Q: Where can thrombolysis in a DVT patient be done best? Which hospital in India should we go to? Is it advisable to go for this, for a female patient (58 years old) having occlusive DVT in both common iliac veins to IVC before 3 months and now have IVC filter placed in jugular veins? The clots are blocking the veins completely.

A:This query is interesting, though not for the patient. I find it interesting that often the doctors at the highest level are treating symptoms and fail to look for the basic pathology. It is now common knowledge that thrombosis of the veins is a serious condition, following the media interest in the aeroplane travel making people susceptible. However, the patient in question is not run-of-the-mill DVT, which might occur incidentally. This patient has very strong thrombotic tendencies and only thrombolysis is not the answer. This patient needs to go for a thorough investigations for finding out the cause of the thrombosis and the most common is Anti Phospholipid antibodies, factor V Leiden, deficiency of Protein C & S and Hyperhomocysteinaemia. If none of these are conclusive, one has to enlarge the field and include connective tissue disorders. The specific answer to the question is that there are many hospitals in India where Thrombolysis is done. Ever since the thrombolysis was used for Myocardial infarction there has been easy access to the thrombolytic agents and expertise has increased. My recommendations would be to use the thrombolysis only in the early stage, in acute DVT, younger patient, who does not have any contraindications to thrombolysis as the results of thrombolysis are comparable with heparinisation in the established DVT as is the case with this patient and risks are not worth the benefit. Second the thrombolysis should be done under strict ICU and Lab monitoring. Drugs to use are rtPa, Urokinase and streptokinase, and are all having bleeding and other complications. Last but not the least, to use these drugs with caution and not more than 2 to 3 days and not to compromise exclusion criteria. Considering the age of the patient and that the symptoms have been 3 months old I feel there is no real justification of thrombolysis. I suggest that she be investigated for thrombotic profile and anticoagulated with warfarin. This will take care of future thrombosis as the current thrombus is now organised and cannot be lysed. I would like to mention that some of these patients who have tendency for DVT can also develop arterial occlusion, so prophylaxis is needed.