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

SLIDE 1

Recent Approaches to Deep Vein Thrombosis Treatment

SLIDE 2

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.

SLIDE 3

Results of DVT

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

SLIDE 4

Purpose of the DVT Treatment

Prevent progression of thrombosis
Prevent PE
Prevent recurrent DVT
Reducing complaints
Opening thrombosed veins
Prevent PTS

SLIDE 5

Classic DVT Treatment

Anticoagulation
UFH / LMWH ± Coumadin
Compression Stocking
Mobilization
Elevation

SLIDE 6

PTS

Hyperpigmentation Ulser Edema Colleteral Veins Eduration Venous Claudication

SLIDE 7

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.

SLIDE 8

MECHANISM OF DVT

SLIDE 9

POST-THROMBOTIC VEIN

SLIDE 10

VENOUS HYPERTENSION
ABNORMAL

MICROCIRCULATION

ABNORMAL LYMPHATIC

FUNCTION

VENOUS OBSTRUCTION

VALVE INSUFFICIENCY

SLIDE 11

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

SLIDE 12

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

SLIDE 13

Alternatives to the Surgical Thrombectomy

Systemic thrombolysis
Catheter directed thrombolysis

(CDT)

Pharmaco-mechanical trombolysis

(PMT)

Rotational
Rheolitic
Ultrasonic

SLIDE 14

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.

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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

SLIDE 17

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

SLIDE 18

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

SLIDE 19

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

SLIDE 20

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

SLIDE 21

SLIDE 22

Hybrid PMT

Pharmacomechanic Thrombectomy
Aspiration Trombectomy
Protective Thrombolysis

Catheter (IVC Filter)

Catheter Directed

Thrombolisis

SLIDE 23

Technic in Hybrid PMT

Protective Thrombolysis Catheter (IVC

Filter)

Seldinger Entry
Venography
PMT
Aspiration
Control Venography
Thrombolysis
Postop anticoagulation

SLIDE 24

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

SLIDE 25

A B C D

Clinical Background

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

SLIDE 26

A B C

Clinical Background

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

SLIDE 27

Clinical Background

Picture 3: Procedure Venography

SLIDE 28

Clinical Background

Picture 4: Post-procedure Venography

SLIDE 29

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

Mewissen 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.

SLIDE 30

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

f the Society for Vascular Surgery

and the American Venous Forum

SLIDE 31

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.

Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum

SLIDE 32

Approach for DVT patient

Clinical findings
Ultrasound
Start anticoagulant treatment
BT venography
Evaluation of thrombolytic treatment

SLIDE 33

Choosing Patient

Bleeding Risk
Clinical degree of DVT : PCD, IVC

thrombus's

Anatomic localization
Life expectation
Patient’s choice

SLIDE 34

Patient Selection

DVT Characteristics

Clinically severe DVT
Phlegmasia Cerulae Dolens
Acute VCI thrombosis
Fast advancing thrombosis despite

treatment

Iliofemoral (CFV) DVT

Patient

Symptoms < 10-14 Days
Low bleeding risk
High life expectancy
Active people
Volunteers

SLIDE 35

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