Reply to “Comment to Deep Vein Thrombosis Induced by Vasculitis in the Behçet’s Syndrome”

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Reply to “Comment to Deep Vein Thrombosis Induced by Vasculitis in the Behçet’s Syndrome”

Behçet’s disease (BD) is a chronic inflammatory condition that primarily affects blood vessels, and one of its most dangerous complications is deep vein thrombosis (DVT)—blood clots in the legs that can lead to pain, swelling, or even life-threatening pulmonary embolism (PE). But managing DVT in BD patients remains controversial, especially when it comes to anticoagulation (blood-thinning drugs). In a 2019 reply to a comment on their 2018 case report, Drs. Yong Chen (from Fudan University’s Huadong Hospital and Southern Medical University’s Integrated Hospital of Traditional Chinese Medicine) and Jian-Long Guan (Fudan University’s Huadong Hospital) shared their clinical insights, emphasizing that personalized care is key to balancing risk and benefit in these patients.

Clarifying Terminology: Inflammation, Not Just Vasculitis

First, the authors addressed a critical terminology point: since BD is already a type of vasculitis (inflammation of blood vessels), the phrase “Vasculitis in The Behçet’s Syndrome” is redundant. They recommended renaming the condition “Deep Vein Thrombosis Induced by Vascular Inflammation in Patients with Behçet’s Syndrome” to better reflect the root cause—vascular inflammation driving clot formation—rather than repeating a diagnostic label.

Aneurysms: A Rare But Important Risk

The commenters had questioned whether their case involved an aneurysm (a weakened, bulging blood vessel), a known complication of vascular BD. To answer this, the authors shared data from their own cohort of 923 BD patients:

  • 17.98% (166 patients) had vascular BD (blood vessel involvement).
  • Only 1.84% (17 patients) had aneurysms or pseudoaneurysms—and most were male (3 times more likely than females).

Crucially, their case patient did not have an aneurysm, confirmed by thorough screening.

The Anticoagulation Debate: Guidelines vs. Personalized Care

The biggest point of discussion was anticoagulation—whether to use blood-thinning drugs for BD-related DVT. The 2018 EULAR (European League Against Rheumatism) guidelines for BD management stated:

  • BD-related venous clots tend to stick to blood vessel walls, so they rarely cause PE (clots traveling to the lungs).
  • Anticoagulants, antiplatelets (drugs that prevent platelet clumping), or antifibrinolytics (drugs that stop clot breakdown) are not recommended because they don’t reduce recurrent DVT risk and may cause life-threatening bleeding if a patient has a pulmonary aneurysm.

But Drs. Chen and Guan disagreed with a “one-size-fits-all” approach. Their case patient had complete DVT blockage in both legs and an elevated D-dimer (a marker of active clotting)—red flags for PE. “Pulmonary embolism should be a major concern here,” they stressed. While EULAR’s warnings about bleeding are valid, the authors argued that clinicians must weigh risks for each patient. Severe clots (like complete leg blockage) demand more aggressive care than mild ones—and anticoagulation may be necessary to prevent progression.

Beyond Guidelines: Clinical Experience and Multidisciplinary Care

The authors also shared real-world evidence to support their approach:

  • They treated a young BD patient with mild limb clots who developed a stroke despite adequate anti-inflammatory treatment—highlighting that inflammation alone doesn’t explain all clot risks.
  • They’ve published on BD-related aneurysms, where surgical intervention saved some patients but not others—reinforcing that multidisciplinary care (combining rheumatology with cardiology) is essential for complex cases.

While EULAR guidelines provide a valuable framework, the authors emphasized that guidelines have limitations. “Clinicians should still gather data and test new ideas,” they said. “Our goal is to balance anti-inflammatory treatment (the foundation of BD care) with targeted clot management—without over- or undertreating.”

Addressing Other Concerns

The commenters raised two additional points:

  1. Immunosuppressive drugs: No single drug is proven superior for BD-related inflammation. The authors agreed more research is needed but noted their patient received adequate DMARDs (disease-modifying antirheumatic drugs) to control inflammation.
  2. Gastrointestinal involvement: BD often affects the intestines, but their patient had an endoscopy that ruled out intestinal damage.

The Takeaway: Personalized Care Over Rigid Rules

For Drs. Chen and Guan, the core message was clear: BD is a variable disease, and DVT management must adapt to each patient’s unique situation. While EULAR guidelines offer important guardrails (like warning about aneurysm-related bleeding), they shouldn’t prevent clinicians from using their judgment—especially for patients with severe clots or high PE risk. As they wrote, “Guidelines give us insights, but they don’t replace clinical experience.”

References

  1. Chen Y, Lu F, Guan JL. Progression of Behcet’s disease with brain involvement: a case report (in Chinese). J Southern Med Univ 2016;36:1737. doi: 10.3969/j.issn.1673-4254.2016.12.26
  2. Chen Y, Cui JS, Cai JF, Zou J, Yazici H, Guan JL. Surgical intervention for Behcet’s disease with aorta aneurysm and pseudoaneurysm: opposite outcomes in two cases. Chin Med J 2017;130:2503–05. doi: 10.4103/0366_6999.216414
  3. Chen Y, Guan JL. Reply to “Comment to Deep vein thrombosis induced by vasculitis in the Behçet’s syndrome”. Chin Med J 2019;132:503–504. doi: 10.1097/CM9.0000000000000120

doi: 10.1097/CM9.0000000000000120

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