Die Therapie der venösen Thromboembolie - Von der Akutbehandlung bis zur Erhaltungstherapie

Eine Gerinnselbildung im tiefen Venensystem ist das Kennzeichen für eine Phlebothrombose, die - über die Entwicklung einer Lungenembolie - sogar lebensbedrohlich werden kann. Im Langzeitverlauf kann aber auch ein postthrombotisches Syndrom die Folge sein. Zwei gute Gründe also, nach der Diagnose unverzüglich über eine Therapie nachzudenken. Die Akutbehandlung mit parenteralen Antikoagulanzien zielt dabei auf die Vermeidung der Lungenembolie, die Erhaltungstherapie, vorwiegend mit Vitamin-K-Antagonisten, wiederum auf die Verhinderung eines Rezidivs. Eine konsequente Kompressionstherapie kann darüber hinaus dazu beitragen, Häufigkeit und Schwere des postthrombotischen Syndroms zu reduzieren. Nicht mehr oder nur noch selten eingesetzt werden inzwischen invasive Behandlungsverfahren wie die Fibrinolyse, die Thrombektomie oder der Cavafilter, für die ein Wirksamkeitsnachweis bis heute nicht vorliegt. Die konservative Therapie hingegen konnte in den letzten Jahren wesentlich optimiert werden.

Venous thrombosis results from the presence of a clot in the venous circulation. A life-threatening and not rare complication in patients with deep vein thrombosis is pulmonary embolism. The post-thrombotic syndrome is a chronic sequelae of venous thromboembolism. For most patients anticoagulation is the only acute treatment modality. Low-molecular-weight heparins represent the current standard of care. Haemodynamic instability in pulmonary embolism requires systemic thrombolysis according to the risk of fatal right heart failure. Vitamin K antagonists remain the standard treatment for maintenance therapy, the duration of their application has to be balanced between the risk of recurrence and the potential for major bleeding. The post-thrombotic syndrome can be effectively prevented by compression therapy.

Key words

venous thromboembolism (VTE) - therapy of VTE - deep vein thrombosis (DVT) - pulmonary embolism - anticoagulation

Literatur

• 1 Arcasoy SM, Vachani A.. Local and systemic thrombolytic therapy for acute venous thromboembolism.  Clin Chest Med. 2003;  24 73-91
• 2 Aschwanden M, Labs KH, Engel H. et al. . Acute deep vein thrombosis: early mobilization does not increase the frequency of pulmonary embolism.  Thromb Haemost. 2001;  85 42-46
• 3 Baldwin ZK, Comerota AJ, Schwartz LB.. Catheter-directed thrombolysis for deep venous thrombosis.  Vasc Endovascular Surg. 2004;  38 1-9
• 4 Beer JH, Burger M, Gretener S. et al. . Outpatient treatment of pulmonary embolism is feasible and safe in a substantial proportion of patients.  J Thromb Haemost. 2003;  1 186-187
• 5 Beyth RJ, Quinn LM, Landefeld CS.. Prospective evaluation of an index for predicting the risk of major bleeding in outpatients treated with warfarin.  Am J Med. 1998;  105 91-99
• 6 Blumenberg RM, Barton E, Gelfand ML. et al. . Occult deep vein thrombosis complicating superficial thrombophlebitis.  J Vasc Surg. 1998;  27 338-343
• 7 Brandjes DPM, Büller HR, Heijboer H. et al. . Randomized trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis.  Lancet. 1997;  349 759-762
• 8 Büller HR, Agnelli G, Hull RD. et al. . Antithrombotic therapy for venous thromboembolic disease. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.  Chest. 2004;  126
• 9 Büller HR, Davidson BL, Decousus H. et al. . Fondaparinux or enoxaparin for the initial treatment of symptomatic deep venous thrombosis.  Ann Intern Med. 2004;  140 867-873
• 10 Büller HR, Davidson BL, Decousus H. et al. . Subcutaneous fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism.  N Engl J Med. 2003;  349 1695-1702
• 11 Decousus A, Leizorovicz A, Parent F. et al. . A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis.  N Engl J Med. 1998;  338 409-415
• 12 Iorio A, Guercini F, Pini M.. Low-molecular-weight heparin for the long-term treatment of symptomatic venous thromboembolism: meta-analysis of the randomized comparisons with oral anticoagulants.  J Thromb Haemost. 2002;  1
• 13 Kearon C, Ginsberg JS, Kovacs MJ. et al. . Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism.  N Engl J Med. 2003;  349 631-639
• 14 Kniemeyer HW, Sandmann W, Schwindt C. et al. . Thrombectomy with arteriovenous fistula for embolizing deep venous thrombosis: an alternative therapy for prevention of recurrent pulmonary embolism.  Clin Investig. 1993;  72 40-45
• 15 Konstantinides S, Geibel A, Olschewski M. et al. . Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism.  Circulation. 2002;  106 1263-1268
• 16 Kucher N, Printzen G, Doernhoefer T. et al. . Low pro-brain natriuretic peptide levels predict benign clinical outcome in acute pulmonary embolism.  Circulation. 2003;  107 1576-1578
• 17 Lee AYY, Levine MN.. Venous thromboembolism and cancer: risks and outcomes.  Circulation. 2003;  107 117-121
• 18 Lee AYY, Levine MN, Baker RI. et al. . Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer.  N Engl J Med. 2003;  349 146-153
• 19 Penede L, Ninet J, Duhaut P. et al. . Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis.  Circulation. 2001;  103 2453-2460
• 20 Philbrick JT, Becker DM.. Calf deep vein thrombosis.  Arch Intern Med. 1988;  148 2131-2138
• 21 Prandoni P, Lensing AWA, Prins MH. et al. . Below-knee elastic compression stockings to prevent the post-thrombotic syndrome. A randomized controlled trial.  Ann Intern Med. 2004;  141 249-256
• 22 Schellong SM, Schwarz T, Kropp J. et al. . Bed rest in deep vein thrombosis and the incidence of scintigraphic pulmonary embolism.  Thromb Haemost. 1999;  82 127-129
• 23 Schulman S, Svenungsson E, Granqvist S.. Anticardiolipin antibodies predict early recurrence of thromboembolism and death among patients with venous thromboembolism following anticoagulant therapy: Duration of Anticoagulation Study Group.  Am J Med. 1998;  104 332-338
• 24 Schwarz T, Schmidt B, Höhlein U. et al. . Eligibility for home treatment of deep vein thrombosis: prospective study.  Br Med J. 2001;  322 1212-1213
• 25 Schwarz T, Thomas Z, Schellong S.. Therapy of isolated calf muscle vein thrombosis with low-molecular-weight-heparin: prospective randomized study.  J Thromb Haemost. 2005;  3
• 26 Simmonneau G, Sors H, Charbonnier B. et al. . A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. The THESEE Study Group. Tinzaparine ou Heparine Standard: Evaluations dans l'Embolie Pulmonaire.  N Engl J Med. 1997;  337 663-669
• 27 van den Belt AG, Prins MH, Lensing AW. et al. . Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism.  Cochrane Database Syst Rev. 2000;  2

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