Surgical Treatment for Acute Deep Vein Thrombosis

Anthony J. Comerota, MD, FACS, FACCDirector, Jobst Vascular Institute

Adjunct Professor of Surgery, University of Michigan

Surgical Treatment for Acute Deep Vein Thrombosis

Venous Thrombectomy in Patients with Iliofemoral DVT

Long-term: Clinical Status and QOL

•95% Venous Insufficiency

•15% Venous Ulceration

•Venous claudication developed in almost 50%

•Limited ambulation in 15%

•Marked hemodynamic impairment

•Markedly reduced QOL

Delis KT et alAnn Surg 2004;239(1):118

Akesson HEur J Vasc Surg 1990

Observations at 5 Years

Iliofemoral DVT: Anticoagulation Alone

Intramuscular Pressures (mmHg)

Iliofemoral DVT

Days

IntramuscularPressure(mmHg)

Anterior & Deep Posterior Compartments (Mean)

Qvarfordt P et alAnn Surg 1983;197:450

• 12 Patients with iliofemoral DVT• Venous thrombectomy• Intramuscular pressures (wick)

(Surrogate for venous pressure)

Pre-Op(Mean)

Post-Op(Mean)

40

30

20

10

0Reduction of pressure to normalReduction of pressure to normalafter thrombus removalafter thrombus removal

Extensive DVT Rx’ed with anticoagulation alone…Extensive DVT Rx’ed with anticoagulation alone…

……obstructs venous returnobstructs venous return

… …causes valve reflux, leading to…causes valve reflux, leading to…

……venous hypertension, which...venous hypertension, which...

……activates the activates the cellular and metabolic pathwayscellular and metabolic pathways leading to chronic venous diseaseleading to chronic venous disease

……Producing avoidable and costly Producing avoidable and costly post-thrombotic morbiditypost-thrombotic morbidity

Basis for Argument

Venous Thrombectomy

Strategy of thrombus removal

– Eliminates obstruction

– Preserves valve function

Iliofemoral DVTIliofemoral DVT

Venous ThrombectomyVenous Thrombectomy

- History -- History -

• Early initial enthusiasm

• Disappointment with results(Lansing and Davis reports)

• Surgeons stopped performing procedure

• Recent enthusiasm– Better understanding principles– Randomized trials– Improved technique– Improved anticoagulation

Iliofemoral DVT

Strategy of thrombus removal– Venous thrombectomy– Catheter directed thrombolysis

…for iliofemoral DVT

ACCP 20082008

“Contemporary” Venous

Thrombectomy

Long-Term Results

Venous Thrombectomy

76%41 months6051984-9910

PatencyFollow-upNo.YearsReports

Iliac Vein Patency

(mean) (mean)

63%45 months1984-99

CompetenceFollow-upNo.YearsReports

Femoral-Popliteal Competence

(mean)(mean)

8

Venous ThrombectomyVenous Thrombectomy

- Randomized Trial -- Randomized Trial -

• Randomized trials: Scandinavian centers

• Iliofemoral DVT: N=63

• Randomized: Venous thrombectomy + AVF + Anticoagulationvs.

Anticoagulation alone

• Endpoints:– Patency– Post-thrombotic morbidity– Complications

• Follow-up: 6 months, 5 years, 10 years Plate G et alJ Vasc Surg 1984

Eur J Vasc Surg 1990Eur J Endovas Surg 1997

• Infrequent - both groups

• One recurrent, symptomatic PE (anticoag.)

• 3 wound complications

• No significant bleeding complication

• 13% early reocclusion (thrombect.)

Early Complications

Plate G et al, J Vasc Surg 1984

Venous ThrombectomyVenous Thrombectomy

- Randomized Trial -

Anticoag.Thrombectomy

6.7 mmHg3.2 mmHg*Exercise Pressure (iliac)

15%4%Venous Claudication

37%17%Varicose Veins

78%54%Swelling

7%42%Asymptomatic

26%52%N Valve fct. (fempop)

35%76%Normal Iliac (venogram)

*successful thrombectomy

Plate G et al, J Vasc Surg 1984

Venous ThrombectomyVenous Thrombectomy

- Randomized Trial - Results: 6 Months (N=51) -

Anticoag.Thrombectomy

60 mmHg43 mmHgAVP

27%11%Severe CVI

18%37%Asymptomatic

37%7%Reflux + obstruction

6%40%N Valve fct. (fempop)

50%78%Patent iliac*

Plate G et al, Eur J Vasc Endovasc Surg 1990

*radionuclide phlebography

Venous ThrombectomyVenous Thrombectomy

- Randomized Trial - Results: 5 Years (N=41) -

14%

43%

33%

78%

Anticoag.Thrombectomy

63 mmHg55 mmHgAVP

18%8%Severe CVI24%54%N Clinical Score

N Valve fct. Femoral Popliteal

41%84%Patent iliac*

Plate G et al,Eur J Vasc Endovasc Surg 1990

*radionuclide phlebography

Venous ThrombectomyVenous Thrombectomy

- Randomized Trial - Results: 10 Years (N=30) -

Acute Post Op

Iliofemoral DVT

Venous ThrombectomyVenous Thrombectomy

- PreOp -- PreOp -

• Know full extent of thrombosis

• Image vena cava

• Therapeutic anticoagulation

• Arrange for complete imaging(leg through vena cava)

Venous ThrombectomyVenous Thrombectomy

- Operative -- Operative -

• Prep entire leg

• Expose CFV, SFJ, FV, profunda

• Infrainguinal thrombectomy first

• Catheter based infrainguinal thrombectomy if massage/compression not successful

• Iliocaval thrombectomy with fluoroscopic guidance

• Correct iliac vein stenosis

• Construct AVF

Femoral Vein Exposure

Venous Thrombectomy

Clot with Venous Hypertension

Venous Thrombectomy

Leg Compression

Venous Thrombectomy

Operative Technique

Venous Thrombectomy

Dual Catheter Technique

Venous Thrombectomy

Dual Catheter Technique

Venous Thrombectomy

Dual Catheter Technique

Venous Thrombectomy

Comerota AJ, Gale S

J Vasc Surg 2006;43:185-91.

Infrainguinal Balloon Catheter Passage

Venous Thrombectomy

Operative Technique

Venous Thrombectomy

Operative Technique

Venous Thrombectomy

Venous Balloon

Venous Thrombectomy

Venous Thrombectomy

Iliofemoral DVT

Completion Phlebogram

Venous Thrombectomy

Correct Iliac Vein Stenosis

Venous Thrombectomy

Comerota AJ, Gale S

J Vasc Surg 2006;43:185-91.

Caval Clot

Venous Thrombectomy

Specimen

Venous Thrombectomy

AV Fistula

Venous Thrombectomy

•Small anastomosis

•↑ venous velocity

•No ↑ pressure

•Permanent

Arteriovenous Fistula

Venous Thrombectomy

clampedclamp

removed

Femoral Vein Pressure

Iliofemoral DVT

AV Fistula and Distal Catheter

Venous Thrombectomy

Posterior Tibial Vein Infusion Catheter

Venous Thrombectomy

Anticoagulation Catheter

Venous Thrombectomy

Venous ThrombectomyVenous Thrombectomy

- PostOp -- PostOp -

• Leg infusion of heparin

• Long-leg compression

• Ambulation

• Pre-discharge venogram

• Long-term anticoagulation

Infrainguinal Phlebogram – Pre Discharge

Venous Thrombectomy

3 Years Post Op

Venous Thrombectomy

•Hairdresser

•No edema

•Minimal symptoms

•N valve function

January 2006

“Contemporary” Venous Thrombectomy

Acute DVT

What’s New in Venous Disease?

RecommendationsRecommendations

“In […patients] with extensive DVT…operative venous thrombectomy may be used to reduce acute symptoms and post-thrombotic morbidity…”

…GRADE 2B…

2008

“After venous thrombectomy, we recommend the same intensity and duration of anticoagulant therapy as those who do not undergo venous thrombectomy”

…GRADE 1C…

Acute DVT

What’s New in Venous Disease?

RecommendationsRecommendations

2008

• More comprehensive procedure than initially reported

• Follows principles of good vascular surgical technique

• Should be offered to all active patients with extensive, symptomatic DVT who cannot be Rx'ed with catheter-based methods

• Significantly reduces postthrombotic morbidity

Contemporary Venous Thrombectomy

SummarySummary