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1 European Venous Centre; Aachen-Maastricht
Prof. Cees H.A. Wittens, MD PhD Head of Venous Surgery Maastricht University Medical Center Uniklinik Aachen
Interventions in the chronic setting with post-thrombotic syndrome
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European Venous Centre; Aachen-Maastricht
Venous hypertension:
Deep venous insufficiency ( < 90 mmHg)
Deep venous obstruction !! (> 200 mmHg)
DVO
Internal causes
External causes
DVT
May-Thurner
Ext. compression
Cancer
Lymphocele
Fibrosis
Aneurysm
ICV atresia
Immobility
Thrombofilia
Pregnancy
Treatment of DVO
Pressure results CFV:
0
10
20
30
40
50
60
70
80
90
100
0 5 10 15 20 25
Pre
ssu
re (
mm
Hg
)
Time (min)
Pressure CFV (healthy)
0
10
20
30
40
50
60
70
80
90
100
0 5 10 15 20 25
Pre
ssu
re (
mm
Hg
)
Time (min)
Pressure CFV (iliac obstruction)
3
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European Venous Centre; Aachen-Maastricht
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European Venous Centre; Aachen-Maastricht
Diagnostics
Clinical examination has to be performed
groin and abdominal wall: especially in
patients with: Venous ulcers
also in:
C 4,5
Venous claudication
Fast recurrent Varicosities
10-15 % will show signs
of central venous obstruction!!
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V European Venous Centre; Aachen-Maastricht
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European Venous Centre; Aachen-Maastricht
Diagnostics
Due to changed therapeutic
options there is a need to
change diagnostics in venous
ulcer disease
Complete venous roadmap !!
Full duplex examination
MRV
CTV
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European Venous Centre; Aachen-Maastricht
Diagnostics
Literature search showed no
comparable results because
there are no reporting standards
for deep venous pathology
registration
LOVE score
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European Venous Centre; Aachen-Maastricht
Scoring systems
LOwer extremity VEnous pathology
scoring system
Each segment:
Post thrombotic leasions
Residual lumen 0 % (occlusion)
10-50 %
50-90 %
90-100%
Collaterals
External compression
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European Venous Centre; Aachen-Maastricht
Treatment options
Conservative: Compression
Anticoagulation
Invasive: PTA alone (obsoleet)
PTA + stenting
Bypass
+ or -
○ Endophlebectomy
○ AV fistulae
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European Venous Centre; Aachen-Maastricht
Indications for treatment:
Improve QoL!!
Skin problems
Venous claudication !
Swollen legs
Pain
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V E C European Venous Centre; Aachen-Maastricht
Cook
Veniti
OptiMed Sinus Venous
Sinus XL flex
New Venous stents
Bard
BS
Medtronic
Bolton
Aachen-Maastricht Experience:
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V European Venous Centre; Aachen-Maastricht
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Patency rates of 314 patients
PTS (n=237)
○ Percutaneous procedure
PTS (n=77)
○ Hybrid procedure
Recanalization and stenting
Endophlebectomy
AV fistula
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Patency rate after stenting (n = 237)
for PTS (percutaneous):
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V European Venous Centre; Aachen-Maastricht
Improved inflow measures
○ Endophlebectomy (CFV involvement)
○ AV fistula
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Indications for Endophlebectomy
Patency rate for PTS (Hybrid (n= 77)
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V European Venous Centre; Aachen-Maastricht
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Clinical improvement
VCSS Baseline 8,0 ±3,8 (2-21)
6 months 5,3 ±3,6 (0-18)
12 months 4,8 ±3,7 (0-15)
Villalta Baseline 10,8 ±4,8 (4-22)
6 months 5,2 ±4,3 (0-15)
12 months 6,2 ±3,9 (0-21)
Venous claudication Baseline 62 (55,6%)
12 months 16 (11,1%)
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VEINES-QOL/Sym overall
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V European Venous Centre; Aachen-Maastricht
E C >6 increase is clinically relevant
QoL patency overall
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V European Venous Centre; Aachen-Maastricht
Treatment options: miscellaneous
Improved inflow measures / timing
○ AV fistulae
Surgical
Percutaneous (future)
○ Postoperative pneumatic compression !!
Improved anticoagulation
○ Oral “Heparines”
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European Venous Centre; Aachen-Maastricht
Conclusion:
PTA and Stenting in PTS: ○ Good patency (>90%)
○ QoL increase (>24 point (>6=clinical relevant)
○ In failure no significant QoL loss
In Europe (850 Million inhabitants)
○ > 1.600.000 people have a significant
deep venous outflow obstruction.
All stent companies join forces
○ Support research (standardization in diagnostics,
treatment and outcome)
○ Create awareness
Major impact if this treatment become routine
21 European Venous Centre; Aachen-Maastricht
Prof. Cees H.A. Wittens, MD PhD Head of Venous Surgery Maastricht University Medical Center Uniklinik Aachen
Interventions in the chronic setting with post-thrombotic syndrome
V E C
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