The Aachen-Maastricht approach for the

endovascular recanalization of deep vein

thrombosis (DVT)

H. Jalaie European Vascular Center Aachen-Maastricht

Department of vascular and Endovascular Surgery

University Hospital Aachen

Germany

6th MUNIC VASCULAR CONFERENCE 2016

Introduction

Kahn et al, Ann Intern Med 2008

• 20-55% of pt’s develop PTS after DVT

• PTS due to deep venous Thrombosis

• Calf: rare

• Popliteal: rare

• Femoral: common

• Iliac/caval: common

• 20 % of thrombosed iliac veins completely recanalize with

anticoagulant therapy

• 44% claudication 5 years post iliac DVT

• 15% ulcers 5 years post iliac DVT

Reason for early clot removal

• Relief of acute symptoms

• Swelling

• Pain

• Edema

• Risk reduction for posthrombotic syndrome (PTS)

• residual venous obstruction

• residual thrombus

• valve incomptence

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EkoSonic® Endovascular System: ultrasound-accelerated catheter-

directed thrombolysis (UACDT)

• Mechanical: high frequency, low energy ultrasound

• Drug: recombinant tissue plasminogen activator (rTPA)• Bolus 5mg, 1mg per hour

• Heparin PTT 40-60 seconds

Roadmap before the lysis

Visualize extend and localization of thrombi and potential stenotic or obstructive

lesions

• Ultrasound imaging

• MR venography

• CT venography

• Lower extremtity thrombosis

classification (LET)

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Start of the lysis

Case 1

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Angiography

24 hours 48 hours

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Angiography

72 hours

Case 2

• 20y. male

• Leg-pain and severe swelling right-sided 3 days

• No risc-factors

• Duplex and CT-scan : DVT iliofemoral and caval

• Ultrasoud accelerated catheter-lysis for 2 days

• Stenting of the underlying pathology

Case 2

Ultrasound accelerated

catheter

After 2 days of lysis

Dedicated venous stent

(before dilatation)

IVC

CVO

Completion angiogram

Case 3

• 57 y. male

• Swelling of the left leg 1 week

• No risc-factors

• Duplex and CT-scan : DVT iliofemoral and caval

with compression of the left iliac vein

• Ultrasoud accelerated catheter-lysis for 3 days

• Stenting of the underlying pathology

Phlebogram before lysis Placement of ultrasound

accelerated lysis catheter

CTV

After Stentimplantation

(before dilatation of the stent)

Result after 3 days of

lysis

Result after 1 day of lysis

Evaluation after

1 year

(multiplane

X-Ray)

Compression of left iliac vein

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No. of patients

(2010-2014)

79

Sex 54 (64,5%) female

Age 41 (19-71)

Thrombophilia 15 (18,9%)

Therapy duration 71,6 h

Point of access popliteal 68%, femoral 32%

Left sided DVT 50 (63,1%)

Right sided DVT 21 (26,6%)

Bilateral DVT 8 (10,1%)

Compression (May Thurner Syndrom) 26 (32,9%)

Demographics

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• Therapeutic success (reduction of Thrombus > 50%) in 80,5%

• Stent-PTA in 58,2%

• minor bleeding (puncture side) in 15,2%

• No major bleeding

• No PE

• No catheter related complications

• No mortality

Results

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• CDT for patients with an acute DVT ( 1g/L during thrombolysis

• CDT schould not exceed more than 72 hours (better 48 h)

• Stenting of residual obstruction with dedicated venous stents

• Accurate anticoagulation

• Regular follow-up

Summary

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Thank you for your attention