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


Prevent VTELife threatening/Life limiting PE

Treatment of DVT


Prevent VTELife threatening/Life limiting PE

Recurrent thrombosisPost-thrombotic syndrome is 6x greater with retrhombosis

Treatment of DVT


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



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


Window for treatment of Acute DVT3 Weeks

Tools for Acute DVT interventions





Infusion catheter


Angiojet

Treatment of Acute DVTPenumbra Thrombectomy System


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)


What happens after the Acute >>> ChronicValve incompetencyStenosis OcclusionTreatment 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

venous thromboembolic disease and current management

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