Presentation on theme: "Joint Hospital Surgical Grand Round"— Presentation transcript:
1 Joint Hospital Surgical Grand Round Yolanda HY ChanKwong Wah Hospital
2 Management of Acute Iliofemoral DVT: Why not Anticoagulation alone?How do you usually treat a patient with acute DVT? Simple… Heparin and Warfarin.I’d say that you are 90% correct, and I’m going to reveal the remaining 10% of the answer in the upcoming 10 minutes or so.
3 Deep Venous Thrombosis Annual incidence1.0 to 1.6 per 1,000 persons per yearIliofemoral DVTComplete / Partial thrombosis of iliac vein +/- common femoral vein10 % of all DVTDeep venous thrombosis is a common clinical condition with an overall annual incidence of 1 in 1000.Iliofemoral DVT, which is defined as complete or partial thrombosis of iliac vein with or without common femoral vein, accounts for 10% of all DVT.The post-thrombotic syndrome: The forgotten morbidity of deep venous thrombosisKahn SRJ Thromb Thrombolysis 21(1), 41-48,2006
4 Iliofemoral DVT Extrinsic compression of iliac vein (80 %) May-Thurner syndromeTumourIrradiationRetroperioneal fibrosisExtension of distal DVTIdiopathic80% of iliofemoral DVT have an underlying extrinsic iliac compression lesion, which include, most commonly, May-Thurner syndrome.May-Thurner syndrome is a benign condition when the right common iliac artery compresses the left iliac vein against the spine and causes it to become narrowed and scarred.Other causes include compression as a result of tumour, irradiation or retroperitoneal fibrosis.Iliofemoral DVT can also be an extension of distal DVT, while the rest are idiopathic.
5 Management of Acute DVT Compression therapy+ AnticoagulationTraditional therapy for acute iliofemoral DVT has been compression therapy together with systemic heparinization followed by Warfarin. It is efficient in reducing thrombus propagation and preventing pulmonary embolism but it fails to solve one big problem… the limb sequelae of DVT.
6 Management of Acute DVT Post-thrombotic syndrome (PTS)PhlegmasiaThis poor patient who has history of DVT of right lower limb happens to suffer from another acute episode on the contralateral side.She’s having quite severe phlegmasia, which literally means painful limb swelling. However, the really torturing fact is what she has been living with her other leg for the past few years – Post-thrombotic syndrome6
7 Post-Thrombotic Syndrome By definition, PTS is a syndrome and there is no one gold standard test for its diagnosis.Patients with PTS complain of …Signs on physical examination include …PTS is a common and costly clinical condition that is, unfortunately, often under diagnosed, under appreciated, and understudied.Relationship between deep venous thrombosis and the post-thrombotic syndromeKahn SRArch Intern Med.2004;164:17-26
8 Post-Thrombotic Syndrome Despite adequate conventional therapyOnly 20 % of iliac vein completely recanalizedEvery fourth patient with proximal DVT developed PTSA prospective cohort study by Prandoni in 1996 followed up 355 patients for 8 years after acute DVT, and found that following adequate conventional treatment, only 20% of iliac vein completely recanalized, and approximately every fourth patient with proximal DVT of the lower limb develop PTS.Ann Intern Med 1996;125:1-7
9 Post-Thrombotic Syndrome Journal of Surgical ResearchThe Socioeconomic Effects of an Iliofemoral Venous ThrombosisO'Donnell TF Jr, Browse NL, Burnand KG, Thomas ML10 or more years after iliofemoral DVT, almost 90 % of patients were unable to work because of leg symptomsPTS has a measurable adverse impact on quality of life. An early study in 1977 showed that 10 or more years after iliofemoral DVT, almost 90% of patients were disabled and unable to work because of leg symptoms.J Surg Res 1977;22:
10 Rationale for Thrombus Removal Early relief of thrombusEliminates luminal obstructionIncreases chance of preserving normal valve function↓ Post-thrombotic morbidityPTS evolves from persistent venous obstruction and venous insufficiency caused by inflammatory destruction of the venous valves.Hence if thrombus is removed early, luminal obstruction is eliminated, and the chance of preserving normal valve function is increased; It reduces post-thrombotic morbidity and offers patients the best chance of a favorable outcome.
11 Thrombus Removal in Acute DVT Until the late 1970s, interventional treatment for iliofemoral DVT was confined to surgical thrombectomy, which requires general anaesthesia, surgical incision, a prolonged recovery period, and most of the time, creation of a temporary arteriovenous fistula.In the 1970’s, early thrombolytic agents such as urokinase and streptokinase were tried in an attempt to accelerate clot dissolution.Although systemic lytic therapy is associated with better outcomes than anticoagulation alone, absolute failure rates are high, most likely due to inadequate penetration of thrombus by the lytic agent.Because of the disappointing results, others have adapted an aggressive regional approach… catheter-directed thrombolysis.
12 Catheter-directed Thrombolysis In this approach, catheters with multiple side-holes were directed into the clotted veins from a puncture of the ipsilateral popliteal vein, contralateral femoral vein or from the right internal jugular vein. A lytic agent, usually tPA, was then infused into the thrombus over a period of hours or sometimes days, until lysis was achieved.An underlying cause, such as a venous stenosis, was often found, and it could be dilated with balloon angioplasty and stented.
13 Catheter-directed Thrombolysis Accelerates thrombolysisLessens overall dose of lytic agentReduces duration of infusion(CDT)CDT accelerates thrombolysis, reduces the overall dose and duration of the infusion of lytic agent; therefore, it is reasonable to expect that complications will be reduced compared with systemic lytic therapy.
14 Catheter-directed Thrombolysis A mural thrombus extends to the IVCAfter 24 hours of catheter-directed thrombolysis, patency of the femoral and iliac veins was restoredwith no residual thrombus in the IVC
15 Extensive iliofemoral DVT Acute onset of symptoms within 14 days Group 1(33)Heparin (5 to 7 days)Warfarin (6 months)Group 2(18)Catheter-directed thrombolysis+/- Angioplasty & StentingA case control trial in 2001 included 51 consecutive patients with extensive iliofemoral DVT of acute onset within 14 days. Patients choose between two modalities: conventional therapy with heparin and warfarin or, lytic therapy with or without percutaneous transluminal angioplasty and stenting.Ann Surg 2001;233:
16 This table shows that the primary iliofemoral venous patency rates were significantly higher in Group 2 with aggressive treatment than in Group 1. Long-term symptom resolution was also achieved in a much higher proportion of patients.Ann Surg 2001;233:
17 Pharmacomechanical Thrombolysis Power-Pulse AngiojetAnd here comes the invention of some new toys… for what we call pharmacomechanical thrombolysis.This Angiojet device uses high-velocity saline jets to create a localised, low-pressure zone at the catheter tip for thrombus aspiration, breakup, and extraction, and treatment times have usually been under 24 hours from start to finish.
18 Pharmacomechanical Thrombolysis There is another similar tool called Trellis-8 device. This catheter isolates a segment of thrombosed vein, injects thrombolytic agent directly into the clot, and the “stirs” the mixture with a rotating wire like a blender. The clot is then aspirated, the catheter moved to a new segment, and the process repeated.Trellis-8 device
19 Pharmacomechanical Thrombolysis A recent paper has documented a significant increase in success, dramatically shorter treatment times, and reduced cost when compared to conventional catheter-directed techniques.
20 ConclusionPatients with iliofemoral DVT are at high risk of post-thrombotic syndromeEarly thrombus removal minimizes PTSCatheter-directed thrombolysis can reduce acute symptoms and prevent PTSPharmacomechanical thrombolysis has the benefit of shortening treatment timePatients with iliofemoral DVT are at particularly high risk for PTS and late disabilityTreatment strategies that feature early thrombus removal may prevent PTS, while stand-alone anticoagulant therapy fails to do so.CDT has great potential to prevent PTS and offers distinct advantages compared with surgical thrombectomy, systemic thrombolysis, and anticoagulation alonePharmacomechanical thrombolysis has the additional benefit of shortening treatment time
21 Management of Acute DVT This is a suggested treatment protocol for acute iliofemoral DVT:Immediate anticoagulation is a must, with compression therapy.After diagnosis is confirmed and extent of DVT delineated with contrast CT scan, patients who are physically active should be seriously considered for thrombus removal.If there is no contraindications to thrombolysis, CDT or pharmacomechanical thrombolysis is suggested.And the underlying venous stenosis can be corrected with balloon angioplasty or stenting.Gloviczki P, Wakefield TW, Comerota A, et alHandbook of venous disorders: Guidelines of the American venous forum
22 Thank YouPTS leads to significant quality of life impairment and socioeconomic costs. As technology continues to improve, many more patients could be spared their otherwise certain post-thrombotic morbidityWith just one gentle reminder: Treatment of acute iliofemoral DVT does not equal to anticoagulation alone.
23 Risks of CDT Major bleeding 8 % Pulmonary embolism Intracranial bleeding %Pulmonary embolismSymptomatic %Fatal %Definition of CDT-related major bleeding is defined as intracranial bleeding or any bleeding severe enough to result in death, surgery, cessation of therapy, or blood transfusionIn a pooled analysis of 19 published studies involving 1.46 patients with acute DVT treated with adjunctive CDT…These frequencies do not appear to exceed those in DVT cohorts treated with anticoagulation alone. Hence, there is no evidence to support a contention that PE prevention would be adversely affected by the use of adjunctive CDTSociety of interventional radiology position statement: Treatment of acute iliofemoral deep vein thrombosis with use of adjunctive catheter-directed intrathrombus thrombolysisVedantham S, Millward SF, Cardella JF, et alJ Vasc Interv Radiol 2006;17:
24 Indications for Intervention Post-thrombotic syndrome- Ambulatory- Reasonable life expectancy- Proximal thrombosisPhlegmasia- Severe symptoms- Limb-threateningPatients with limited clot burden do not justify the risks and expense of this form of treatment. Nor do the many patients with extensive DVT in association with late-stage cancer, who generally do not live long enough to benefit from a reduced incidence of PTS.Indications for thrombolysis in deep venous thrombosisGogalniceanu P, Johnston CJ, Khalid U, et alEur J Vasc Endovasc Surg 2009 Aug;38(2):192/19824
25 Post-Thrombotic Syndrome Relationship between deep venous thrombosis and the post-thrombotic syndromeKahn SRArch Intern Med.2004;164:17-26
26 Predictive factors of PTS Ipsilateral recurrence of DVTIliofemoral locationOld ageObesityFailure of prompt recovery from acute symptomsInsufficient oral anticoagulant therapyPost-thrombotic syndrome: Prevalence, prognostication and need for progressPrandoni P, Kahn SRBr J Haematol 2009;145(3):
27 Contraindications to CDT Bleeding disordersActive internal bleedingRecent GI bleeding or CVARecent major surgery (< 10 days)Severe hypertensionMetastatic malignancy with CNS involvementIliofemoral deep vein thrombosis: Conventional therapy versus lysis and percutaneous transluminal angioplasty and stentingAbuRahma AF, Perkins SE, Wulu JT, et alAnn Surg 2001;233:
28 Catheter-directed Thrombolysis After thrombolytic therapy, flow was restored within the small and chronically diseased iliac vein; however there was a large residual thrombus in the common iliac veinThe common iliac vein was treated with a balloon-expandable stent to compress the residual thrombus, and the external iliac and distal common femoral veins were treated with a self-expanding stentFinal subtraction venogram shows complete restoration of iliac vein flow and no residual filling defects28
29 Management of Acute DVT AnticoagulationLessen propagation of thrombusPrevent pulmonary embolismThrombus removalProvide early symptom reliefMinimize PTSThe common mistakes is for clinicians to treat all DVT patients with anticoagulation only, and belatedly refer those who complain of severe pain and swelling during follow-up for consideration of thrombolysis or thrombectomy – too late for them to achieve their goals.
30 Post-Thrombotic Syndrome The average cost of treating PTS was US $ 4,700PTS is a costly chronic condition too. In a Swedish study in 1997, the average overall direct medical cost of treating late complications of DVT was $ 4700, or approximately 75% of the cost of treatment of the primary DVT.Ann Intern Med 1997;126(6):
31 Catheter-directed Thrombolysis Numerous reports have been published over the years supporting favorable outcomes of catheter-directed thrombolysis for acute DVT.Three of the larger reports demonstrate approximately an 80% success rate…31
32 Catheter-directed Thrombolysis … and a high percentage of asymptomatic patients at nearly one-year follow-up.Despite its good results, the infusion requires monitoring in an ICU setting, with frequent trips to the imaging suite to check progress. Infusions of 2 or 3 days have been common.32