Deep Vein Pathophysiology: Reflux & Obstruction

Disclosure Peter J. Pappas, M.D.

I have no financial relationship(s) to disclose.

Deep Vein Pathophysiology:

Reflux and Obstruction

Peter J. Pappas M.D.

Chairman, Department of Surgery

The Brooklyn Hospital

2011 International Vein

Congress

16.8

2

81.2

29.6

22.8

92.4

0.8

7.6

27.6

64

7.2

5.2

25.2

23.2

86.8

3.6

16.8

0 10 20 30 40 50 60 70 80 90 100

Ref lux + obstruction

Obstruction

Ref lux

Deep

Perforating

Superf icial

Congenital

Primary + Secondary

Secondary

Primary

Active Ulcer

Healed Ulcer

Skin changes

Edema

Varicose veins

Prominent veins

Telangiectases

Percent

Clinical, etiologic, anatomic and pathophysiologic data (n= 250 limbs)Clinical

Etiologic

Anatomic

Pathophysiologic

Labropoulos N. Vasc Surg 1997;31:224-5

Chronic Venous Disease – Pathophysiology

Chronic Venous Disease – Pathophysiology

Pathophysiology

Isolated Obstruction – 2%

Incompetence + Obstruction – 16.8%

Incompetence plus obstruction

most severe morbidity!

Labropoulos N. Vasc Surg 1997;31:224-5

Etiology

- Non-thrombotic Venous Lesions

- Post-thrombotic Lesion

Leads to Venous Hypertension

Deep venous thrombosis is the most

common cause of venous obstructions

Chronic Venous Obstruction – Pathophysiology

Chronic Venous Obstruction – Clinical Presentation

Swelling/Pain

Venous claudication

Lipodermatosclerosis

Venous ulceration

Signs and symptoms of venous congestion

Chronic Venous Obstruction - Location

Chronic Venous Obstruction - Location

Chronic Venous Obstruction - Location

Algorithms for workup of CVI often emphasize

reflux and testing for outflow obstruction

above inguinal ligament is omitted

- Don’t look for it

- Don’t see it when we look at it

- Don’t know how to measure it

Chronic Venous Obstruction – Diagnostic Evaluation

Hemodynamic tests

Chronic Venous Obstruction – Diagnostic Evaluation

Lack of accurate objective noninvasive or

invasive tests for evaluation

of hemodynamically significant CVO

Morphologic diagnosis of venous obstruction

Chronic Venous Obstruction – Diagnostic Evaluation

Duplex US

RIA LIA

VB

Velocity ratio

Poststenotic/prestenotic >2.5

18cm/s

210cm/s

V2/V1= 12

Chronic Venous Obstruction – Diagnostic Evaluation

Duplex US

Labropoulos N, et al. J Vasc Surg 2007;46:101-7

Chronic Venous Obstruction – Complimentary test

CTV/MRV

Neglen P, Raju S. J Vasc Surg 2002;35:694-700

•IVUS is superior to phlebography for the

morphologic diagnosis of iliac venous outflow

obstruction.

•With IVUS, fine intraluminal and mural details

were detected (eg, trabeculation, frozen valves,

mural thickness, and outside compression) that

were not seen with venography.

The median stenosis on

phlebographic

results was 50%

on IVUS 80%.

Chronic Venous Obstruction – “The standard”

• Comparison of IVUS with venography in the

assessment of chronic iliac vein obstruction

• 304 consecutive limbs during balloon dilation

and stenting of an obstructed iliac venous

segment

IVUS - Venous obstruction

Neglen P, Raju S. J Vasc Surg 2002;35:694-700

Methods

• With IVUS, fine intraluminal and mural

details were detected (eg, trabeculation,

frozen valves, mural thickness, and outside

compression) that were not seen with

venography.

IVUS - Venous obstruction

Neglen P, Raju S. J Vasc Surg 2002;35:694-700

Methods

The median stenosis on phlebographic

results was 50% on IVUS 80%.

Neglen P, Raju S. J Vasc Surg 2002;35:694-700

IVUS is superior to phlebography

for the morphologic diagnosis

of iliac venous outflow obstruction.

IVUS - Venous obstruction

Conclusion

Pre-intervention Imaging

Post-intervention Result

• Think obstruction

• Clinical signs and symptoms

postthrombotic disease

Severe C3, C4-6

pain out of proportion to lesion

no detectable lesion explaining symptoms

• Positive indicators of obstruction

stenosis/occlusion on venogram, MR-V, CT-V

presence of collaterals

Chronic Venous Obstruction – How to find it?

Chronic Venous Obstruction –Treatment

Chronic Venous Obstruction –Treatment

Results of open bypass surgery

Chronic Venous Obstruction –Treatment

Stenting of the venous outflow is the

preferred initial treatment over bypass

Technically simple

Minimally invasive

Outpatient procedure

Low morbidity

Does not preclude later open surgery

• 982 Chronic, nonmalignant

obstructions

• Femoral-ilio-caval segments

• Mean age 54

• Primary/secondary 518:464

Neglen P et al

J Vasc Surg 2007;46:979

Chronic Venous Obstruction - Treatment

0 6 12 18 24 30 36 42 48 54 60 66 720

10

20

30

40

50

60

70

80

90

100

Primary

Assisted-primary/Secondary

302 192 143 120 96 80 65 55 43 34 24 16302 189 135 110 87 72 54 45 36 26 18 11

Months

Pa

ten

cy

Ra

tes

(%

)

100%

79%

[SEM <10%]

Chronic Venous Obstruction - Treatment

Neglen P et al

J Vasc Surg 2007;46:979

Chronic Venous Obstruction – Clinical Response

QoL-Scores (CIVIQ)

Total score (mean±SD)

Pre Post

Leg pain 3.5±1.1 2.6±1.2***

Work 3.5±1.1 2.7±1.3***

Sleep 3.2±1.3 2.5±1.3***

Social

Activity 25.1±8.4 21.4±9.0***

Morale 26.0±9.8 22.1±9.7***

VCSS 8.5 (range: 4-18)

2 (range: 2-3)

VDS 2 (range:0-9)

0 (range:0-2)

Hartung O, et al. J Vasc Surg 2005;42:1138-44

Neglén et al. J Vasc Surg 2007;46:979

Endovascular

Mid-thigh UG-access FV

Chronic Venous Obstruction - Treatment

Chronic Venous Obstruction - Treatment

Hybrid

Endophlebectomy + stenting

• 47yo male presented with LLE non-healing

venous ulcer.

• VDU – LLE GSV/SSV reflux, pelvic collaterals

and CIV occlusion

Chronic Venous Obstruction – Case: CIV occlusion

Chronic Venous Obstruction – Case: CIV occlusion

Chronic Venous Obstruction – Case: CIV occlusion

• 59 yo woman with

chronic LLE swelling.

Venous claudication.

Skin pigmentation

• Prior DVT 15 yr ago

• CS-4, ES, AS,D,P, PR,O

Chronic Venous Obstruction – Case: EIV occlusion

Chronic Venous Obstruction – Case: EIV occlusion

Chronic Venous Obstruction – Case: EIV occlusion

Chronic Venous Obstruction – Case: EIV occlusion

Chronic Venous Obstruction – Case: EIV occlusion

Massive Ilio-femoral VTE

During Pregnancy

• Lytic therapy contra-indicated due to risk of

placental, fetal and maternal bleeding

• Percutaneous Mechanical Thrombectomy

– Trellis

– Angiojet

– Ekos

• Open Thrombectomy

32 Week Pregnancy

Iliofemoral DVT of Pregnancy: RB

32 Week Pregnancy

Iliofemoral DVT of Pregnancy: RB

Trellis® Catheter

32 Week Pregnancy

Iliofemoral DVT of Pregnancy: RB

EKOS LysUS

System®

Post Trellis ®, LysUS ®, Angiojet®

Iliofemoral DVT of Pregnancy: RB

Decision to perform

operative venous

thrombectomy

Substantial residual

thrombus…hence…

Completion Phlebogram

Iliofemoral DVT of Pregnancy: RB

Completion Phlebogram

Iliofemoral DVT of Pregnancy: RB

• Patient

Asymptomatic

• Rx’ed with SQ

LMWH

24 Month Follow-Up

• Patient pregnant

• Normal venous function

• Asymptomatic

• On prophylaxis

2 Years Post Rx

Iliofemoral DVT of Pregnancy: RB

HPI

• 35 y/o male evaluated by an outside vascular surgeon for a one week history of mild left leg swelling and groin pain.

• Venous duplex and MRV performed at this outside institution demonstrated an isolated left iliac vein thrombosis and possible iliac vein stenosis.

• Patient was referred to University Hospital for lytic therapy.

• On arrival to the ED, the patient was short of breath and found to have a PE by chest CT.

• He was admitted and started on intravenous Heparin.

History

• PMHx- testicular ca 6 yrs ago – No radiation/chemotherapy, no lymph node

dissection

• PSHx-left orchiectomy

• Meds-none

• Allergy-NKDA

Physical Exam

• Lungs-CTA B/L

• Cardiac-RRR, no murmurs

• Abdomen-soft, non tender, no organomegaly,

not distended

• Vascular exam-palpable distal pedal pulses b/l

• Extremity- minimal LLE swelling

– No difference in leg circumferences

Hospital Course HD #1

• Admitted to vascular surgery service

• CT scan of chest -small PE

• IV heparin initiated

• Venous duplex performed

CT Angiogram: PE in Left Pulmonary Artery

CFV flow pattern on admission

Phasic Flow Loss of Phasicity

LCIV thrombosis on admission

Hospital Course-HD#2

• IVC filter placed.

• Mechanical thrombectomy with an Angioget

system.

• Chest pain, bradycardia, decreased oxygen

saturation to 90s.

• Procedure aborted.

Codes

• 37620 – IVC filter placement

• 75940-26 – SI code for IVC filter placement

• 36010-50 – Cannulation of IVC via bilateral

Common Femoral Vein approaches

• 75827-26,59 – SI code for Inferior

Venacavagram

• 37187 – Code for initial venous mechanical

thrombectomy.

Hospital Day 2-5

• Patient continued on IV heparin and started on Coumadin.

• Poor response to coumadin with minimal change in INR. PTT was always therapeutic.

• Hospital day 5, patient’s left leg increased in size.

• Venous duplex repeated. Demonstrated thrombus from filter to infra-popliteal tibial veins.

Left CFV, DFV, FV, POPV, GSV thrombosis

Captured thrombus in the IVC filter

Hospital Day 6:

Thrombectomy/Thrombolysis

• Patient taken to cardiac cath lab and placed in prone position. An ultrasound guided cannulation of PV.

• Pulse spray with tPA

• Mechanical thrombectomy

• Left lower extremity venogram

• Catheter left in femoral and popliteal vein overnight with continuous infusion of TPA

Percutaneous mechanical

thrombectomy • Angiojet (Possis)

• Xpedior cath

• 4-12 mm vessels

• OTW 0.035 system

• 6Fr catheter

• 120 cm working length

• 6 saline jets

• Venturi effect

Percutaneous mechanical

thrombectomy

Codes for Hospital Day 6

• 36005-58 – Cannulation of Femoro-popliteal

vein

• 76937-26,58 – US Guidance SI code

• 75820-26,58 – SI code for LE venogram

• 37188-58 – Secondary mechanical

thrombectomy

• 37201-58 – Overnight instillation of TPA

• 75896-26,58 – SI code for infusion of

thrombolytics overnight

Hosptial Day 7

• Venogram through existing catheter demonstrated

liquified thrombus in Femoral and popliteal

veins.

• Mechanical thrombectomy performed and

catheter repostioned into left external iliac vein.

• TPA infusion continued.

Codes For Hospital Day 7

• 75898-26,58 – Venogram through existing

catheter

• 37188-58 – Repeat venous mechanical

thrombectomy

• 75896-26,58 – SI code for continued instillation

of lytic therapy

• 36012-58 – Repositioning catheter into external

iliac veins.

Hospital Day 8

• Venogram through existing catheter demonstrated

no resolution of IVC thrombus.

• Mechanical thrombectomy attempted without

success.

• Lysis continued for another 24 hours.

Codes for Hospital Day 8

• 75898-26,58 – Venogram through existing

catheter

• 37188-58 – Mechanical thrombectomy

• 75896-26,58 – SI code continued instillation of

thrombolytics

Hospital Day 9

• Venogram through existing catheter demonstrated

no resolution of IVC thrombus.

• TPA infusion terminated. Catheters removed.

Sheath removed three hours later.

• Patient anticoagulated with coumadin again.

Codes for Hospital Day 9

• 75898-26,58 – Venogram through

existing catheter.

Chronic Venous Obstruction:

Pharmacomechanical and Open

Venous Thrombectomy

Peter J. Pappas M.D.

Professor and Director

Chairman, Department of Surgery

The Brooklyn Hospital

BSN Jobst Seminars

[SEM <10%]

0 6 12 18 24 30 36 42 48 54 60 66 720

10

20

30

40

50

60

70

80

90

100

Primary

Assisted-primary

Secondary

603 383 290 243 195 165 139 114 88 69 53 34603 381 287 242 195 165 139 114 88 69 53 34603 373 267 218 176 143 113 90 68 52 39 24

Months

Pa

ten

cy

Ra

tes

(%

)

93%89%

67%

Chronic Venous Obstruction - Treatment

Neglen P et al

J Vasc Surg 2007;46:979

0 6 12 18 24 30 36 42 48 54 60 66 720

10

20

30

40

50

60

70

80

90

100

Primary

Assisted-primary

Secondary

303 191 147 123 99 87 74 59 45 35 29 18303 189 144 122 99 87 74 59 45 35 29 18303 184 132 107 89 74 59 45 32 26 21 13

Months

Pa

ten

cy

Ra

tes

(%

)

86%

80%

57%

[SEM <10%]

Chronic Venous Obstruction - Treatment

Neglen P et al

J Vasc Surg 2007;46:979