Venous Thromboembolic Disease and Current Management
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Transcript of Venous Thromboembolic Disease and Current Management
VTE and Venous Insufficiency
Jimmy C. Haouilou, MD, FACS, RPVIChief vascular surgerySt John Hospital and Medical Center11-10-2016Venous Thromboembolic Disease and Current Management
Deep Venous InsufficiencyAcute and Chronic DVT Lower extremitiesEndovascular interventionsOpen interventionsPulmonary EmbolismCurrent treatment
Thoracic outlet syndrome Venous
TOPICS
CEAPClinicalC0: None visibleC1: TelangiectasesC2: Varicose veinsC3: EdemaC4: Lipodermatosclerosis or atrophic blancheC5: Healed ulcerC6: Active ulcerVenous Insufficiency
CEAPClinicalC0: None visibleC1: TelangiectasesC2: Varicose veinsC3: EdemaC4: LipodermatosclerosisC5: Healed ulcerC6: Active ulcerVenous Insufficiency
CEAPEtiologyEc: CongenitalEp: PrimaryEs: Secondary
AnatomicAs: SuperficialAd: DeepAp: PerforatorVenous Insufficiency
CEAPEtiologyEc: CongenitalEp: PrimaryEs: Secondary
AnatomicAs: SuperficialAd: DeepAp: PerforatorVenous Insufficiency
CEAPPathophysiologic:Pr: RefluxPo: ObstructionPro: Both
Add S or A to determine symptomaticVenous Insufficiency
Risk of DVT in hospitalized patients:Medical: 10-20%General Surgery: 15-40%Stroke: 20-50%Ortho: 40-60%Major Trauma: 40-80%Critical Care: 10-80%
Chest 2008, Geerts et al. 381-453S
DVT
Risk of DVT in hospitalized pts:Medical: 10-20%General Surgery: 15-40%Stroke: 20-50%Ortho: 40-60%Major Trauma: 40-80%Critical Care: 10-80%
PREVENTION
Chest 2008, Geerts et al. 381-453S
DVT
Why such a high DVT incedence???
Inflammatory FactorsTransient hyperciagulable stateLocal trauma/muscle injuryDecreased ambulation
DVT
Goal:Prevent thrombus extension3x risk of reflux in involved segments
Treatment of DVT
Goal:Prevent thrombus extension3x risk of reflux in involved segments
Prevent VTELife threatening/Life limiting PE
Treatment of DVT
Goal:Prevent thrombus extension3x risk of reflux in involved segments
Prevent VTELife threatening/Life limiting PE
Recurrent thrombosisPost-thrombotic syndrome is 6x greater with retrhombosis
Treatment of DVT
Goal:Prevent thrombus extension3x risk of reflux in involved segments
Prevent VTE/PELife threatening/Life limiting PE
Recurrent thrombosisPost-thrombotic syndrome is 6x greater with retrhombosis
Venous insufficiency/Venous HypertensionPost-thrombotic syndrome
Treatment of DVT (Acute/Chronic)
Start with short course of UFH or LMWH (Grade 1A)Starting with VKA only has 3x increase or recurrent VTEBrandjes et al. NEJM, 1992. 1485-89Recurrent VTE 15x higher with inadequate early anticoagHull et al. NEJM, 1986, 1109-14
Early ambulation (Grade 1A)Decreases PTS by 50%Brandjes et al. Lancet, 1995. 759-62
Early use of compression stockings (Grade 1B)Complete recanalization 82% vs. 60% (early vs delayed)Arpaia et al. Blood Coag Fibrinolysis. 2007, 131-7
Treatment of Acute DVT
Acute DVTEdema and pain
Acute extensive DVTPhlegmasia
Venous gangrene
Acute DVT
Why perform an intervention on a extensive acute DVT???
If patients with iliofemoral DVT are treated by anticoagulation alone, 90% will have ambulatory venous hypertension resulting in objective findings of venous insufficiency, 40% will have venous claudication, and up to 15% will develop venous ulceration within 5 years.
Acute DVT
Treatment of Acute DVT
Treatment of Acute DVT
Thrombus removal for Acute DVT Selected patients with extensive acute proximal DVT (iliofemoral)Good functional statusLow risk of bleeding complications
Correct underlying venous lesions with PTA/StentsPoss staged procedure
After thrombolysis continue standard treatmentEven if complete resolution of DVT
Systemic thrombolytic therapy as well as operative venous thrombectomy is still a 2nd option
Treatment of Acute DVT
Window for treatment of Acute DVT3 Weeks
Tools for Acute DVT interventions
Treatment of Acute DVT
Treatment of Acute DVT
Treatment of Acute DVT
Treatment of Acute DVT
Infusion catheter
Treatment of Acute DVT
Angiojet
Treatment of Acute DVTPenumbra Thrombectomy System
Treatment of Acute DVT
Results of acute DVT interventions:Multicenter randomized trial demonstrated that patients undergoing venous thrombectomy vs. patients receiving anticoagulation alone:Improved iliac vein patency (P < .05)Lower venous pressure (P < .05)Less edema (P < .05)Fewer post-thrombotic symptoms (P < .05)
Treatment of Acute DVT
What happens after the Acute >>> ChronicValve incompetencyStenosis OcclusionTreatment of Chronic DVT
Treatment of Chronic DVT
Treatment of Chronic DVT
Treatment of Chronic DVT
Treatment of Chronic DVT
Venous Ulcer
Why consider an intervention?
Pulmonary emboli large enough to cause right ventricular dysfunction are associated with a 6-fold increase in hospital mortality and a 2.4-fold increase in 1-year mortality.PE Interventions
SymptomaticAcceptable bleeding riskLife limitingLife threateningR heart strain
PE Interventions
Results:Immediate clinical improvement.Follow up Card US almost always shows resolution or improvement of right heart abnormalities.
PE
Young patient
Unprovoked
Non-line related
Possible exercise related
TOS EFFORT VEIN THROMBOSISPaget-Schroetter syndrome
Upper Extremity DVT
TOS
39Adjunctive treatments for these residual defects include balloon venoplasty, with or without stents, jugular turndown procedures, and open repair, with or without patch venoplasty. All reports to date however note a significant late re-thrombosis rate, and return of symptoms.
TOS
40Adjunctive treatments for these residual defects include balloon venoplasty, with or without stents, jugular turndown procedures, and open repair, with or without patch venoplasty. All reports to date however note a significant late re-thrombosis rate, and return of symptoms.
TOS
TOS
42The skin incision is centered over the second rib and angled up into the sternal notch. (Hannon)
TOS
43Again, an operative specimen showing how chronic much of this process is, and why acute lytic therapy often has little effect (Slattery)
TOS
44Again, an operative specimen showing how chronic much of this process is, and why acute lytic therapy often has little effect (Slattery)
Key to a good long term success is
Correct and prompt diagnosis
Complete evaluation
Access to current treatment options
Regular follow upVenous disease (Acute or Chronic)
Thank You