In this episode of the BackTable Podcast, vascular surgeon Dr. Nicolas Mouawad and interventional radiologist Dr. Raja Ramaswamy share their insights on the changing landscape of deep vein thrombosis (DVT) management, steps of mechanical thrombectomy, and current research on DVT interventions.

---

CHECK OUT OUR SPONSOR

Inari Medical

https://www.inarimedical.com/

---

SYNPOSIS

The guests start by describing their typical referral patterns, noting that most cases come through the emergency department. In terms of workup, it is important to distinguish between acute and chronic DVTs and classify the thrombosis location as either proximal (femoral vein or higher) or distal. Anticoagulation, usually with direct oral anticoagulants, is always started, with efficacy largely determined by patient compliance.

Regarding endovascular intervention, thrombolysis may be an effective adjunctive treatment if the clot occurred within a two-week timespan, but it carries a bleeding risk and requires ICU monitoring. On the other hand, mechanical thrombectomy is an option for both acute and chronic clots, allows for intervention in patients with high bleeding risk, and does not require post-procedural hospitalization. Both physicians emphasize that interventions should be employed if there are long-term benefits of avoiding post-thrombotic syndrome and pulmonary embolism.

The physicians walk through a typical mechanical thrombectomy procedure, which involves the thrombectomy device, venogram, intravascular ultrasound, and possible stent placement. Finally, they discuss recent data, including the ATTRACT Trial for thrombolytics and the CLOUT Registry and Trial for ClotTriever use. Notably, they mention the DEFIANCE Trial as a current prospective randomized clinical trial for ClotTriever use in the iliofemoral region.

---

TIMESTAMPS

00:00 - Introduction

03:48 - DVT Referral Patterns and Treatment Algorithms

08:55 - Choosing an Anticoagulation Regimen

11:01 - DVT Interventions

13:54 - Patient Scenarios and Treatment Decisions

22:29 - Post-Thrombotic Syndrome

26:16 - Mechanical Thrombectomy Technique

35:45 - Postoperative Care

39:09 - The Evolution of Mechanical Thrombectomy

43:38 - ATTRACT Trial

46:20 - CLOUT Trial

---

RESOURCES

Inari ClotTriever System:

https://www.inarimedical.com/clottriever-system

ATTRACT Trial:

https://www.nejm.org/doi/full/10.1056/NEJMoa1615066

CLOUT Trial:

https://pubmed.ncbi.nlm.nih.gov/35218955/

DEFIANCE Trial:

https://evtoday.com/news/inari-medical-begins-defiance-randomized-clinical-trial-of-clottriever-system-in-dvt