1. Venous Thromboembolic Disease 2015
Majdi Ashchi, DO, FACC, FSCAI, FSVM, FABVM
C (904)
W(904)

2. DISCLOSURES
NONE

3. Outline & Objectives: Brief Discussion : VTE
Discuss Controversy & Literature About Treatment of Proximal DVT vs Distal DVT ( Infra-Popliteal)
Diagnostics Modalities & Risk Stratification of VTE
Epidemiology of VTE
Risk Factors For VTE
Guideline for Dx and Treatment of DVT/ VTE
Treatment of VTE ( Medical & Mechanical) & their risks and complications.

5. Can u be any healthier?

6. VTE- Venous Thromboembolism
VTE –pathologic thrombosis that occurs within the venous circulation.
Most common form of VTE is DEEP VENOUS THROMBOSIS (DVT) of the lower extremity
Most Life threatening manifestation is embolization of thrombus resulting in Pulmonary Embolism.
VTE is often SILENT disease.
Accurate assessment of clinical symptoms, signs, risk factors, and appropriate use of objective diagnostic tests is important in the accurate diagnosis, prevention and treatment of VTE.

7. Epidemiology of VTE DVT is a major USA clinical problem
Incident 500k-2 m cases per year
ICD-9 for DVT showed 250K admissions per year
Estimated LOS 24 hours to 7 days.
Major 3 complications:
Recurrent non-fatal VTE
Post-thrombotic Syndrome
Fatal Pulmonary Embolism

10. (Spain)

11. Of PE

13. ETIOLOGY- Risk Factors
Virchow’s Triad characterizes the development of thrombosis as a result of a combination of venous stasis , venous endothelial injury & hypercoagulability.
Understanding risks for developing VTE can help determine choice of prevention modalities, as well as diagnosing of VTE when patients present with symptoms & signs of thromboembolic disease.
Risk factors can be both acquired or inherited, & combinations of risk factors are often present.
Common risk factors:
History of VTE
Immobility
Hospitalization
Surgery
Malginancy
Infection
Thrombophilia

14. Virchow’s Triad
Burns
Fractures
,Inherited or aquired

15. RISK FACTORS Immobility Endovascular Devices Medical Illness
Major Surgery (THR, TKR, Hip Fx, CA Sx, Abdominal operations requiring general anesthesia > 30 min)
Trauma
Lower Extremity Paresis
Sedentary LifeStyle
Long Distance Travel
Medical Illness
CHF OSA Cancer Liver Disease
Nephrotic Syndrome
Previous Venous Thrombosis
(x8 fold if hospitalized)
Obesity
Autoimmune & Inflammatory Disorder
Hematologic & Myloproliferative Disorder
Polycythemia Vera
Paroxysmal Nocturnal Hemoglobinuria
Inherited Or Acquired Thrombophilia
Factor V leiden mutation
Prothrombin gene Mutation
Protein S & C Deficiency
Antithrombin III Deficiency
HIT
Aniphospholipid Antibody Syndrome
External Compression Syndromes
May-Thurner Syndrome
Paget-Schroetter Syndrome
Hematoma
Tumor
Endovascular Devices
Central Venous catheters
Hemodialysis Catheters
IVCF (risk for DVT_
Pacemaker/Defibrillator Wires
Extracorporeal membrane Oxygenation catheters
Demographic/Behavioral
Age
Smoking
Sedentary Lifestyle
Long distance travel
Pregnancy
Drug Induced
Chemotherapy
Estrogen Containing Oral Contraceptives or HRT
Selective Estrogen Modulators (eg. Tamoxifen)

17. Study Of PE

22. After stopping therapy

24. Brain-glioblastoma is highest

35. Signs & Symptoms of DVT Majority Of Patients with DVT are ASYMPTOMATIC
Edema
Erythema
Tenderness with dorsiflexion of foot ( Homan’s sign)
Calf pain on palpation ( Pratt Sign)
Both signs have S&S <50%
Bluish Discoloration

36. Clinical Findings Difficult to diagnose clinically
Requires a high index of suspicion
S & S: Lack sensitivity and specificity
(seen in many disorders)
Dyspnea – may be present on exertion only, MC sx in PIOPED II
Pleuritic Chest Pain – more frequent than hemoptysis in PIOPED II
Hemoptysis
Fever (seen in up to 14% of patients with PE)
Palpitations, Lightheadedness, Wheezing
Tachypnea, Tachycardia, Crackles
Sx’s may be sudden in onset or evolve over days to weeks

37. Clinical Findings Pulmonary Infarction: Acute Massive PE:
Pleuritic CP, Hemoptysis, Pleural Rub – Seen in 10% of PE
Occurs rarely because of 3 sources of Oxygen (pulmonary artery, bronchial artery and the airway) and 2 sources of nutrients
Acute Massive PE:
Large clot in the proximal pulmonary artery
Sudden onset of syncope, hypotension, respiratory failure, myocardial ischemia and cardiac arrest
PIOPED II:
Dyspnea, Tachypnea, Pleuritic CP or signs of DVT were seen in majority of patients with PE
Conversely, PE was infrequently iagnosed in the absence of these symptoms
Signs of DVT seen in 41% of patients with PE and Symptoms of DVT seen in 39% of patients with PE Look for signs and symptoms of DVT

39. Diagnosis Of DVT (1)
Traditional Clinical Criteria to diagnose PE and DVT for the lower extremity are neither S nor S and have poor positive predictive value.
Highest diagnostic accuracy achieved when pretest clinical assessment tools (i.e. Wells criteria) are combined with objective biomarker and image testing in defined management strategies.

40. Diagnosis Of DVT (2) Wells Criteria ( point system)
Combining the Wells clinical predicted model with a single duplex us (DUS) is a management strategy that yields a significant improvement on the diagnostic accuracy: Positive pretest probability of venous thromboembolism of
3% in Low risk
16% in Moderate risk
74.6% in High risk
Patients with Negative US for DVT, frequency of thromboembolic events in 3 months is only 0.6%.

41. BLOOD WORK: D Dimers, Troponins
Echocardiography

42. Vascular Medicine 2010; 15:399

43. D-Dimer Fibrin degradation product elevated in active thrombosis
ELISA-Enzyme linked immunosorbent assay-most available & validated.
Clinical value of D-dimer relies on its high negative predictive value.
D-Dimer level <0.5 ng/dl or less in the setting of a low or intermediate pretest probability (eg Wells score <=2) confers a risk of PE or DVT of less than 1% in 3 months.
Positive D-Dimer with a high pretest probability for PE or DVT, should prompt the clinician to proceed with imaging.

44. Duplex Ultrasound
Reliable method for evaluating symptomatic proximal DVT. It is considered diagnostic for proximal DVT.
Several criteria but Non compressibility in acute DVT is the most accurate diagnostic feature with >95% S&S when compared to venography.
DUS is less reliable in diagnosis of isolated calf DVT, with S & S <70%.

45. Contrast Venography Reference standard ( Including Pulmonary)
Invasive so it is less favored
Useful in areas where DUS shown poor diagnostic accuracy (IVC, Iliac Vein, Calf veins)
Can cause nephropathy, Induced superficial thrombophlebitis, DVT, and can be used with dye limitation and limb limitation.

46. CTV : LEFT LEG DVT

47. CTV -computed Tomography Venography
Used or preferred when DUS is non-diagnostic
Similar to MRV in showing anatomy veins etc.
NOT first line role diagnostic study for DVT
Significant External Beam Radiation
Preferred for lungs in PE ( superior to V/Q scan)
Contra-indicated in renal failure, DM, CHF

48. MRV : LEG DVT

49. MRV-Magnetic Resonance Venography
Comparable to angiography in S&S
Used where DUS is not preferred or less sensitive
MRV allows for simultaneous leg imaging
Provides accurate venous flow information i.e. Iliac veins, IVC ( central venous anatomy)
Aids to differentiate Acute from remote DVT.
10% of patients can not have it due to metals in body or claustrophobia.

50. IVUS DVT in iliac vein- May Thurner Syndrome
Most accurate way to dx and check for compressibility
Unable to do other modalities

51. Pulmonary Embolism-Risk Stratification
BNP
TROPONIN
ECHOCARDIOGRAPHY

52. RISK FACTORS Immobility Endovascular Devices Medical Illness
Major Surgery (THR, TKR, Hip Fx, CA Sx, Abdominal operations requiring general anesthesia > 30 min)
Trauma
Lower Extremity Paresis
Sedentary LifeStyle
Long Distance Travel
Medical Illness
CHF OSA Cancer Liver Disease
Nephrotic Syndrome
Previous Venous Thrombosis
(x8 fold if hospitalized)
Obesity
Autoimmune & Inflammatory Disorder
Hematologic & Myloproliferative Disorder
Polycythemia Vera
Paroxysmal Nocturnal Hemoglobinuria
Inherited Or Acquired Thrombophilia
Factor V leiden mutation
Prothrombin gene Mutation
Protein S & C Deficiency
Antithrombin III Deficiency
HIT
Aniphospholipid Antibody Syndrome
External Compression Syndromes
May-Thurner Syndrome
Paget-Schroetter Syndrome
Hematoma
Tumor
Endovascular Devices
Central Venous catheters
Hemodialysis Catheters
IVCF (risk for DVT_
Pacemaker/Defibrillator Wires
Extracorporeal membrane Oxygenation catheters
Demographic/Behavioral
Age
Smoking
Sedentary Lifestyle
Long distance travel
Pregnancy
Drug Induced
Chemotherapy
Estrogen Containing Oral Contraceptives or HRT
Selective Estrogen Modulators (eg. Tamoxifen)

53. Acquired Risk Factors Major surgery
THR, TKR, Hip Fx, CA Sx, Abdominal operations requiring general anesthesia > 30 min.
Trauma
Spinal Cord Injury
Oral Contraceptives
Hormone Replacement
Pregnancy / Post-Partum
Previous VTE
8-fold increased if hosp.
Prolonged bedrest or immobility – “eThrombosis”, bedrest most of the day >3 days
Prolonged air or ground travel
“Economy Class Syndrome”
Acute Medical Illness - MC
Advance Age > 40 yrs. (risk doubles with each decade)
Cancer
Procoagulant effect
Venous obstruction
Immobility
Central venous catheters
Chemotherapy

54. Hereditary Risk Factors
Protein C deficiency
Protein S deficiency
Antithrombin deficiency
*Factor V Leiden mutation – Most Common
*Lupus Anticoagulant
*Anticardiolipin Antibody
*Hyperhomocysteinemia
*Prothrombin Gene A mutation
*Can be accurately measured in the presence of acute clot or tx.* –

55. ECG Findings Non-specific
In up to 70% patients
Sinus Tachycardia – MC
Massive PE
(Signs of Right Heart strain)
S1Q3T3
RBBB
RAD
P wave Pulmonale
T wave inversion in the precordial leads may correlate with more severe RV dysfunction
ECG Scoring system to assess degree of vascular occlusion – clinical utility not proven yet

56. S1Q3T3, RBBB

57. Echocardiography
Helps rule out other etiologies – tamponade, ischemia, valvular dz, cardiomyopathy, etc. as the cause of patient’s symptoms
Very useful in Massive PE – see hemodynamic instability
PE in proximal pulm. artery  Increased RV Afterload  rise in RV wall tension  RV dilation, RV hypokinesis, Tricuspid Regurgitation and PHTN
Pulmonary artery dilation, septum bulges into LV, Reduced size of LV in diastole :“D” sign
McConnell Sign – Regional RV dysfunction with sparing of RV apex contractility
Rarely, a clot may be seen directly in the Right heart –
RV thrombus seen in 4% of patients
RV dysfunction doubles morality from PE.

58. Echocardiography When TR peak flow velocity exceeded
In A prospective study , 132 patient with PE:
When TR peak flow velocity exceeded
2.5 m/sec &
the RIGHT over LEFT ventricular ratio was >0.5,
then the Sensitivity of 93% and specificity of 81% in predicting PE.

61. Right Atrial Thrombus

62. Right Ventricular Thrombus

63. Chest Radiography Normal (12% patients)
Non-specific findings – Cardiomegaly, Atelectasis, Infiltrates, Pleural effusion, Elevated diaphragm
Hampton’s Hump – pleural-based, wedge-shaped pulmonary infiltrate – seen in pulmonary infarction
Westermark Sign – focal oligemia
Fleischner’s Sign- prominent central pulm. artery

64. D-Dimer
Only helpful when levels are normal because that makes PE unlikely
Should be considered together with clinical probability in the evaluation of PE, best used in the ER setting where results can be obtained rapidly
NL level with low clinical probability  low likelihood of PE  no further imaging needed
Non-specific when elevated
Infection, Cancer, Trauma, Recent surgery, Advanced age, Late pregnancy, T. Bil >2 mg/dL, Inflammation, etc.

66. Arterial Blood Gas (ABG)
Pt’s with PE usually have hypoxia.
NL Oxygen levels do not rule out PE!
32% of pt’s with PE had PaO2 > 80 mmHg in PIOPED II
Resp. Alkalosis may be present with tachypnea
Resp. Acidosis may seen with Massive PE
PIOPED Study – 38% patients with angiographic PE had NL PaO2>80, NL PACO2 >35, and NL A-a gradient with no prior cardiopulmonary disease (14% if had prior cardiopulmonary disease)

67. Troponin Levels Not sensitive as a diagnostic tool
Elevated in up to 50% of patients with moderate-to-large PE
Not sensitive as a diagnostic tool
Used for Risk Stratification
Elevated Troponin levels  Markedly higher incidence of prolonged hypotension and 30-day mortality
Mechanism: presumed to be from acute right heart overload
Meta-analysis of 20 observational studies with PE: Troponin had odds ratio of 9.44 of PE attributed death.
In combo :Troponin +BNP levels, mortality predictions become more precise.

68. BNP Levels May be elevated but are non-specific
Seen in any condition with ventricular stretch
Many patients with PE have NL levels (insensitive)
Sensitivity 60% and Specificity 62% in hemodynamically stable patients with suspected PE
Degree of elevation = Risk of complications
BNP & NT-proBNP have usefulness in prognosis of clinical out come

69. BNP Levels
BNP precursor is N-terminal pro-brain naturetic peptide (NT-ProBNP).
Meta-Analysis of 16 studies
Mortality x 16 times in acute PE when
NT-ProBNP is over 600 ng/L
Mortality x 6 times greater when BNP exceeded 100 pg/mL.
Level <50 pg/mL  Benign clinical course
Adverse outcomes (resp. failure, hypotension, cardiac arrest, death, thrombolysis)

70. V/Q Scan Resulted into following categories:
High, Intermediate, Low, Very Low probability, NL
Probability of PE increases with:
Size of perfusion defects
Number of moderate-to-large size defects
Perfusion defects much larger than ventilation defects or present in the absence of ventilation defects
Chest X-Ray can be done instead of ventilation scan
Greatest utility when no cardiopulmonary disease

71. V/Q Scan PIOPED results: (compared V/Q to pulm angio.)
NL scan rules out PE / makes it very unlikely
Low prob scan does NOT exclude a PE – need work-up
Low prob scan + low clinical prob increases the predictive value of the low-prob scan
Intermediate prob scan needs further w/up in pt’s with a high clinical probability of PE
Intermediate prob scan + low clinical prob + NL D-dimer  no further work-up or treatment

72. V/Q Scan PIOPED results:
High prob scan is diagnostic unless low clinical prob or a prev. hx. of PE with similar V/Q scan
“Non-diagnostic” category = Low + Intermediate probability scans = Majority of patients  require further w/up (PE neither ruled in or ruled out)
Baseline V/Q scan for ALL patients suspected of PE? – can compare to future V/Q scans (esp. if question of tx failure or recurrence of PE arises)

73. V/Q Scan  Clinical Probability  Scan Category High Intermediate Low
PIOPED results: Likelihood of PE
 Clinical Probability 
Scan Category High Intermediate Low
High 95% 86% %
Intermediate
Low
Normal

74. CT Angiogram (CTA)
aka Spiral CT, Helical CT, CT Pulm Angio (CT-PA), electron beam CT, contrast-enhanced CT arteriography
Offers significant value in the diagnosis of PE
Commonly used study, “new kid on the block””
Advantages:
Widespread availability
Ability to identify alternative pulmonary process (pneumonia, etc.)
Speed of scanning – takes just seconds to scan!
Relative safety and requires less contrast than pulm. angiogram
High specificity for PE – 96% in PIOPED II Study

75. CT Angiogram (CTA) Disadvantages: Requires reader expertise
Need for contrast – use with caution in renal insufficiency
Contra-indicated with contrast allergy
Inability to visualize beyond the segmental arteries
Greatest utility for Main, Lobar and Segmental pulmonary arteries – improving with newer CT scanners (128-slice scanners are now becoming available – compare to 4-slice scanners used in the PIOPED II trial)
Only 83% sensitivity

76. CT Angiogram (CTA)
PIOPED II – evaluated ability of CTA to predict presence or absence of PE
All patients had a V/Q scan, CTA w/ or w/o CTV, leg ultrasound
If PE not ruled in or ruled out, then patients had pulmonary angiogram
Dx. of PE required 1 of the following:
High prob V/Q scan
Abnormal pulmonary angiogram
Abnormal leg ultrasound with a non-diagnostic V/Q scan
Exclusion of PE required 1 of the following:
NL V/Q scan
NL pulmonary angiogram
Low prob V/Q scan with Wells score <2 and NL leg U.S.
Clinical probability assessment done using Wells Score

77. CT Angiogram (CTA) CTA alone - Sensitivity 83%, Specificity 96%
CTA+CTV - Sensitivity 90%, Specificity 95%
 Clinical Probability 
Variable High Moderate Low
True + CT 96% 92% 58%
(+ pred value)
True - CT 60% 89% 96%
(- pred value)
CTA+/-CTV were non-diagnostic with a discordant clinical probability

78. CT Angiogram (CTA) Isolated SUBSEGMENTAL PE on CTA:
No evidenced-based recommendations
Are these clinically significant?
Difficult to definitively exclude a clot remaining in the legs
Patients may have an ongoing risk of such a clot in the legs
Therefore, treat these patients

79. Diagnosis & Treatment of PE

84. L CFV Thrombosis

85. L CFV Thrombosis

86. L SFV Thrombosis

87. R CFV & SFV Thrombosis

88. R Popliteal Vein Thrombosis

89. Pulmonary Angiogram “Gold Standard” for diagnosis of PE
Dx of PE requires a filling defect or a vessel cut-off sign
Negative pulm angiogram excludes clinical PE
Detects PE reliably when done within 1 week of symptom onset – even if anticoagulation is initiated
Perfusion defects present for at least 7 days w/o resolution
For up to 14 days in a majority of patients
Low rate of morbidity & mortality
0.8% incidence of major non-fatal complications
0.5% death rate in PIOPED study
Greater radiation exposure than CTA

90. DVT : proximal vs Distal
DISTAL : Isolated distal DVT encompasses those located below the knee in the calf veins . ( popliteal vein is not involved). Most calf DVT are located in the posterior Tibial and peroneal veins while AT vein and muscular vein DVTs are uncommon.
PROXIMAL: located in the popliteal, femoral, or iliac veins.

91. INFRAPOPLITEAL DVT (distal), DOES IT EVEN MATTER AND SHOULD WE TREAT IT ???

92. Infra-Popliteal DVT
In a patient with a below knee venous thrombosis, is oral anticoagulation necessary to prevent a pulmonary embolus ?

93. GUIDELINES of Infrapopliteal tx
Isolated calf DVT can be managed with serial duplex US surveillnce or anticoagulated ??
TRUE
FALSE

94. Propagation of DVT during Surveillance
NO prophylaxis
J V Surg 2012;55;550-61

96. GUIDELINES:

97. WHO Might get surveillance or Anticoagulation?
Recent Surgery & risk of bleeding
Inherent Contraindication to anticoagulation
Medication compliance issues or questioned
Patient preference.
Anticoagulation
Remote location to vascular laboratory
No direct contraindication
Significant Limb pain/swelling
Prior History of VTE/known thrombophilia
Patient preference

98. Anticoagulation VS Surveillance
Reduce risk of propagation/embolization
No Need for Multiple return visits for DUS
? Reduction in long term symptoms of venous insufficiency
NO risk of anticoagulant induced hemorrhage
Able to keep close tabs on the patient/symptoms
Risk of propagation/embolization is low.

99. Distal DVT- Indication for anticoagulation (both 1)
Asymptomatic distal DVT
Symptomatic DVT who opted for surveillance
DVT extension into or toward the proximal vein during surveillance
Patient considered by clinician to be at risk for extension to the proximal veins which includes:
Unprovoked DVT
D-Dimer >500 mg/ml
Extensive thrombosis involving multiple veins (>5cm length and >7mm in diameter)
Thrombosis close to the proximal veins.
(Continue)
Inpatient status
Prolonged immobility
Prior DVT or Pulmonary E
Peristent/Irreversible Risk factors such as active cancer.
Chest 2012; 141: e419S.

100. THERAPY GOAL of therapy of DVT is
Prevention Of:
Thrombus propagation
Thrombus embolization
Early & Late thrombus recurrence
Proper Anticoagulation is the first critical step in effective treatment of DVT.
Complications can develop soon after DVT detection which gives a narrow window of opportunity for safe and effective intervention
Secondary stage of treatment involves maintenance of sufficient anticoagulation to prevent recurrence of DVT

101. THERAPY ACUTE CHRONIC Anticoagulation
UFH
LMW & Fondaparinux
Warfarin
New Anticoagulants
Catheter Directed Thrombolysis & Percutaneous Venous Thrombectomy
Compression Therapy
Ambulation
IVCF
Duration of Anticoagulation
Therapy In Cancer Patients
New Anticoagulants
Comparison of New Oral Antithrombotic Agents
Pradaxa, Eliquis, Xarelto, Savysa
Comparison of Anticoagulants

102. THERAPY
ACUTE
Catheter Directed Thrombolysis & Percutaneous Venous Thrombectomy
“Open Vein Hypothesis”
ACCP recommended subset
Compression Therapy
Post Phlebitic syndrome is a common
RCPC showed graduated compression therapy to decrease incident of PPS by half if used for two years at mmg Hg.
Patient compliance and cost was an issue
AMBLUATION
Immobilization is no longer recommended for acute DVT patients who can ambulate
Decrease DVT symptoms in patients who ambulate quickly without increase in PE.

103. Target Specific Anticoagulants=NOVEL Anticoagulants
Savysa

104. *Pradaxa is the only Dialaizable TSA
Xarelto
Eliquis
Savysa
Pradaxa
*Pradaxa is the only Dialaizable TSA

109. Eliquis

111. =PRADAXA
= Savaysa

112. Pradaxa

113. Savaysa

115. THROMBOPROPHYLAXIS VTE Prophylaxis in Medical
Prophylaxis in Medical Population
Without Thromboprophylaxis:
Low to Moderate Risk
LMWH, LDUH, Fondaparinux are effective in reducing VTE vs placebo and hence ACCP & ACP endorses it
NO difference in efficacy or safety between BID or TID dose of LDUH
LDUH & LWMH shown equivalency with respect to safety and efficacy in hospitalized medical patient
Mechanical Devices in medical patient does not have enough data. So, use only when can NOT use anticoagulants.
RPCT found that extending VTE prophylaxis beyond 28 days resulted in reduction of the incident of VTE at higher expense of statistically significant bleeding risk. So more studies needed to determine population that needs extended prophylaxis post hospitalization and beyond 28 days.

116. THROMBOPROPHYLAXIS VTE Prophylaxis in Surgical
Prophylaxis in Surgical Population
ACCP recommend use of LDUH, LMWH or Fondaparinux for the majority of patients undergoing major surgical procedures.
LDUH has been shown effective in elective hip surgery but NOT proven to decrease VTE in major knee surgery or with hip fractures. Hence , ACCP recommends either LWMH or Coumadin.
NO ROLE of antiplatelet therapy as sole therapy in reducing VTE.
AAOS does endorse ASA for thrombophylaxis in non-trauamatic hip or knee arthroplasty surgery.
Mechanical devices are less effective than pharmacologic prophylaxis.
ACCP does not recommend it as sole therapy unless patient contraindicated to pharmacologic therapy
Combination therapy not well studied but could be used in very high risk patients.

117. THROMBOPROPHYLAXIS VTE Prophylaxis in Surgical
Prophylaxis in Surgical Population
Extended duration prophylaxis for major abdominal and ortho surgeries in meta-analysis showed to be beneficial
KNEE & HIP to 35 days ( ACCP)
Post major abdominal –pelvic cancer surgeries up to 28 days.
Rivaroxaban has been approved to reduce VTE based on trials
12-14 days post knee replacement (VTE higher with knee but in short term)
35 days post hip surgery (duration of risk higher in hip)
Start 6-10 hours postop and after surgically hemostasis
Caution and not recommended with creat clear <30 mL/min

118. Complications of Anticoagulation
Bleeding
Heparin Induced Thrombocytopenia
Warfarin Skin Necrosis

119. Therapy-Inferior Vena Cava Filters-Indications
Absolute Indications
Documented PE or proximal DVT, with a contraindication to anticoagulation
Complication of anticoagulation necessitating cessation of therapy, and progression of venous thromboembolic disease despite therapeutic anticoagulation
Relative Indications
Massive PE, with poor cardiopulmonary reserve
Large free-floating proximal DVT
Poor Medical compliance with anticoagulants
Prophylactic filter placement in high-risk & poor prophylaxis candidates

120. Conclusions:
DVT is a major clinical problem in USA with estimated 500k-2 million cases per year
Clinical Presentation & Use of appropriate testing are important for confirming Dx of DVT & PE
Major Guidelines for prevention of DVT and PE for both surgical & Medical patients. Risk should be assessed
Treatment option , acute and chronic
Understand Anticoagulation related complication
IVCF indication

121. Thank you for your attention