Recent Approaches to Deep Vein Thrombosis Treatment ILIOFEMORAL - PowerPoint PPT Presentation

Recent Approaches to Deep Vein Thrombosis Treatment

ILIOFEMORAL DVT IN FOLLOWING 5 YEARS AFTER DVT 95% ambulatory venous hypertension 90% findings of venous insufficiency 40% venous claudication 15% venous ulcer 2.6 times more recurrent DVT Akesson H, Eur J Vasc Surg 1990;4(1):43-8. Delis KT, Ann Surg 2004;239(1):118-26. Prandoni P. Haematologica 1997;82(4):423-8.

Results of DVT • Pulmonary Embolism (PE) • Phlegmasia Cerulea Dolens • Recurrent DVT • Post-thrombotic syndrome (PTS)

Purpose of the DVT Treatment • Prevent progression of thrombosis • Prevent PE • Prevent recurrent DVT • Reducing complaints • Opening thrombosed veins • Prevent PTS

Classic DVT Treatment • Anticoagulation • UFH / LMWH ± Coumadin • Compression Stocking • Mobilization • Elevation

Venous Claudication PTS Colleteral Veins Hyperpigmentation Eduration Edema Ulser

PTS Incidence • In Society Studies • Total venous stasis rate after DVT • 7% per year • 14% in 5 years • 20% in 10 years • 27% in 20 years • Cumulative ulcer incidence is 20% in 20 years. • In Clinical Studies • PTS rate after DVT • 17% (3% severe) at 1 year • 23% in 2 years • 28% in 5 years (9% severe) • 29% in 8 years Mohr DN, et al. Mayo Clin Proc 2000;75:1249 – 1256 Prandoni P et al. Ann Intern Med 1996;125(1):1 – 7.

MECHANISM OF DVT

POST-THROMBOTIC VEIN

VENOUS OBSTRUCTION • VENOUS HYPERTENSION • ABNORMAL MICROCIRCULATION • ABNORMAL LYMPHATIC VALVE INSUFFICIENCY FUNCTION

OPEN VEIN CONCEPT If thrombus eliminates early in DVT, • Venous obstruction will decrease • Valve functions will be protected • Venous hypertension will decrease • Post-thrombotic fate can be prevent

Early cleaning of thrombus Surgical Thrombectomy vs. Anticoagulation PRT • Longer patens • Less venous pressure • Less edema • Less PTS Plate G, et al. Eur J Vasc Endovasc Surg 1997;14(5):367-74

Alternatives to the Surgical Thrombectomy • Systemic thrombolysis • Catheter directed thrombolysis (CDT) • Pharmaco-mechanical trombolysis (PMT) • Rotational • Rheolitic • Ultrasonic

Systemic Thrombolysis • More efficient than heparin (58% vs 0%, P =0 .002) • No difference in PTS side (25% vs 56%, P = 0.07) • Major bleeding is high (14% vs 4%, P = 0.04) ielsen TT. Cardiology 1989;76:274-284. Goldhaber SZ, Am J Med 1984;76: 393-397. Goldhaber SZ, Am J Med 1990;88:235-240.

Catheter directed Thrombolysis (CDT) Advantages • Easy • Less invasive • Efficient in early stages (>50 lizis:%80) • Efficient to reduce PTS Disadvantages • Long Treatment (24-72 saat) • Bleeding risk %11

Aspiration Thrombectomy • 110 acute, 29 subacute iliofemoral DVT • Manuel aspiration thrombectomy • Result: • <%50 thrombectomy: %3.4 • %50-95: %30.4 • >%95 %66.2 • PE 1 • Bleeding 0 Oğuzkurt L ve ark. Diagn Interv Radiol 2012; 18:410– 416

Ultrasonic PMT EKOS Endowave (EKOS Corporation, ABD) Omniwave (Omnisonics Medical Technologies, ABD) Advantages: • Decreases time by %50 • Decreases tPa dosage by %50 • Effective in early cases Disadvantages: • 12-48 hours of treatment time • PE • Bradycardia • Major bleeding risk • Not effective in chronic lesions

Rhyolitic Angiojet device (Angiojet; Possis) Hydroliser; Cordis, Oasis Thrombectomy System; Boston Scientific Aspirex, Rotarex; Straub Medical Advantages : • No vessel contact • No thrombolytic use Disadvantages: • Hemolysis • Bradyarrhythmia • Device Set-up • High force vacuum, risk of rupture • Not effective in chronic lesions

Pharmacomechanical Thrombectomy (PMT) Mantis, Invamed Cleaner; Argon Medical Advantages: • Aggressive mechanical effect • Effective on wall adherent thrombus • Short procedure time • Effective in late thrombi (not- chronic) • Low bleeding risk Disadvantages : • Not effective on chronic lesions

Hybrid PMT • Pharmacomechanic Thrombectomy • Aspiration Trombectomy • Protective Thrombolysis Catheter (IVC Filter) • Catheter Directed Thrombolisis

Technic in Hybrid PMT • Protective Thrombolysis Catheter (IVC Filter) • Seldinger Entry • Venography • PMT • Aspiration • Control Venography • Thrombolysis • Postop anticoagulation

Clinical Background • 6 month follow-up, 62 patients • Iliac, Ilio-Femoral, Femoro-Popliteal • Acute-Subacute • Avg Treatment Time: 54.3 mins • Avg tPa Amount: 21.2 mg • Technical Success: 61 Patients(98.4%) • 1 month opening rate: 61 Patients(98.4%) • 6 month opening rate : 60 Patients (96.8%) • 5 patients after major surgery without tPa use Budak et al., Initial Experience With A New Pharmacomechanical Thrombectomy Device For Deep Venous Thrombosis With Hybrid Thrombectomy Approach

Clinical Background A B C D A) TPS Thrombolysis Catheter with IVC Filter, B) Mantis Thrombectomy Device, C) Dovi Aspiration System, D) Viper Catheter Directed Thrombolysis Device

Clinical Background B C A Picture 2. Pre-procedure Venography: A) TPS Filter Catheter Placement, B-C) Occluded Ilio-Femoral Vein

Clinical Background Picture 3: Procedure Venography

Clinical Background Picture 4: Post-procedure Venography

ADJUVAN ILIOCAVAL STENTING • This technique is using for remove the venous outflow obstacle and prevent recurrence thrombus after thombolysis • Indication: • External Pressure(May-Thurner S.) • Inefficient iliocaval lizisit • Efficient to prevent recurrence thrombosis (13% vs 73%, P < .01) • After stenting 1 year patens is %79 Mew issen MW et al. Radiology 1999;211:39-49 Mickley V et al. J Vasc Surg 1998;28:492-497. Hartung O et al. J Vasc Surg 2008;47: 381-387.

Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum Suggested situations for early thrombus removal strategies are below: • Functional and mobilize patients •First time iliofemoral DVT’s < 14 days (Grade 2C) • Especially if there is a limb losing threat caused by iliofemoral DVT (Grade 1A). If resources are suitable it is suggested that using PMT over CDT. If, Thrombolytic treatment is contra-indicated surgical thrombectomy is the suggested procedure (Grade 2C) Meissner MH, et al. J Vasc Surg 2012;55:1449-62.

Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum • PMT is not suggested for Isolated femoropopliteal DVT (Grade 1C) • If, Thrombolytic treatment is contra-indicated surgical thrombectomy is the suggested procedure (Grade 2C) • In CDT adjuvan IVC filter is not suggested to use (Grade 1C) • IVC filter is suggested under the following situations : (Grade 2C) • In PMT • Thrombus that reached IVC • PE patients • Adjuvan stent: • Self-exp stents are suggested to use in chronic thrombus or pressure related iliocaval obstructions (Grade 1C) • STEnt is not suggested for femoropopliteal lesions • After thrombus removal procedure anticoagulant treatment continues (Grade 1A) Meissner MH, et al. J Vasc Surg 2012;55:1449-62.

Approach for DVT patient • Clinical findings • Ultrasound • Start anticoagulant treatment • BT venography • Evaluation of thrombolytic treatment

Choosing Patient • Bleeding Risk • Clinical degree of DVT : PCD, IVC thrombus's • Anatomic localization • Life expectation • Patient’s choice

Patient Selection DVT Characteristics Patient • Clinically severe DVT • Symptoms < 10-14 Days • Phlegmasia Cerulae Dolens • Low bleeding risk • Acute VCI thrombosis • High life expectancy • Fast advancing thrombosis despite • Active people treatment • Volunteers • Iliofemoral (CFV) DVT

Non-Suitable Patients • Low life expectancy • Patients with limited movement • High bleeding risk (trauma, surgery, TSP) • Femoropopliteal chronic (>28 days) DVT • Isolated popliteal thrombosis • Asymptomatic DVT