in the ATTRACT trial, the
in the conservative treatment arm and these results relatively large number of patients were a mix of patients
appeared to persist over a longer period of follow up (PTS with iliofemoral DVT and patients with more distal loca-
at 6 months CT vs. CBT 27.2% vs. 3.4%, p<0.001; tion of DVT. This warrants mention, since the risk of the

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Figure 2. Flow chart showing the clinical algorithm and decision process as proposed for patients with acute deep vein thrombosis (DVT); CBT –
Catheter-based therapy; PE – pulmonary embolism; RV - right ventricular. *Severity of symptoms, patients’ age, comorbidities, and life
expectancy; **Interventionalists with experience in the endovascular treatment of acute DVT and availability of thrombectomy devices, IVUS and
dedicated venous stents.

development of the PTS, which was the primary endpoint statements suggest that the implementation of IVUS in
in this study, depends on the location of DVT with a lower venous recanalization procedures potentially affects
risk in patients with femoropopliteal manifestation of DVT endovascular treatment strategies [25, [26, 27]. In contrast
than in patients with iliofemoral location of DVT [12]. to the CaVenT study, which suggested cost effectiveness of
Moreover, intravascular ultrasound (IVUS) was not rou- CBT of DVT, the ATTRACT trial questioned the cost-effec-
tinely applied for the detection of underlying mechanical tiveness of CBT [28]. Focusing on quality of life, however,
obstructions or residual thrombus in ATTRACT. Previous the ATTRACT trial demonstrated greater improvements of

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disease-specific quality of life in the CBT group than in the chronic iliac vein obstructions no benefit of antiplatelets
CT group [29]. was shown [38].
Finally, the CAVA trial, was statistically underpowered:
only 58 patients (75%) of the interventional treatment
arm, and 57 patients (76%) of the standard treatment arm
3.4 Ongoing studies
could be included in the per-protocol analysis (initially Newer endovascular thrombectomy devices allow throm-
planned sample size 180 patients) [23]. bus removal by a pure mechanical approach. The use of
Two metaanalyses of these RCT data demonstrated that modern catheter-based mechanical thrombectomy sys-
CBT potentially reduced the risk of moderate to severe forms tems allow the CBT of acute DVT without need for throm-
of the PTS in patients with acute proximal DVT [30, 31]. bolytic agents, which has the potential to further reduce the
Recent propensity-score matched post-hoc analyses risk of bleeding associated with interventional thrombec-
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comparing a single-arm registry with RCT-data suggest a tomy procedures. Up to now, data from RCTs are missing.
clear benefit of a pure mechanical CBT of acute DVT in The results of ongoing studies will provide data on the effi-
comparison with catheter-based thrombolysis [32, 33]. cacy and safety of mechanical CBT in acute DVT
(Table III).
3.3 Clinical perspective
In recent years new catheter-based mechanical thrombec- 3.5 Gaps in evidence
tomy systems have been developed, which have potentially
improved the efficacy and safety of CBT in acute DVT,  Objectifiable hemodynamic parameters that may be
which may be confirmed by ongoing clinical trials. In any used to define the presence or absence of the PTS
case, it warrants mention that the success of CBT in acute  Need of stent placement depending on interventional
DVT substantially depends on patient selection, timing of approach (mechanical versus pharmacomechanical
the procedure, decision making on stent placement, and techniques)
periinterventional anticoagulation management (therapeu-  Impact of long-segment stent placement on duration
tic dose low-molecular weight heparin vs. direct oral anti- of anticoagulation
coagulants vs. vitamin K antagonists; Figure 2). Regarding  Impact of iliocaval/iliofemoral thrombus removal on
the timing of thrombus removal, a time window of up to future rates of silent pulmonary embolism
2 weeks after onset of symptoms has most commonly been  Benefit of CBT with modern thrombectomy systems on
applied. the risk of PTS in patients with infrainguinal DVT
Apart from the thrombus removal strategy, the applica-
Recommendations for interventional therapy of acute
tion of IVUS for the assessment of residual thrombus and
DVT
underlying mechanical obstructions, as well as the use of
dedicated venous stents (if stent placement is needed)
Recommendation Class of Level of
are recommended [25, [26, 27, 34]. Especially young
recommendation evidence
patients with severe symptoms due to an iliocaval or iliofe-
In patients with severe symptoms due
moral location of acute DVT are likely to have a benefit
to iliofemoral and/or iliocaval location IIa A
from CBT [35]. CBT of acute DVT should therefore be con- of acute DVT CBT should be
ducted in centers with expertise in interventional manage- considered [14, 15, 18, 19, 20, 23, 24].
ment of VTE. It warrants mention, that, although The involvement of a vascular expert
endovascular CBT has largely replaced open surgical in the decision-making process and
I C
thrombectomy in acute proximal DVT, a multidisciplinary the periinterventional management
management is recommended in patients qualifying for of patients undergoing CBT is
recommended.
thrombus removal.
Vascular and coagulation experts with expertise in It is recommended that
interventionalists with expertise in
endovascular thrombus removal strategies should be I C
endovascular treatment of iliofemoral
involved in the decision making, the periinterventional and/or iliocaval obstructions are
management and the postinterventional duplexsono- involved in CBT of DVT.
graphic and clinical follow-up of these patients (Figure 2). For endovascular treatment of acute
Continuous periinterventional full-dose anticoagulation is DVT the use of catheter-based IIa B
essential in patients with acute DVT undergoing CBT [36, mechanical thrombectomy should be
preferred over CDT or USAT [32, 33].
37]. Up to now, there are no data supporting different anti-
coagulation regimens between patients with acute DVT For endovascular treatment of acute
DVT the use of intravascular
who are managed by CBT vs. patients with acute DVT
ultrasound should be considered to IIa B
who are managed conservatively [36]. Moreover, there assess the presence of residual
are no data supporting the routine use of antiplatelet agents iliofemoral/iliocaval obstructions
in patients who underwent stent placement for acute DVT. after CBT and to guide stent
placement [25, 26, 27].
Even in patients who underwent stent placement for

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Table II. Published randomized controlled trials (RCT) comparing catheter-based therapy (CBT) on top of anticoagulation versus conservative therapy (anticoagulation alone) in patients with acute pulmonary
embolism (PE). Table shows primary endpoint data not including post-hoc and additional long-term outcome analyses

Patients Follow-up
Study Type randomized Indication Experimental arm Comparator arm Primary endpoint(s) duration Hypothesis validated

ULTIMA [41] Multicenter 59  intermediate high-risk PE CDT on top of Anticoagulation  difference in the RV/ 90 days Yes: mean difference RV/LV
RCT (8 sites)  Onset within past 14 days anticoagulation LV ratio from baseline ratio from baseline to 24 hours
 RV/LV ratio  1 to 24 hours- CBT 0.30±0.20 versus
anticoagulation 0.03±0.16
(P<0.001)

SUNSET PE [39] Multicenter 81  intermediate high-risk PE USAT Standard CDT  thrombus load 90 days Yes: mean reduction of
RCT (3 sites)  Onset within past 14 days reduction measured by thrombus score from baseline
 RV/LV ratio  1 CT using a modified to 48 hours: USAT 31±4 to 22±7
Miller scoring system vs. standard CDT 33±4 to 23±7
(P =0.76)

OPTALYSE [45] Multicenter 101  intermediate risk CDT Compared 4 tPA change in RV/LV ratio 365 days Yes: Change RV/LV ratio from
RCT (27 sites)  Onset within past 14 days regimens measured by CTA from baseline to 48 hours
Arm 1 (4 mg/site/2 baseline to 48 Arm 1: –0.40 ±0.37 (P<0.0001)
 RV/LV ratio 0.9
h), arm 2 (4 mg/site/ Arm 2: –0.35 ±0.27 (P<0.0001)
4 h), arm 3 (6 mg/
Arm 3: –0.42 ±0.32 (P<0.0001)
site/6 h), and arm 4
(12 mg/site/6 h). Arm 4: –0.48±0.51 (P=0.0011)

CANARY [77] Multicenter 94  intermediate high-risk PE Catheter-directed Anticoagulation  proportion of patients 90 days Yes: patients with an RV/LV
RCT (2 sites) thrombolysis on top with RV/LV ratio ratio >0.9 at 3-month follow-up:
of anticoagulation greater than 0.9 at 3- CDT 4.3% vs. 12.8%
month follow-up (OR, 0.31; 95% CI, 0.06-1.69;
P = .24)

Abbreviations. CBT – catheter-based therapy, CDT – catheter-directed thrombolysis, CT – computed tomography, CTA – computed tomography angiography, PE – pulmonary embolism, RCT – randomized controlled trial, RV/LV –
right ventricle/left ventricle, tPA – tissue plasminogen activator, USAT – ultrasound assisted thrombolysis.

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O. Schlager et al., ESVM Guidelines intervention in VTE
 O. Schlager et al., ESVM Guidelines intervention in VTE 9

Recruiting
Status
Recommendation Class of Level of
recommendation evidence

If stent placement is required to

reduce residual iliofemoral/iliocaval
obstructions after CBT of DVT, the use I C

constructed as a win
of dedicated venous stents is

treatment failure or
ratio, a hierarchy of

assessment of PTS
therapy escalation,

severity (assessed
Composite clinical
Primary endpoint
recommended.

with the Villalta

occurrence of
the following,
In patients undergoing CBT with or
without stent placement for

endpoint
symptomatic acute iliofemoral and/or I B

scale)
iliocaval DVT full dose anticoagulation
is recommended [14, 15, 18, 19, 20,
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23, 24].

After CBT of acute DVT with or without

stent placement a regular follow-up

Experimental arm
Table III. Ongoing randomized controlled trials (RCT) on thrombus removal strategies in patients with deep vein thrombosis (DVT) as listed on ClinicalTrials.gov

Anticoagulation +
including clinical and I C

catheter-based
thrombectomy
duplexsonographic assessment, as

mechanical
well as anticoagulation management
is recommended.

4. Interventional therapy of
Comparator arm

Anticoagulation
pulmonary embolism (PE)
4.1 Therapeutic aims
The aim of CBT of PE is to fragment, dissolve or remove
clots from the pulmonary arteries and thereby improve

Abbreviations. DVT – deep vein thrombosis, PTS – postthrombotic syndrome, RCT – randomized controlled trial.
hemodynamics (increase in systemic pressure, decrease
in pulmonary pressure, reduction in heart rate, reduction
in right ventricular afterload and improvement in gas
exchange) with a lower risk of bleeding compared to sys-
temic thrombolysis. Over the last decade, the scientific
Design

RCT

debate on these therapeutic approaches has substantially

intensified and a growing body of knowledge and evidence
has been accumulated through the publication of mostly
single-arm studies, registries, small randomized trials and
Iliofemoral DVT

case series [39, 40, 41, 42, 43, 44, 45, 46, 47].
Population

Overall, success rates are close to 90% and bleeding

complications are low; especially with lytic-free CBT or
low dose local thrombolysis 45, 46. Recent data from a ret-
rospective analysis and a meta-analysis show that CBT is
superior to anticoagulation alone in patients with interme-
diate-high risk or high-risk PE in terms of mortality and
ClinicalTrials.gov ID

readmission for VTE [48, 49]. Moreover, data from the

NCT05701917

FLASH registry and an interim analysis of the STRIKE-PE

study could show immediate reduction of the mean pul-
monary artery pressure [46, 50].
According to recent recommendations of the European
Society of Cardiology, the use of CBT should be restricted
to high-risk patients with contraindications to systemic
thrombolysis or failure of systemic thrombolysis, or to
RCT of ClotTriever

anticoagulation in

patients with an intermediate high-risk PE presenting with

system versus

hemodynamic deterioration [51]. Based on newer data,

(DEFIANCE)
thrombosis
Study title

recent consensus documents advocate a more liberal

deep vein

approach considering certain red flags associated with clin-

ical deterioration [52, 53].

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 10 O. Schlager et al., ESVM Guidelines intervention in VTE

4.2 Available data and cheap technique to promote catheter-based thrombus

removal in PE. However, RCT-based data are missing,
Data from large-scale RCTs comparing CBT with CT of PE and new effective large-bore aspiration catheters have
are limited (Table II). Especially RCTs addressing clinical increasingly replaced this approach in recent years [48].
endpoints are scarce and several studies refer to surrogate Regarding mechanical CBT of PE with large-bore
parameters, such as change in the right ventricular to left thrombectomy devices, the FlowTriever Pulmonary
ventricular (RV/LV) ratio, reduction of thrombus burden Embolectomy Clinical Study (FLARE) was a prospective
on computed tomography pulmonary angiogram (CTPA), multicentre, single-arm study demonstrating a 25% reduc-
or change in pulmonary pressure, while conclusions on tion of RV/LV-ratio by using a large-bore (20F or 24F)
the effect of CBT on mortality are largely missing [39, 41, mechanical aspiration device in patients with intermediate
42, 43, 45, 46, 47, 54]. high-risk PE [47]. The major bleeding rate in this prospec-
The Ultrasound Accelerated Thrombolysis of Pulmonary tive study was 0.9%, and no intracranial hemorrhage was
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Embolism (ULTIMA) trial was the first RCT comparing observed. With 93 minutes, the mean procedure time was
the effect of USAT on top of anticoagulation on RV function longer compared to other CBT trials. Assessing the same
with anticoagulation alone with UFH in intermediate high- device, procedure times were further reduced in the
risk patients [41]. Patients included in the study were ran- FlowTriever All-Comer Registry for Patient Safety and Hemo-
domized to anticoagulation as standard of care or to USAT dynamics (FLASH) registry (43 minutes) [46]. Overall, the
on top of anticoagulation. USAT was conducted by using rt- data from FLARE were confirmed in the FLASH registry
PA at a maximum dose of 20 ± 1 mg (in patients with bilat- with a reduction in mean pulmonary artery pressure,
eral device placement 10 ± 0.5 mg per side). As primary improvement in cardiac index and improvement in right
outcome the RV/LV ratio between baseline and 24 hours ventricular function. Safety of mechanical thrombectomy
after initiation was significantly reduced (1.28 ± 0.19 at procedures was demonstrated, as well. Since two-thirds of
baseline to 0.99 ± 0.17 at 24 hours, p<0.001) [41]. No sig- patients were not referred to an intensive care unit in these
nificant reduction of the RV/LV ratio was observed in the studies, this approach seems to be a cost- and personnel
control group (1.20 ± 0.14 at baseline to 1.17 ± 0.20 at 24 saving approach [54].
hours, p=0.31). No serious adverse events, particularly no The Evaluating the Safety and Efficacy of the Indigo aspira-
major bleeding complications, were recorded in relation tion system in Acute Pulmonary Embolism (EXTRACT PE)
to the interventional procedure. It needs to be noted, that study was another prospective, single arm multicentre
this study was not sufficiently powered to draw conclusions study demonstrating hemodynamic improvement and sig-
regarding the prevention of CTEPH with USAT. nificant reduction of RV/LV ratio in parallel with a satisfy-
While in the ULTIMA trial 10 mg of rt-PA was used per ing safety profile (1.7% major bleedings) by using an 8
side and the mean therapy time was 15 hours modified pro- French aspiration device [43].
tocols with shorter duration and less rt-PA were investi- Further development of this aspiration system aimed at a
gated in the The Optimum Duration of Acoustic Pulse reduction of blood loss. In A Prospective, Multicenter Study
Thrombolysis Procedure in Acute Pulmonary Embolism of the Indigo Aspiration System Seeking to Evaluate the
(OPTALYSE) trial showing that even USAT with low dose Long-Term Safety and Outcomes of Treating Pulmonary
rt-PA is effective in improving RV function [41, 45]. The Embolism (STRIKE-PE) this technology showed a signifi-
OPTALYSE trial aimed to determine the lowest possible cant reduction in the RV/LV ratio and the pulmonary artery
rt-PA dose for USAT in patients with acute intermediate pressure. The positive effects on these parameters were
risk PE. In this trial, a shorter duration and a lower dose also reflected in improved Borg Scale and the classification
of rt-PA delivery was safe and effective in reducing clot bur- of the New York Heart Association (NYHA). In addition,
den and the RV/LV ratio. the median procedure time of 33.5 minutes requires men-
In analogy to the BERNUTIFUL trial, the efficacy and tioning as well as the low rate of major adverse events
safety of USAT vs. conventional CDT of submassive PE (2.7%) demonstrating safety of these procedures [57].
was assessed in the Standard versus Ultrasound-Assisted Most recently, the results of the Randomized controlled
Catheter Thrombolysis for Submassive Pulmonary Embolism trial of mechanical thrombectomy vs. catheter-directed throm-
(SUNSET sPE) trial, which did not demonstrate a benefit of bolysis for acute hemodynamically stable pulmonary embolism
USAT in this group of patients [39]: The primary endpoint (PEERLESS) study suggested a potential benefit of
– a pulmonary artery thrombus reduction assessed by a mod- mechanical thrombectomy over CDT in patients with inter-
ified Miller Score – was equal between USAT and CDT [39]. mediate high-risk PE [54]. The primary endpoint of this
Other studies comparing these two treatment modalities RCT, a composite of all-cause mortality, intracranial hem-
drew similar conclusions [55, 56]. It needs to be acknowl- orrhage, major bleeding, clinical deterioration and/or esca-
edged, that the number of patients with high-risk PE included lation to bailout, and postprocedural intensive care unit
in some of the above-mentioned studies was low (approxi- admission and length of stay, occurred less frequently in
mately 10%) and therefore potentially limits a robust conclu- patients undergoing mechanical thrombectomy in compar-
sion on the efficacy of USAT in this risk category. ison with patients who underwent CDT (win ratio 5.01,
Apart from USAT, manual catheter-based thrombus- 95% CI 3.68–6.97). This difference was primarily attributed
fragmentation (e.g. by using a pigtail catheter) is a simple to lesser admissions to an intensive care unit (ICU) in

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 O. Schlager et al., ESVM Guidelines intervention in VTE 11

patients who underwent mechanical thrombectomy than in many studies. Nevertheless, PERT implementation has
patients who underwent CDT (OR 95.4, 95% CI 34.6– been associated with more standardized care, increased
263.6). Moreover, the intensive care unit stays >24 hours use of advanced therapies such as extracorporal membrane
were lower in patients who underwent mechanical oxygenation (ECMO) and CBT [62]. In addition, the estab-
thrombectomy vs. CDT (OR 2.18, 95% CI 1.4–3.4), as well lishment of a PERT appears to reduce ICU stay duration
as clinical deterioration and/or escalation to bailout ther- and mortality [63].
apy was less frequent in patients who underwent mechan- A key role of a PERT is to determine the optimal timing
ical thrombectomy (3.09, 95% 1.11–8.63). There were no for advanced interventions (Figure 3). This question is the
differences in mortality, intracranial hemorrhage or major subject of current research. However, recent studies sug-
bleeding. These findings are corroborated by real-world gest that patients with intermediate-high and high-risk PE
retrospective data [58]. may benefit from an early interventional approach.
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The major aim in the contemporary management of In a retrospective cohort study, Zhang et al. evaluated
patients with PE should be the early involvement of a pul- 133 patients who underwent either early (<12 hours) or late
monary embolism response team (PERT) including inter- (>12 hours) CBT. The primary composite endpoint included
ventionalists with expertise in endovascular thrombus 30-day mortality, cardiac arrest, hemodynamic instability,
removal strategies. Vascular experts should be integrated and 90-day readmission. Early intervention was associated
in the PERT to optimize the decision-making process, the with a significant reduction in this composite endpoint, along
(peri)interventional patient management, and the follow- with shorter ICU and overall hospital stays [64]. Similar find-
up of patients with PE (Figure 1). ings were reported in a large-scale study involving nearly
The definition of clearly defined criteria for lack of treat- 12,000 patients. Using a cutoff of 24 hours the study demon-
ment success is the subject of ongoing studies, and there is strated that early CBT significantly reduces 90-day mortality
currently some gap in evidence. The use of different scores, and rehospitalization rates [61]. However, definitive conclu-
e.g. the National Early Warning Score (NEWS) or the Com- sions regarding optimal timing and patient selection will
posite Pulmonary Embolism Shock Score (CPES) may be require data from prospective randomized trials.
helpful for further treatment strategy planning [59, 60]. Finally, it needs to be addressed that open surgical
For example, NEWS in pulmonary embolism is currently embolectomy might be a suitable therapeutic option for
being investigated in the Ultrasound-facilitated, catheter- pulmonary embolism, for example in patients with clots
directed thrombolysis in intermediate-high risk pulmonary in transit through a patent foramen ovale. In-hospital
embolism (HI-PEITHO, NCT04790370) trial. So far, it mortality of patients undergoing open surgery is higher
appears reasonable to consider hemodynamic and respira- compared with patients allocated for CBT and highly asso-
tory parameters (e.g. heart rate, oxygen demand, blood ciated with pre-hospital cardiopulmonary resuscitation
pressure) in patients with acute PE and continuous antico- [65, 66]. Prospective randomized trials are lacking and
agulation within 24 hours for the evaluation as lack of ther- decisions on surgical embolectomy in selected cases
apeutic success [61]. remain to be consensus based within the PERT.
Beyond acute management, appropriate follow-up is cru-
cial for patients recovering from PE. Those experiencing
4.3 Clinical perspective persistent dyspnea or reduced exercise capacity should be
Over the last years the use of catheter-based therapies referred to specialized centers for evaluation of CTEPH
for PE has steadily increased and a growing number of or PPS and for referral to suitable therapies (e.g., balloon
newer devices for CBT of PE is now available. Up to now, angioplasty, surgical embolectomy) if necessary.
robust evidence supporting a routine use of CBT in PE is
scarce since available studies have been single-arm
4.4 Ongoing studies
registries, retrospective analyses, or small, underpowered
randomized trials. However, several large-scaled prospec- Currently, there is a lack of large RCTs in the field of
tive randomized controlled trials are currently recruiting interventional treatment of PE. Recently several trials
(Table IV). investigating the efficacy and safety of CBT versus antico-
Patients with complex PE should be managed at centers agulation have been initiated and are currently enrolling. In
with appropriate expertise in advanced management of these trials, the above-mentioned interventional tech-
VTE (e.g. CBT, surgical thrombus removal or extracorporal niques, USAT as well as large-bore catheter aspiration sys-
circulatory support) and patient selection should be carried tems, are applied on top of anticoagulation to assess their
out by the PERT. efficacy and safety in comparison with anticoagulation
Skills and knowledge of the following disciplines should alone. The data of these trials will help us to get a better
be integrated in the management of patients with acute understanding of potential benefits of CBT in patients with
VTE: vascular medicine, cardiology, radiology, emergency intermediate-high risk and high-risk PE and are likely to
medicine, vascular surgery, cardiac surgery, pulmonology, modify future treatment strategies (Table IV). The use of
intensive care, and hemostaseology. systemic thrombolysis in patients with intermediate-risk
Data on the impact of a PERT on patient outcomes are PE is also the subject of ongoing clinical trials. In the
heterogeneous, partly due to the retrospective nature of Pulmonary embolism Thrombolysis Trial (PEITHO trial),

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 12 O. Schlager et al., ESVM Guidelines intervention in VTE
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Figure 3. Flow chart showing the clinical algorithm and decision process as proposed for patients with acute pulmonary embolism (PE). CBT –
catheter-based therapy, PERT – pulmonary embolism response team. List of red flags [73, 74, 75, 76]. *Heart rate  100/min, respiratory rate >
20/min, systolic blood pressure <110 mmHg, lactate level > 2 mmol/L, RV/LV ratio > 1, TAPSE < 16 mm, heart failure, active malignancy.
**Interventionalists with experience in the endovascular treatment of acute PE and availability of thrombectomy devices and circulatory support.

systemic thrombolysis with tenecteplase significantly pro- currently recommended as routine treatment for interme-
tected patients from hemodynamic decompensation [67]. diate high-risk PE. Data from the currently enrolling
However, the beneficial effect was reduced by bleeding PEITHO 3 trial, which is comparing a reduced-dose alte-
complications, and therefore systemic fibrinolysis is not plase regime with anticoagulation, are awaited [68].

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Table IV. Ongoing randomized controlled trials (RCT) on thrombus removal strategies in patients with pulmonary embolism (PE) as listed on ClinicalTrials.gov

Study title ClinicalTrials.gov ID Population Design Comparator arm Experimental arm Primary endpoint Status

Ultrasound-facilitated, catheter- NCT04790370 Patients with RCT Anticoagulation Anticoagulation + PE-related mortality, PE recurrence, Recruiting
directed thrombolysis in intermediate-high USAT cardiorespiratory decompensation or
intermediate-high risk pulmonary risk PE collapse
embolism (HI-PEITHO)

RCT of large-bore thrombectomy NCT06055920 Patients with RCT Anticoagulation Anticoagulation + Composite clinical endpoint constructed Recruiting
versus anticoagulation in intermediate risk PE mechanical as a win ratio, a hierarchy of the following,
intermediate-risk pulmonary catheter-based which are assessed post randomization:
embolism (The PEERLESS II) thrombectomy clinical deterioration (hemodynamic or
respiratory worsening up to 30 days), all-
cause hospital re-admission by 30 days,
O. Schlager et al., ESVM Guidelines intervention in VTE

bailout therapy up to 30 days, dyspnea my

modified medical research council at 48-

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hour visit

RCT of high-risk pulmonary NCT06588634 Patients with high- RCT Anticoagulation Anticoagulation + Composite clinical endpoint of all-cause Recruiting
embolism comparing FlowTriever risk PE mechanical mortality, cardiac arrest, bailout to an

under the license CC BY 4.0 (https://creativecommons.org/licenses/by/4.0)

system vs. standard of care catheter-based alternative therapeutic strategy, major
(PERSEVERE) thrombectomy bleeding

A prospective, multicenter, RCT NCT05684796 Patients with RCT Anticoagulation Anticoagulation + Change in RV/LV ratio at 48 hours Recruiting
evaluating anticoagulation alone intermediate-high mechanical
vs. anticoagulation plus risk PE catheter-based
mechanical aspiration with IndigoÒ thrombectomy
aspiration system for the
treatment of intermediate high risk
acute pulmonary embolism
(STORM PE)

Pulmonary Embolism - Thrombus NCT05591118 Patients with RCT Anticoagulation any CDT device Peak Oxygen Consumption (PVO2): time Recruiting
Removal With Catheter-Directed submassive PE cleared by the FDA frame 3 month
Therapy (PE-TRACT) (thrombectomy or NYHA Classification: time frame 12 month
infusion catheter; Incidence of Major Bleeding at Day 7

Abbreviations. PE – pulmonary embolism, RCT – randomized controlled trial, USAT – ultrasound assisted thrombolysis.

Vasa (2025), 1–17

13
 14 O. Schlager et al., ESVM Guidelines intervention in VTE

4.5 Circulatory support  Value of reduced dose systemic thrombolysis and com-
parison with CBT
Veno-arterial ECMO or other circulatory support devices  Effect of CBT on development of post-PE syndromes
may be used in situations with severe right ventricular fail- and/or CTEPH
ure. Although data from large trials in this area are lacking,  Systemic thrombolysis in intermediate high-risk pul-
there are data suggesting a benefit of circulatory support in monary embolism (e.g. PEITHO 3 trial)
the treatment of high-risk PE [69, 70].  Benefit of mechanical circulatory support in high-risk
PE patients
 Management of clots in transit
4.6 Gaps in evidence

 Periinterventional anticoagulation, especially heparin 5. Inferior vena cava (IVC) filters

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dosing
 Optimal timing of CBT While there are data suggesting that IVC filters may pre-
 Definition of “failure of CT” vent the occurrence of (subsequent) massive PE, the overall
quality of evidence on their efficacy and safety is limited
and inconsistent [71, 72]. It needs to be acknowledged that
IVC filters potentially may increase the risk of DVT and the
Recommendations for interventional therapy of acute risk of persisting scarring or obliteration of the IVC, while
PE the effect on overall mortality can be questioned.

Recommendation Class of Level of

recommendation evidence

It is recommended to implement a
PERT with the involvement of a
Recommendations for insertion of IVC
vascular expert in the decision I C filters
making on interventional treatment
of acute PE.

The involvement of a vascular expert

Recommendation Class of Level of
in the periinterventional I C recommendation evidence
management of patients undergoing
CBT is recommended. The routine implantation of IVC
filters in patients diagnosed with III A
It is recommended that
acute DVT is not recommended.
interventionalists with expertise in I C
endovascular treatment of PE are The routine implantation of IVC
involved in CBT of PE. filters in patients diagnosed with III A
acute PE is not recommended.
It is recommended that CBT of PE is
performed in centers with the Placement of IVC filters may be
possibility of hemodynamic, I C considered in patients with PE and
respiratory, and circulatory support progression of DVT or PE despite IIb C
during and following thrombus therapeutic dose anticoagulation
removal. [72].

In patients with intermediate-high Placement of IVC filters may be

risk PE and insufficient clinical considered in patients with acute
improvement within 24 hours of IIa B proximal DVT and/or PE and IIb B
anticoagulation, CBT should be contraindication to therapeutic dose
considered [41, 49]. anticoagulation [72].

In patients presenting with high-risk The involvement of a vascular expert

PE and contraindication to systemic in the decision- making process on
I C I C
thrombolysis or failure of systemic the implantation of IVC-filter is
thrombolysis, it is recommended to recommended.
consider CBT.

UFH is the anticoagulant of choice in

the periinterventional phase of I C
planned CBT or systemic
thrombolysis.
Conclusion
After CBT, a clinical follow-up is The field of interventional therapy for VTE, including both
recommended including
DVT and PE, has rapidly evolved over recent years, driven
echocardiographic and I C
duplexsonographic assessment, as by technological advancements and increasing clinical
well as anticoagulation
management.

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 O. Schlager et al., ESVM Guidelines intervention in VTE 15

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