In this episode, Pip and Rich discuss the C-TRACT trial: Vedantham et al. Endovascular Therapy for Post-Thrombotic Syndrome — A Randomized Trial. 2026

N Engl J Med 2026;394:2293-2304

C-TRACT (Chronic Venous Thrombosis: Relief with Adjunctive Catheter-Directed Therapy) was a phase 3, publicly funded, multicentre, open-label, assessor-blinded RCT published in NEJM that randomised 225 patients with moderate-to-severe post-thrombotic syndrome (PTS) and imaging-confirmed iliac-vein obstruction to endovascular therapy (iliac-vein stenting + enhanced antithrombotic therapy) plus standard care versus standard care alone.

Key Results

At 6 months, the endovascular group had a statistically significant reduction in PTS severity by the Venous Clinical Severity Score (VCSS: 8.1 vs. 10.0, adjusted difference −2.0 points; P=0.001). Quality-of-life scores also improved with a 14.5-point improvement in venous disease–specific QoL (VEINES-QOL) and a 6.1-point improvement in the SF-36 physical component summary with the intervention.

However, bleeding was significantly higher in the intervention group (11.6% vs. 3.6%; P=0.03).

In the episode, Pip and Rich discuss key critical appraisal points including:

• Modest primary endpoint difference. The 2-point VCSS difference, while statistically significant, is relatively small on a 0–30 scale. The clinical meaningfulness of this difference at the individual patient level is debatable, though the authors argue that many patients shifted to lower severity categories.
• Open-label design. The trial was open-label, which is a significant limitation for patient-reported outcomes like quality of life. While the primary outcome (VCSS) was assessed by blinded evaluators, the large QoL differences (which are the most compelling results) are susceptible to expectation and performance bias - a limitation the authors themselves acknowledge.
• Short follow-up. Results are reported at only 6 months. Stent patency, durability of benefit, and long-term safety (including stent-related complications and the consequences of enhanced antithrombotic therapy) remain unknown.
• The relevance of enhanced antithrombotic therapy which confounds the intervention. The endovascular arm received both stenting and additional antithrombotic therapy, making it impossible to disentangle the contribution of each component and likely explaining the higher bleeding rate.
• Generalisability. The trial was limited to patients with iliac-vein obstruction and moderate-to-severe PTS, a specific subset of the broader PTS population. Results should not be extrapolated to milder disease or non-iliac obstruction.

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On this episode, Pip and Rich chat to Consultant Haematologist, Dr Kate Musgrave and Thrombosis Nurse Specialist, Vicky Marr about how they developed and implemented a natural language processing model that identifies cases of hospital acquired thrombosis. Implementing this strategy in their hospital in Newcastle-Upon-Tyne has led to saving thousands of hours of manually trawling radiology reports - enabling them to focus on what matters - interacting with patients. The tool is now available for implementation across the NHS. This is a must-listen for anyone wanting to improve efficiency in their hospital.

Read more about the project here.

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