Transcript Document

Ambulatory Venous Hypertension
Components
• Obstruction
• Valve incompetence
• Obstruction and valve incompetence
…Highest venous pressure
…Most severe morbidity
Iliofemoral DVT
Contraindication to Lysis
Yes
No
Surgical Thrombectomy
+ AVF
Catheter-directed
Thrombolysis
No
Anticoagulation
Success
Yes
Venous Thrombectomy vs. Anticoagulation
Randomized Trial
• 63 patients: iliofemoral DVT
• Thrombectomy + AVF vs. Anticoagulation
• Follow-up: 6 mos, 5 yrs, 10 yrs
• Patency
– Valve function
– Venous hemodynamics
– Clinical evaluation
Plate G et al,
J Vasc Surg 1984
Venous Thrombectomy vs. Anticoagulation
Results: 5 years (n=41)
Thrombectomy Anticoag.
Patent iliac*
78%
50%
N Valve fct. (fempop)
40%
6%
Reflux + obstruction
7%
37%
Asymptomatic
37%
18%
Severe CVI
11%
27%
43 mmHg
60 mmHg
AVP
*radionuclide phlebography
Plate G et al,
Eur J Vasc Endovasc Surg 1990
Acute DVT
Thrombolytic Therapy: ACCP 2004
“…There is no evidence that supports
the use of thrombolytic agents for the
initial treatment of DVT….”
Recommend against the routine use of catheterdirected thrombolysis (Grade 1C)
…Treatment..[with lytic Rx] .. Be confined to
patients requiring limb salvage. (Grade 2C)
Buller H, et al
Chest 2004;126:401S
Catheter-Directed Lysis Iliofemoral DVT
Improvement in Quality of Life
• Significantly better QOL with lysis
Physical function
Stigma
Health distress
Post thromb Sx
• Successful lysis correlated w/QOL
• Lytic failures and heparin Rx similar
Comerota AJ et al
J Vasc Surg 2000
Catheter-Directed Lysis Iliofemoral DVT
Improvement in Quality of Life
• 35 consecutive patients
• Iliofemoral DVT
• Randomized
Cath-dir SK (pulse spray)
vs.
Anticoagulation alone
• Follow-up 1week/6mos
– Clot lysis
– Venous reflux
Elsharawy M, et al
Eur J Vas Surg. 2002; 24:209
Catheter-Directed Lysis Iliofemoral DVT
Randomized Trial: Outcome at 6 months
Anticoag
Lysis
(n=17)
(n=18)
Patency
12%
72%
<0.001
Reflux
41%*
11%
0.04
LOS
6d
7d
0.4
*Underestimate 20 occlusion
Elsharawy M, et al
Eur J Vas Surg. 2002; 24:209
P-valve
Postthrombotic Syndrome
Elastic Stockings (30-40 mmHg)
Postthrombotic Syndrome
Control Stocking RRR P-value
Brandjes DP
47%
21%
55%
<.01
49%
24%
51%
<.01
(n=194)
Lancet 1997;349:759
Prandoni P
(n=170)
Patho Hemst Thromb 2002;32(suppl 2):72
A Strategy of Thrombus Removal
for Venous Thromboembolism:
We Owe it to Our Patients