yolanda hy chan kwong wah hospital. management of acute iliofemoral dvt: why not anticoagulation...

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  • Yolanda HY Chan Kwong Wah Hospital
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  • Management of Acute Iliofemoral DVT: Why not Anticoagulation alone?
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  • Deep Venous Thrombosis Annual incidence 1.0 to 1.6 per 1,000 persons per year Iliofemoral DVT Complete / Partial thrombosis of iliac vein +/- common femoral vein 10 % of all DVT The post-thrombotic syndrome: The forgotten morbidity of deep venous thrombosis Kahn SR J Thromb Thrombolysis 21(1), 41-48,2006
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  • Iliofemoral DVT Extrinsic compression of iliac vein (80 %) May-Thurner syndrome Tumour Irradiation Retroperioneal fibrosis Extension of distal DVT Idiopathic
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  • Management of Acute DVT Compression therapy + Anticoagulation
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  • Management of Acute DVT Post-thrombotic syndrome (PTS) Phlegmasia
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  • Post-Thrombotic Syndrome Relationship between deep venous thrombosis and the post-thrombotic syndrome Kahn SR Arch Intern Med.2004;164:17-26
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  • Post-Thrombotic Syndrome Despite adequate conventional therapy Only 20 % of iliac vein completely recanalized Every fourth patient with proximal DVT developed PTS Ann Intern Med 1996;125:1-7
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  • Post-Thrombotic Syndrome 10 or more years after iliofemoral DVT, almost 90 % of patients were unable to work because of leg symptoms J Surg Res 1977;22:483-488 Journal of Surgical Research The Socioeconomic Effects of an Iliofemoral Venous Thrombosis O'Donnell TF Jr, Browse NL, Burnand KG, Thomas ML
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  • Rationale for Thrombus Removal Early relief of thrombus Eliminates luminal obstruction Increases chance of preserving normal valve function Post-thrombotic morbidity
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  • Thrombus Removal in Acute DVT Early removal of thrombus Thrombolysis Systemic Intrathrombus (Catheter- directed) Thrombectomy Surgical
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  • Catheter-directed Thrombolysis
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  • Accelerates thrombolysis Lessens overall dose of lytic agent Reduces duration of infusion (CDT)
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  • Catheter-directed Thrombolysis
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  • Group 1 (33) Heparin (5 to 7 days) Warfarin (6 months) Group 2 (18) Catheter-directed thrombolysis +/- Angioplasty & Stenting Extensive iliofemoral DVT Acute onset of symptoms within 14 days Ann Surg 2001;233:752-760
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  • Pharmacomechanical Thrombolysis Power-Pulse Angiojet
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  • Pharmacomechanical Thrombolysis Trellis-8 device
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  • Pharmacomechanical Thrombolysis
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  • Conclusion Patients with iliofemoral DVT are at high risk of post-thrombotic syndrome Early thrombus removal minimizes PTS Catheter-directed thrombolysis can reduce acute symptoms and prevent PTS Pharmacomechanical thrombolysis has the benefit of shortening treatment time
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  • Management of Acute DVT Gloviczki P, Wakefield TW, Comerota A, et al Handbook of venous disorders: Guidelines of the American venous forum
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  • Risks of CDT Major bleeding8 % Intracranial bleeding0.02 % Pulmonary embolism Symptomatic0.9 % Fatal0.1 % Society of interventional radiology position statement: Treatment of acute iliofemoral deep vein thrombosis with use of adjunctive catheter-directed intrathrombus thrombolysis Vedantham S, Millward SF, Cardella JF, et al J Vasc Interv Radiol 2006;17:613-616
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  • Indications for Intervention Post-thrombotic syndrome - Ambulatory - Reasonable life expectancy - Proximal thrombosis Phlegmasia - Severe symptoms - Limb-threatening Indications for thrombolysis in deep venous thrombosis Gogalniceanu P, Johnston CJ, Khalid U, et al Eur J Vasc Endovasc Surg 2009 Aug;38(2):192/198
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  • Post-Thrombotic Syndrome Relationship between deep venous thrombosis and the post-thrombotic syndrome Kahn SR Arch Intern Med.2004;164:17-26
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  • Predictive factors of PTS Ipsilateral recurrence of DVT Iliofemoral location Old age Obesity Failure of prompt recovery from acute symptoms Insufficient oral anticoagulant therapy Post-thrombotic syndrome: Prevalence, prognostication and need for progress Prandoni P, Kahn SR Br J Haematol 2009;145(3):286-295
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  • Contraindications to CDT Bleeding disorders Active internal bleeding Recent GI bleeding or CVA Recent major surgery (< 10 days) Severe hypertension Metastatic malignancy with CNS involvement Iliofemoral deep vein thrombosis: Conventional therapy versus lysis and percutaneous transluminal angioplasty and stenting AbuRahma AF, Perkins SE, Wulu JT, et al Ann Surg 2001;233:752-760
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  • Catheter-directed Thrombolysis
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  • Management of Acute DVTAnticoagulation Lessen propagation of thrombus Prevent pulmonary embolism Thrombus removal Provide early symptom relief Minimize PTS
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  • Post-Thrombotic Syndrome The average cost of treating PTS was US $ 4,700 Ann Intern Med 1997;126(6):454-457
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  • Catheter-directed Thrombolysis
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