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12/15/2015 1 Line-associated DVT, Calf Vein DVT and Superficial Vein Thrombosis: What to do. Ian Del Conde, MD, FACC Vascular Medicine and Cardiology Miami Cardiac and Vascular Institute HeartWell December 12, 2015 Disclosures CONSULTANT Merck; New Haven Pharmaceuticals ADVISORY BOARD Merck, IC Sciences SPEAKER’S BUREAU Johnson & Johnson, BMS, Pfizer

Line-associated DVT, Calf Vein DVT and Superficial Vein ... · Line-associated DVT, Calf Vein DVT and Superficial Vein Thrombosis: What to do. Ian Del Conde, MD, FACC Vascular Medicine

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Text of Line-associated DVT, Calf Vein DVT and Superficial Vein ... · Line-associated DVT, Calf Vein DVT...

  • 12/15/2015

    1

    Line-associated DVT, Calf Vein DVT

    and Superficial Vein Thrombosis:

    What to do.

    Ian Del Conde, MD, FACC

    Vascular Medicine and Cardiology

    Miami Cardiac and Vascular Institute

    HeartWell

    December 12, 2015

    Disclosures

    CONSULTANT

    Merck; New Haven Pharmaceuticals

    ADVISORY BOARD

    Merck, IC Sciences

    SPEAKER’S BUREAU

    Johnson & Johnson, BMS, Pfizer

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    2

    1. Line-associated DVT

    2. Calf Vein DVT

    3. Superficial Vein Thrombosis

    Line-Associated DVT

    PICC line Hemodialysis

    Catheters

    And P-A-C

    PPM/AICD

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    3

    Venous Anatomy of

    the Upper Extremity

    DEEP VEINS

    Brachiocephalic V.

    Jugular V.

    Subclavian V.

    Axillary V.

    Brachial V.

    Ulnar V.

    Radial V.

    SUPERFICIAL VEINS

    Cephalic V.

    Basilic V.

    ProximalDistal Anticoagulation

    Anticoagulation

    may not be necessary

    Line-Associated Venous Thrombosis:

    Epidemiology Overview

    • 50-60% of all cases of UEDVT are line-associated.

    • Two-thirds are asymptomatic• Risk factors:

    – Active cancer– Radiation therapy, chemo, TPN– Catheter tip not at atriocaval junct– Catheter size (AICD/CRT)– Prior central venous catheterization

    The DVT FREE Steering Committee. Circulation. 2004; 110: 1605-1611

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    Symptoms and Physical Exam

    Symptoms: discomfort, pain, paresthesias, discoloration, swelling

    Symptoms and Physical Exam

    Symptoms: discomfort, pain, paresthesias, discoloration, swelling

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    Symptoms and Physical Exam

    Symptoms: discomfort, pain, paresthesias, discoloration, swelling

    Questions to Address: Patient Factors

    1. What vein segment is involved?

    2. Is proximal extension likely?

    3. Any indication of SVC syndrome?

    4. Contraindication to

    anticoagulation?

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    Questions to Address: Catheter Factors

    1. Is the catheter still needed? (IV meds, blood draws, TPN, etc.)

    2. Is the catheter functional?

    3. Any evidence of infection?

    Management of Catheter Associated UE DVT

    Routine catheter removal is generally not

    recommended

    • Difficult access, continued need for further IV access should be considered

    • Must be able to anticoagulate the patient

    Removal is warranted in:

    • Malfunctioning catheter, infection, contraindication to anticoagulation,

    persistent signs and symptoms despite

    treatment.

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    What do the Guidelines Say?

    • Anticoagulate for as long as the catheter remains in place.

    • If the catheter is removed, and the DVT involves the axillary or subclavian veins, anticoagulate

    for 3 months (longer if the patient has cancer).

    Calf Vein

    Thrombosis

    Opinions differ:

    • Need to examine calf veins?

    • Need to treat?

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    DEEP VEINSAnterior tibial V.

    Posterior tibial V.

    Peroneal V.

    MUSCULAR VEINSGastrocnemius V

    Soleal V.

    SUPERFICIAL VEINSGreater saphenous V.

    Short saphenous V.

    Veins of the Calf

    Observations:

    • With no treatment, 15% propagate to popliteal vein.

    • Pulmonary embolism rarely occurs (

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    Muscular vs. Deep Vein Thrombosis

    Does location of calf vein thrombosis matter?

    • 50% of calf vein thrombosis are in the muscular veins

    Pain Swelling

    Muscular +++ +

    Deep + ++

    Muscular

    (n=457)

    Axial

    (n=222)

    P value

    Death 3.8% 4.1% 0.98

    Recurrence 1.5% 1.4% 0.98

    No difference!

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    • Who to treat with anticoagulation?

    • Symptomatic patients

    • Risk factors for extension

    • Full-dose anticoagulation,(same as for prox. DVT)

    Calf Vein Thrombosis: Bottom Line

    2012 ACCP Guidelines

    • Extensive

    • > 2 veins

    • Close to prox. veins

    • > 7 mm in diameter

    • Who to treat with anticoagulation?

    • Symptomatic patients

    • Risk factors for extension

    • Full-dose anticoagulation,(same as for prox. DVT)

    • If anticoagulation is not prescribed, serial duplex ultrasounds for 2 weeks.

    Calf Vein Thrombosis: Bottom Line

    • Extensive

    • > 2 veins

    • Close to prox. veins

    • > 7 mm in diameter

    2012 ACCP Guidelines

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    34F, otherwise healthy.

    Acute R leg pain during

    a basketball game.

    Swollen, painful leg.

    Venous duplex:Acute thrombosis of the

    gastrocnemius vein.

    Should this patient be anticoagulated?

    Scimitar sign

    Gastrocnemius Tear

    No anticoagulation!!

    Repeat duplex US in 1 week.

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    Superficial Vein

    Thrombosis

    Femoral V.

    Peroneal V.

    Ant. Tibial V.

    Greater

    Saphenous V.

    (GSV)

    Common

    Femoral V.

    Small

    Saphenous V.

    (SSV)

    Dorsal

    Venous arch.

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    Femoral V.

    Peroneal V.

    Ant. Tibial V.

    Greater

    Saphenous V.

    (GSV)

    Common

    Femoral V.

    Small

    Saphenous V.

    (SSV)

    Dorsal

    Venous arch.

    GSV

    FVCFV

    CFV

    Femoral V.

    Peroneal V.

    Ant. Tibial V.

    Greater

    Saphenous V.

    (GSV)

    Common

    Femoral V.

    Small

    Saphenous V.

    (SSV)

    Dorsal

    Venous arch.

    GSV Thrombus

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    Femoral V.

    Peroneal V.

    Ant. Tibial V.

    Greater

    Saphenous V.

    (GSV)

    Common

    Femoral V.

    Small

    Saphenous V.

    (SSV)

    Dorsal

    Venous arch.

    Varicose veins 82%

    Prior DVT/PE 22%

    Cancer 6%

    Immobility 8%

    Recent Hospitalization 9%

    Surgery 4%

    Trauma 5%

    Hormone 13%

    Risk Factors for Superficial V. Thrombosis

    Ann Intern Med 2010;152:218

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    What is the incidence of DVT/PE in

    Patients with SVT?

    844 patients

    • Whole leg Duplex US

    Proximal DVT 10%

    Calf DVT 14%

    PE 4%

    Total VTE = 25%

    Ann Intern Med 2010;152:218

    • 1 in 4 patients will have DVT/PE

    US imaging in for all SVT patients

    CTA in selected patients

    •With isolated SVT, VTE rates low

    @ 3 months: DVT 3% PE 0.5%

    •Risk factors for VTE complications :

    Male gender, prior VTE, cancer, no varicosities

    SVT Epidemiology: Bottom Line

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    How should patients with

    isolated Superficial Vein

    Thrombosis be treated?

    Arixtra for SVT TreatmentCALISTO Trial

    NEJM 2010;363:1222

    1º endpoint: death, DVT/PE, SVT extension into SFJ @ 11 wks

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    1º endpoint: 1.2% vs. 6.3%; NNT = 20

    (death, DVT/PE, SVT extension into SFJ @ 11 weeks)

    NEJM 2010;363:1222

    CALISTO Trial

    Fondaparinux (Arixtra)

    Placebo

    • With isolated SVT, VTE rates low @ 3 months

    • Who to treat?

    • Severe symptoms

    • Great saphenous vein involvement (vs. tributary)

    • Long segment (> 5 cm)

    • Proximity to saphenofemoral junction (5 cm)

    • SVT extension/propagation

    • Risk factors for VTE complication (prior VTE, or cancer)

    SVT Treatment: Bottom Line

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    • How to treat?

    Arixtra 2.5 mg QD (prophy dose)

    Prophylactic does LMWH

    Novel Anticoagulant?

    • How long to treat?

    6 weeks

    SVT Treatment: Bottom Line

    •Lower limb SVT ≥ 5 cm in length, we suggest

    prophylactic fondaparinux or LMWH for 45

    days over no anticoagulation (Grade 2B).

    •We suggest fondaparinux 2.5 mg daily over

    prophylactic LMWH (Grade 2C).

    2012 ACCP Guidelines: Superficial Vein Thrombosis

    ACCP Guidelines 2012

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    Thanks

    [email protected]