h. arjomand, md, facc, fscai, fsvmcta of abdomen and pelvis (2) cil b e et al. radiology...
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H. Arjomand, MD, FACC, FSCAI, FSVM Henry Ford Hospital
Detroit, MI
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Philadelphia
“The Thinker” (Rodin Museum)
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Seacoast of Maine & New Hampshire
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Detroit
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Acute Venous Thromboembolism (VTE)Outline
Clinical case examples Overview of acute VTE types:
Deep Venous Thrombosis (DVT) Pulmonary Embolism (PE)
Prognostic markers and outcome Dose regimen of Novel Oral Anticoagulants
(NOAC) Brief discussion on role of endovascular
therapy
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Clinical Case Patient:
38 y/o woman without any prior medical history; no know prior DVT;
Symptom: Painful (heaviness) swelling of left arm of 12-18
hrs duration Exam:
significant Lt UE swelling, tenderness Doppler:
Lt axillary & subclavian vein thrombosis
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Paget-Schroetter Syndrome (PSS)Clinical Profile (1)
Spontaneous thrombosis of UE veins AxilloSubclavian Vein Thrombosis (ASVT): Primary (Spontaneous) - rare Secondary: due to indwelling UE venous
catheters for venous access, pacemakers, or cancer - common
First postulated by Paget in 1875; described as a cause of acute pain and swelling of the arm by Schroetter in 1884
Occurs in physically active individuals after unusually strenuous use of the arm and shoulder
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Paget-Schroetter Syndrome (PSS)Clinical Profile (2)
Presence of underlying compressive anomaly of thoracic outlet Usually bilateral → risk of thrombosis of both arms
Sx: dull, aching pain in the shoulder or axilla swelling of the arm and hand
Embolic complications can occur in 1/3 of pts Dx:
Venous Doppler, CT/CTA, MRI/MRA, Venogram Tx:
Anticoagulation +/- Endovascular (CDT, PMT, ….) +/- Surgical Tx of thoracic outlet abnormality
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Venous ThromboembolismOutcome/Risk Over Time *
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Acute Venous Thromboembolism (VTE)
DVT: Highly prevalent, with incidence of one in 1,000 3rd most common cardiovascular disease in the
US In those treated with effective anticoagulation
PE can still occur in as many as 20% Proximal DVT in iliofemoral venous segments
is associated with significant complications Post-thrombotic syndrome (PTS) may occur in
60% of patients months to years after an acute episode of DVT despite anticoagulation
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Post-Thrombotic Syndrome (PTS)
Limb pain, heaviness, tightness, numbness; edema (worsens with activity); decreased stamina; varicosities; and “Stasis Ulcers”
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Acute VTE - Treatment Options Anticoagulation therapy alone Thrombolytic therapy:
Systemic Catheter-Directed Thrombolysis (CDT)
Endovascular therapy: EndoWave Ultrasound-Assisted CDT
○ Ekos Peripheral Infusion System Percutaenous Mechanical Thrombectomy (PMT)
○ Angiojet Rheolytic System
Isolated Pharmacomechanical Thrombolysis○ Trellis-8 Peripheral Infusion System
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VTE – Treatment Options
EKOS
Angiojet
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ACCP - Antithrombotic Therapy for VTE2012
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NOAC – Dose Regimen Rivaroxaban:
15 mg by mouth twice daily for three weeks followed by 20 mg once daily
Apixaban: 10 mg twice daily for seven days followed by 5
mg twice daily Edoxaban:
60 mg once daily (30 mg once daily in patients with a creatinine clearance of 30-50 mL/minute or low body weight ≤60 kg)
Dabigatran: 150 mg twice daily
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Pulmonary Embolism (PE)Clinical Case
Patient: 78 y/o woman with h/o HTN, ↑ Chol, COPD
Symptom: SOB, chest pain, & Rt LE swelling
Lab: Elevated D-dimer, Troponin & BNP
Doppler: Rt LE (femoral) DVT
Chest CT Echo
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Piazza, G. et al. Circulation 2006;114:e28-e32
Pulmonary Embolism (PE)The pathophysiology of right ventricular dysfunction secondary to acute PE
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Pulmonary Embolism (PE)Clinical Case (2)
Hypotensive, hypoxic Was offered systemic thrombolysis
refused due to concern about ICH Was offered endovascular options:
Refused due to concern about the risk! Treated with Levophed for hypotension &
shock Underwent IVC filter placement
Concern of inability to tolerate additional PE
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Pulmonary Embolism (PE)Clinical Case (2)
Underwent IVC filter placement Concern of inability to tolerate additional PE
Had prolonged hospitalization Survived to hospital discharge
Had significant residual respiratory compromise
= Massive PE
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Summary (1)
VTE is very common, and contributes to significant long-term morbidity and mortality
No significant advances in outcome over the past decade
Emerging treatment options: Novel oral anticoagulants (NOAC) Newer endovascular options Potential improvement of CV outcome;
hopefully
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Summary (2)
Appropriate therapy has the
potential of improving outcome of
patients with VTE
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Clinical Case Patient:
26 y/o woman without any prior medical history; no know prior DVT; no trauma
Symptom: persistent painless swelling of left thigh for
several years Exam:
significant asymmetry of thigh circumference (Left >>> Right)
Doppler: normal bilateral LE venous Doppler
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CTA of Abdomen and Pelvis (1)
Cil B E et al. Radiology 2004;233:361-365
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CTA of Abdomen and Pelvis (2)
Cil B E et al. Radiology 2004;233:361-365
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Iliac Venogram (1)
Cil B E et al. Radiology 2004;233:361-365
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Iliac Venogram (2)Lt Iliac Vein Stent
Cil B E et al. Radiology 2004;233:361-365
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Specific VTE SyndromesClinical Pearle
Persistent edema of the left leg may be due to
“May-Thurner Syndrome”
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May-Thurner Syndrome (MTS)Clinical Profile (1)
Originally described in 1957 Autopsy study involving 430 cadavers
Occurs in younger pts, usually 20-50 yrs old, mostly women
Also known as: Iliac vein compression syndrome Cockett syndrome Iliocaval compression syndrome
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May-Thurner Syndrome (MTS)Clinical Profile (2)
Compression of Lt common iliac vein by the overlying Rt common iliac artery Lt LE edema Asymmetric feet appearance
Persistent venous compression → intimal injury → stenosis → predisposes to thrombosis
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May-Thurner Syndrome (MTS)Clinical Profile (3)
Occurs in 4-5% of pts undergoing evaluation for LE venous disorders
Progressive disease with substantial long-term disabling complications
Without associated thrombosis, many cases are probably not recognized on LE venous Doppler
Dx: clinical profile, CTA/CTV, Venogram Tx: Endovascular; rarely surgical
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Catheter-directed thrombolysis (CDT) Iliofemoral Venous Thrombosis
No large-scale randomized trial Recommended in recent ACCP guidelines for
treatment for VTE Advantage:
Lower risk (by 50%) of post-thrombotic syndrome (from 60% to 30%)
Shorter hospital stay (esp with newer treatment modalities: ultrasound-assisted CDT, PMT,…)
Sharifi M, et al. Cathet Cardiovasc Interv 2009;75:S43.
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Isolated Pharmacomechanical ThrombolysisTrellis-8 Peripheral Infusion system
Total of 1,409 limbs treated in 1,304 patients: Patency: 95% Majority of cases (> 83%) were completed in
less than two hours in the single-setting Reduced dose of thrombolytic drugs by 30% No bleeding complications
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Pulmonary Embolism (PE)Thrombolysis (1)
Regimen: tPA - 100 mg intravenously over 2 hrs
Indications: Accepted:
○ Persistent hypotension (SBP <90 mmHg or a drop in SBP of ≥40 mmHg from baseline )
Potential:○ Right ventricular dysfunction○ Free-floating right atrial or ventricular thrombus○ Patent foramen ovale (PFO)
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33
14
0
10
20
30
40
n = 48 n = 91
Death (%)
PFO (+)
Konstantinides et al. Circulation 1998;97:1146
PFO (-)
P = 0.015
Outcome of Patients with Acute PE & PFO
Patients with Major Acute PE (n = 139)
33
14
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Kucher, N. et al. Circulation 2006;113:577-582
ICOPER Study:International Cooperative Pulmonary Embolism Registry
Patients with massive PE:Reperfusion Tx: 35No reperfusion Tx: 73
A.Overall mortality (P=0.40)
B.Cardiovascular mortality (P=0.34)
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52 y/o man with Bilat Proximal DVT, SOB & ↓BP while on i.v. heparin
Prior to Thrombolysis After Thrombolysis (24 hrs later)
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Kucher, N. et al. Circulation 2006;113:577-582
ICOPER Study:International Cooperative Pulmonary Embolism Registry
Patients with massive PE:IVC Filter: 11No IVC Filter: 97
A. Overall mortality (P = 0.006)
B. Cardiovascular mortality (P=0.005)
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Venous Thromboembolism (VTE) IVC Filters - Indications
Accepted: Absolute contraindication to anticogulation Failure of anticoagulation/acute Proximal DVT Following surgical embolectomy Peri-procedural (with CDT or PMT)
Potential: Compromised pulm vascular bed; would poorly
tolerate another embolic event Proximal DVT in pts with poor cardiopulm reserve VTE in pts with increased risk of bleeding
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Percutaenous Mechanical Thrombectomy (PMT) in Patients with Massive/Submassive PE
51 pts with acute PE & hemodynamic compromise, treated Angiojet Rheolytic System Technical success: 92% Major bleeding: 8% In-hospital mortality: 16% Long-term outcome: no CV mortality at
3-yr follow-up
Chechi T, et al. Cathet Cardiovasc Interv 2009;73:506-513.
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