moll - how to approach · 1. baseline f/u doppler ultrasound: when stopping anticoagulation. [ageno...

ISTH Advanced Training CourseDubai, UAE

ISTH Advanced Training Course

How to Approach a Patient with Venous Thrombosis

4 5

Stephan Moll, MDUNC Chapel Hill, NC

ISTH Educational WorkshopBangkok, Nov 4-7, 2017

ISTH Educational Workshop


‐ 2 ‐

Research Support/P.I. No conflicts

Employee No conflicts

Consultant No conflicts

Major Stockholder No conflicts

Speakers Bureau No conflicts

Honoraria No conflictsScientific Advisory Board No conflicts

Off-label use of a drug or medical device: None

Disclosures


20 Teaching points

History

Diagnostic Testing

Treatment

1

2

3

Content


Arm Clots – Basics of Anatomy

Deep Veins

Brachial veins

Axillary vein

Radial veins Ulnar veins

Subclavian veinAxillary vein

(a deep vein)Brachial vein (a deep vein)

Superficial Veins

Cephalic vein

Basilic vein

Cephalic vein Basilic vein

Median forearm vein

Median cubital veinMedian cephalic

vein


Common iliac veinInternal iliac veinExternal iliac veinCommon femoral vein

Greater saphenous vein(GSV; medial thigh + calf) Deep femoral vein

Lesser saphenous vein(LSV; in back of calf)

Femoral vein (Superficial femoral vein)

Gastrocnemius vein

Soleus veinAnterior tibial vein

Peroneal veinPosterior tibial vein

Popliteal vein

Superficial veins Deep Veins

Proximal veins

Distal veins

Leg Clots – Basics of Anatomy


Know arm and leg venous anatomy

Take home point #1

Basics

Teaching point


Imaging


“Acute” = acute or subacute (day to weeks, up to 3 months)

Dilated vein

“Spongy” appearance

Hypo-echoic intraluminal material

Caveats

Diagnosing recurrent DVT

Doppler Ultrasound Caveats

Decision is conglomerate of:

New clinical symptoms, DD, Doppler ultrasound[Bates SM.ACCP guidelines, Chest 2012;141:351S-418S]


1. Chronic or acute appearing?

(acute: spongy, hypo-echogenic, dilated vein)

2. Comparison to previous Doppler US study

3. How big is the clot?

Doppler Ultrasound Caveats


Caveats

CT Scan Caveats

If CTA results do NOT match pre-test clinical assessment:

CTA is wrong in ca. 50 % of cases

Review CTA with best radiologist

[Stein P. NEJM 2006;354:2317‐27]

Acute vs chronic PE

- sub-segmental PE


Radiological Imaging

CTEPH Screening

1. Chest Xray (CXR)

2. Chest CT angiogram (CTA)

3. Lung ventilation-perfusion scan (VQ scan)


VQ scan can NOT differentiate between acute and chronic

VQ abnormalities frequently persist for months

(of 157 PE patients, 66 % had VQ abnormality at 3 months)[Wartski M et al. J Nucl Med 2000;41:1043-8]

VQ Caveats

VQ Scan

CTA is insensitive to detect chronic PE (CTEPH)

VQ scan is test of choice


Know limitations of Doppler ultrasound and CTA

Take home point #1

Basics

Teaching point


3. Patient preference

2. Risk for Bleeding

(a)..., (b..., (c) …

1. Risk of recurrent VTE

(a)..., (b)..., (c)...

Conglomerate decision of:

a)….., (b)….., (c)…..

0 10

Warfarin “Hate Factor”

Blood Thinner “Dislike Factor”


Teaching points

VTE: R leg prox DVT in 3-2011. VTE risk factors: (a)... (b)…, (c)…

Arterial thromboembolism: Wedge-shaped L renal infarct. Arterial thromboembolic and arteriosclerosis risk factors: (a)..., (b)..., (c)...

Assessment

Define clot.

List clot risk factors: (a)…, (b)…, (c) …


Teaching points

Assessment

Define clot.

List clot risk factors: (a)…, (b)…, (c) …

“Warfarin Hate Factor”


History

Step back! First question: Does patient really need to be on

long-term anticoagulation?

1. “Blood Clot” in the history – Review: Symptoms; Hospitalization?

Treatment? Risk factors – of each episode.

2. Obtain previous Doppler/CTA report, d/c summary.

3. Then decision: “superficial clot” vs “DVT”, proximal or distal.

4. List all VTE risk factors: (a)…., (b)…., (c)….

Inpatient: Patient admitted for GI bleed - on warfarin.

Consult: “When to restart anticoagulation?”


Question/revisit the indication/diagnosis!• In the patient on long-term anticoagulation: Detailed h/o each clot.

Get objective records.• “Previous leg clot”: Was it DVT or superficial clot? Prox. or distal?• “Protein C, S, AT deficiency; APLA syndrome”

Teaching points

Reviewing the History


• “There is no family history of bleeding or clotting”.

• “Nobody in the family had a clot”.

Obtain a detailed family history.

Teaching point

Family History


Social History


Examination

Mid-calf circumference: R > L by 2 cm


1. Stockings (30/40 mm Hg)

2. CT or MR venogram

3. Angioplasty, stenting

4. Home compression pump

5. Pain Clinic, gabapentin

6. Disability assistance

Postthrombotic Syndrome


1. Good history

2. 3 flights of stairs with pulse oximeter

3. Cardiac echo

4. VQ scan

History and Work-up After PE

Pulmonary HTN Clinic

6 min walk test

Pulmonary pressure

measurements and angiogram


1. PTS treatment: 30/40 mm stockings; venogram + stenting?

2. Recognize post-PE syndrome and CTEPH

Teaching points

After a DVT or PE


VTE due to major transient risk factor

Woman with unprovoked VTE

Woman with VTE on hormones

Long-term

3 months

• PE• DVT

Man with unprovoked VTE

Non-major transient risk factor

• PE• DVT

Strong Throm

bophilia

D-dim

er

+

‐

[Choosing Wisely®; Hicks LK, et al. Hematology Am SocHematol Educ Program. 2014;2014: 599‐603]

ACCP, AHA, ISTH, BJH, ACF

LABSVTE: Duration of Anticoagulation


VTE due to major transient risk factor

Woman with unprovoked VTE

Woman with VTE on hormones

Long-term

3 months

• PE• DVT

Man with unprovoked VTE

Non-major transient risk factor

• PE• DVT

Strong Throm

bophilia

D-dim

er

+

‐

[Choosing Wisely®; Hicks LK, et al. Hematology Am SocHematol Educ Program. 2014;2014: 599‐603]

ACCP, AHA, ISTH, BJH Teaching point

Recurrence triangle

LABSVTE: Duration of Anticoagulation


3. Patient preference

“Warfarin Hate Factor”

2. Risk of Bleeding

(a)…., (b)…., (c) …..

1. Risk of recurrent VTE

(a)…., (b)…., (c) …..

LABSDuration of Anticoagulation

Conglomerate decision of:


4. … if you don’t know how to interpret test or what to do with results.

3. … while patient is on an anticoagulant.

1. … during an acute thrombotic episode.

2. … a hospitalized patient.

Do NOT test ….

LABSThrombophilia Testing


LABSLab Testing

[Moll S. J Thromb Thrombolys 2015;39:367‐378]


Teaching points

• Be clear whom to test and when to test (“4 rules”)• Be aware of influence of anticoagulants on thrombophilia labs

LABSLab Testing

ISTH Advanced Training CourseDubai, UAE[http://files.www.clotconnect.org/DVT_and_PE.pdf]

Patient Education


Patient Education


LABSAdditional Things to Mention…

1. Baseline f/u Doppler ultrasound: when stopping anticoagulation.[Ageno W et al. JTH 2013; 11: 1597–1602]

2. “Long-term” anticoagulation = extended = lifelong. But:

Re-evaluation every so often (once per year).

3. Offer and encourage clinical trial participation.


LABSSummary – 3 Key Points

VTE: Define; risk factors: a)…, b..., (c) ...

“Recurrence triangle”

“Warfarin/DOAC hate factor”

20 Teaching points

moll - how to approach · 1. baseline f/u doppler ultrasound: when stopping anticoagulation. [ageno...

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