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Deep Vein Thrombosis Deep Vein Thrombosis DVT facts, statistics, and therapeutic options MICHAEL A ARATA MD INTERVENTIONAL RADIOLOGY INTERVENTIONAL RADIOLOGY MEMORIAL UNIVERSITY MEDICAL CENTER SAVANNAH, GEORGIA SAVANNAH, GEORGIA DVT facts, statistics, and therapeutic options MICHAEL A ARATA MD INTERVENTIONAL RADIOLOGY INTERVENTIONAL RADIOLOGY MEMORIAL UNIVERSITY MEDICAL CENTER SAVANNAH, GEORGIA SAVANNAH, GEORGIA

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DVT Overview I.Prevalence II.Risk Factors III.Clinical Presentation IV.Causes of Limb Swelling V.Treatment Strategies VI.Clinical Experience-Case Review 2

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The Problem of DVT: Statistics DVT occurs in approx. 2 million Americans each year. Approx 1/3 develop PEDVT occurs in approx. 2 million Americans each year. Approx 1/3 develop PE The combined annual incidence for DVT is approximately 2.5%-5% of the adult populationThe combined annual incidence for DVT is approximately 2.5%-5% of the adult population DVT recurs in 5-10% of patients the year after anticoagulationDVT recurs in 5-10% of patients the year after anticoagulation DVT recurs in 30% of patients eight years after anticoagulationDVT recurs in 30% of patients eight years after anticoagulation 1996 American Heart Association Scientific Statement on DVT

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Risk Factors for DVT Age >40 years Cancer Obesity Previous or family history of DVT/PE Recent surgery Paralysis or immobility Contraceptives/Hormone replacement therapy Pregnancy Serious illness: CHF, MI, sepsis Coagulation disorders 4

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DVT: Clinical Presentation Calf pain/tenderness Swelling Calor, rubor Cyanosis or pallor Superficial venous dilatation Loss of pulses in severe DVT 5

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Causes of Limb Swelling: Acute DVT Arterial ischemia Superficial phlebitis Joint effusion Hematoma Bakers cyst Arthritis Fracture Cellulitus Dermatitis 6

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Causes of Limb Swelling: Chronic Post-phlebitic syndrome Chronic venous insufficiency Venous obstruction Other Heart failure RSD Hypoproteinemia- cirrhosis Medication 7

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DVT Treatment Strategies: Timing Sooner is Better! < 3 Weeks Good < 1 Week Better < 3 Days Best 8

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Rationale for Early Treatment of DVT Early treatment increases probability of maintaining normal valve function Damaged valves lead to venous insufficiency Decrease recurrent DVT risk Restore normal venous flow Clear thrombogenic substrate Decrease risk for PE Asymptomatic PE occurs in majority of patients with DVT 9

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Delayed Complications: Post-Phlebitic Syndrome Post-Phlebitic Syndrome -- spectrum symptoms seen after DVT pain edema pigmentation ulcer Occurs in 50 to 70% cases proximal DVT Prevalence estimated to be as high as 2 percent in the general population 10

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Delayed Complications: Post-Phlebitic Syndrome Post-Phlebitic Syndrome - Result of venous hypertension Venous hypertension Venous insufficiency- valve damage Venous occlusion- Chronic DVT/ Scarring 11

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DVT Treatment Strategies: Historical Standard Primary intention-Prevent PE Anticoagulation Heparin, Warfarin, LMWH IVC Filter Placement Catheter-Directed Thrombolytics Select cases 12

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Vascular Thrombosis Technology has revolutionized field Lysis/thrombectomy STD of care MI Acute stroke Acute limb ischemia Massive PE DVT- effort thrombosis/SVC syndrome

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Why Not LE DVT? Large clot burden Systemic lysis-not effective Initial revascularization devices inadequate Catheter directed lysis more effective Costly-ICU stay Poor Patient tolerance

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Treatment Strategies: Investigational New treatments to rapidly remove thrombus: Mechanical Thrombectomy Physical removal of clot burden Often used in combination with lytics Power Pulse Spray Accelerated thrombolysis delivered by AngioJet system 15

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Clinical Experience: Mechanical Thrombectomy for DVT Experience as reported by K. Kasirajan, MD 17 patients with extensive DVT treated with AngioJet 7 of 17 patients had

Clinical Experience: Mechanical Thrombectomy for DVT Complete (> 90% of initial thrombus removed) Substantial (> 50% -- 90% of initial thrombus removed) Partial (> 50% of initial thrombus removed) No Response Response to AngioJet Treatment 18 Kasirajan K, Arata M, Swischuk S, Hunter D, Cazenave C, Rheolytic thrombectomy for management of venous thrombosis: Results of a multicenter venous registry. J Vasc Interven Radiol 2003: 14: S16 9% 16% 25% 50%

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Clinical Experience: Mechanical Thrombectomy for DVT Reported Conclusions: AngioJet Mechanical thrombectomy is a safe adjunct or alternative to thrombolysis for DVT Debulking with AngioJet may result in elimination or reduction of lytic dose A sufficiently powered study is warranted to assess effects 19 Kasirajan K, Arata M, Swischuk S, Hunter D, Cazenave C, Rheolytic thrombectomy for management of venous thrombosis: Results of a multicenter venous registry. J Vasc Interven Radiol 2003: 14: S16

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AngioJet Xpeedior 120 20

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Clinical Experience: Power Pulse Spray Reported Conclusions: 25 lower extremities Thrombolytic success 100% Same day treatment 52% Procedure complete after Power Pulse Spray 80% 21 Arata M, Pappas J, Personal experience

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Deep Vein Thrombosis Deep Vein Thrombosis Mechanical Thrombectomy Case Examples This program was developed for educational purposes only. The AngioJet System is not indicated for use in the venous system.

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Initial Venogram IVC Filter Initial popliteal venogram demonstrating DVT Initial femoral venogram demonstrating DVT Initial iliocaval venogram demonstrating DVT

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Sequential Venograms Following AngioJet Thrombectomy Sequential venograms performed following thrombectomy passes

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Completion Venogram Completion LE venogram Completion pelvic venogram Completion cavogram

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Deep Vein Thrombosis Deep Vein Thrombosis Power Pulse Spray Case Examples This program was developed for educational purposes only. The AngioJet System is not indicated for use in the venous system.

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Initial Venogram Initial thrombus Venogram demonstrating focal femoral DVT

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F/U Overnight Lysis Venogram following overnight lysis demonstrating marked DVT progression Venogram following overnight lysis demonstrating caudal progression of DVT

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Thrombectomy Video Video of thrombectomy and PPS

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Power Pulse Spray LE venogram following PPS demonstrating complete lysis Pelvic venogram following iliac stenting

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Initial Venogram Initial popliteal venogram demonstrating DVT Initial femoral venogram demonstrating DVT Initial iliocaval venogram demonstrating DVT

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Following Power Pulse Spray Completion popliteal venogram Completion femoral venogram Completion pelvic venogram

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Summary DVT Major healthcare problem Management focus- decades old Prevent propagation Anticoagulation IVC filter Revolution in vascular technology

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Summary Power Pulse Spray Same day treatment-cost effective Preliminary results superior to lysis Potentially safer Substantially more patient friendly