Abstract
OBJECTIVES: This systematic review and meta-analysis compared the effectiveness and safety of lytic and non-lytic early thrombus removal strategies in addition to anticoagulation versus anticoagulation alone. BACKGROUND: Early thrombus removal strategies have been developed to prevent post-thrombotic syndrome (PTS) following acute iliofemoral deep vein thrombosis (DVT). METHODS: This review followed PRISMA guidelines using a registered protocol (CRD42023437158). The MEDLINE and Embase databases, as well as trial registries, were searched without limitations. Head-to-head or single-armed trials or studies that reported the rate of PTS in patients with iliofemoral DVT (symptomatic for <28 days) and early thrombus removal were included. The rates of PTS, moderate-severe PTS, major bleeding, risk-benefit ratio, DVT recurrence, and mortality were pooled in meta-analysis with fixed or random effects. RESULTS: Across all study designs (20 studies), the rate of PTS was 24.5% (95% CI: 19.5-30.3%) for lytic therapies, 18.8% (1 study) for non-lytic therapy, and 40.4% (95% CI: 35.3-45.7) for anticoagulation alone. The number needed to treat was 6 for PTS and 15 for moderate-severe PTS. In randomized trials, the odds of major bleeding with lytic therapies were 4.9 (95% CI: 1.3-19.1) compared with anticoagulation; the number needed to harm was 33. There was no major bleeding for mechanical thrombectomy. CONCLUSIONS: Early thrombus removal reduces PTS and moderate-severe PTS, while increasing nonfatal major bleeding. Mechanical thrombectomy removes major bleeding risk, but efficacy evidence is limited to 1 observational study.