Transcript DVT - Lancet

Deep Vein Thrombosis
DVT facts, statistics,
and therapeutic options
MICHAEL A ARATA MD
INTERVENTIONAL RADIOLOGY
MEMORIAL UNIVERSITY MEDICAL CENTER
SAVANNAH, GEORGIA
DVT Overview
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III.
IV.
V.
VI.
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Prevalence
Risk Factors
Clinical Presentation
Causes of Limb Swelling
Treatment Strategies
Clinical Experience-Case Review
The Problem of DVT: Statistics
• DVT occurs in approx. 2 million Americans
each year. Approx 1/3 develop PE
• The combined annual incidence for DVT is
approximately 2.5%-5% of the adult population
• DVT recurs in 5-10% of patients the year after
anticoagulation
• DVT recurs in 30% of patients eight years after
anticoagulation
1996 American Heart Association Scientific Statement on DVT
Risk Factors for DVT
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Age >40 years
Cancer
Obesity
Previous or family history of DVT/PE
Recent surgery
Paralysis or immobility
Contraceptives/Hormone replacement therapy
Pregnancy
Serious illness: CHF, MI, sepsis
Coagulation disorders
DVT: Clinical Presentation
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Calf pain/tenderness
Swelling
Calor, rubor
Cyanosis or pallor
Superficial venous dilatation
Loss of pulses in severe DVT
Causes of Limb Swelling: Acute
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DVT
Arterial ischemia
Superficial phlebitis
Joint effusion
Hematoma
Baker’s cyst
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Arthritis
Fracture
Cellulitus
Dermatitis
Causes of Limb Swelling: Chronic
Post-phlebitic syndrome
 Chronic venous insufficiency
 Venous obstruction
Other
 Heart failure
 RSD
 Hypoproteinemia- cirrhosis
 Medication
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DVT Treatment Strategies:
Timing
Sooner is Better!
 < 3 Weeks Good
 < 1 Week Better
 < 3 Days Best
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Rationale for Early Treatment
of DVT
 Early treatment increases probability of
maintaining normal valve function
– Damaged valves lead to venous insufficiency
 Decrease recurrent DVT risk
– Restore normal venous flow
– Clear thrombogenic substrate
 Decrease risk for PE
– Asymptomatic PE occurs in majority of patients
with DVT
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Delayed Complications:
Post-Phlebitic Syndrome
 Post-Phlebitic Syndrome -- spectrum
symptoms seen after DVT
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pain
edema
pigmentation
ulcer
 Occurs in 50 to 70% cases proximal DVT
 Prevalence estimated to be as high as 2
percent in the general population
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Delayed Complications:
Post-Phlebitic Syndrome
 Post-Phlebitic Syndrome - Result of
venous hypertension
 Venous hypertension
– Venous insufficiency- valve damage
– Venous occlusion- Chronic DVT/
Scarring
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DVT Treatment Strategies:
Historical Standard
Primary intention-Prevent PE
 Anticoagulation
– Heparin, Warfarin, LMWH
 IVC Filter Placement
 Catheter-Directed Thrombolytics
– Select cases
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Vascular Thrombosis
 Technology has revolutionized field
 Lysis/thrombectomy STD of care
– MI
– Acute stroke
– Acute limb ischemia
– Massive PE
– DVT- effort thrombosis/SVC syndrome
Why Not LE DVT?
 Large clot burden
– Systemic lysis-not effective
– Initial revascularization devices
inadequate
 Catheter directed lysis more effective
– Costly-ICU stay
– Poor Patient tolerance
Treatment Strategies:
Investigational
New treatments to rapidly remove thrombus:
 Mechanical Thrombectomy
– Physical removal of clot burden
– Often used in combination with lytics
 Power Pulse Spray
– Accelerated thrombolysis delivered by AngioJet
system
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Clinical Experience: Mechanical
Thrombectomy for DVT
 Experience as reported by K. Kasirajan, MD
– 17 patients with extensive DVT treated with AngioJet
» 7 of 17 patients had <50% thrombus removal
» 9 patients thrombolytics used achieving <90% thrombus
removal
 Conclusion: PMT with adjunctive thrombolytic is less
invasive, low risk option in patients with extensive DVT
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Kasirajan K, Gray B, Ouriel K, Jvasc Inter Radiol 2001 Feb;12(2):179-85
Clinical Experience: Mechanical
Thrombectomy for DVT
 44 patient retrospective study
– DVT- mechanical thrombectomy using AngioJet
 Key Findings
– 54.5% of patients received thrombolysis
administered pre-AngioJet
– 56.8% of patients received adjunctive
thrombolysis
– No major complications were related to the use of
AngioJet
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Kasirajan K, Arata M, Swischuk S, Hunter D, Cazenave C, Rheolytic thrombectomy for management of
venous thrombosis: Results of a multicenter venous registry. J Vasc Interven Radiol 2003: 14: S16
Clinical Experience: Mechanical
Thrombectomy for DVT
 Response to AngioJet Treatment
Complete (> 90% of
initial thrombus
removed)
No Response
9%
16%
50%
Partial (> 50%
of initial
thrombus
removed)
25%
Substantial
(> 50% -- 90% of
initial thrombus
removed)
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Kasirajan K, Arata M, Swischuk S, Hunter D, Cazenave C, Rheolytic thrombectomy for management of
venous thrombosis: Results of a multicenter venous registry. J Vasc Interven Radiol 2003: 14: S16
Clinical Experience: Mechanical
Thrombectomy for DVT
 Reported Conclusions:
– AngioJet Mechanical thrombectomy is a
safe adjunct or alternative to
thrombolysis for DVT
– Debulking with AngioJet may result in
elimination or reduction of lytic dose
– A sufficiently powered study is warranted
to assess effects
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Kasirajan K, Arata M, Swischuk S, Hunter D, Cazenave C, Rheolytic thrombectomy for management of
venous thrombosis: Results of a multicenter venous registry. J Vasc Interven Radiol 2003: 14: S16
AngioJet® Xpeedior® 120
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Clinical Experience:
Power Pulse Spray
 Reported Conclusions:
– 25 lower extremities
– Thrombolytic success 100%
–Same day treatment 52%
–Procedure complete after Power Pulse
Spray 80%
Arata M, Pappas J, Personal experience
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Deep Vein Thrombosis
Mechanical Thrombectomy
Case Examples
This program was developed for educational purposes only. The AngioJet System is not indicated for use in the venous system.
Initial Venogram
Initial popliteal venogram
demonstrating DVT
Initial femoral venogram
demonstrating DVT
Initial iliocaval venogram
demonstrating DVT
IVC Filter
Sequential Venograms Following
AngioJet Thrombectomy
Sequential venograms performed following thrombectomy passes
Completion Venogram
Completion LE venogram
Completion pelvic venogram
Completion cavogram
Deep Vein Thrombosis
Power Pulse Spray
Case Examples
This program was developed for educational purposes only. The AngioJet System is not indicated for use in the venous system.
Initial Venogram
Venogram
demonstrating focal
femoral DVT
Initial thrombus
F/U Overnight Lysis
Venogram following overnight lysis
demonstrating marked DVT progression
Venogram following overnight lysis
demonstrating caudal progression of DVT
Thrombectomy Video
Video of thrombectomy
and PPS
Power Pulse Spray
LE venogram following PPS
demonstrating complete lysis
Pelvic venogram following iliac stenting
Initial Venogram
Initial popliteal venogram
demonstrating DVT
Initial femoral venogram
demonstrating DVT
Initial iliocaval venogram
demonstrating DVT
Following Power Pulse Spray
Completion popliteal
venogram
Completion femoral
venogram
Completion pelvic
venogram
Summary
 DVT
– Major healthcare problem
– Management focus- decades old
»Prevent propagation
 Anticoagulation
 IVC filter
– Revolution in vascular technology
Summary
 Power Pulse Spray
–Same day treatment-cost effective
–Preliminary results superior to lysis
–Potentially safer
–Substantially more patient friendly