Which DVT Patients are Suitable for Revascularization

Stephen Black

Consultant Vascular Surgeon

Clinical Lead for Venous and Lymphoedema Surgery

Guy’s and St Thomas’ Hospital London

Disclosure

Speaker name:

Stephen Black

I have the following potential conflicts of interest to report:

Consulting : Medtronic, Cook, Optimed, Volcano, Veniti

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

I do not have any potential conflict of interest

Acute DVT

PTS

Catheter Directed Thrombolysis in Iliofemoral DVT

Technique Semba/Dake

Feasibility- Mewissen n=473 Baekgaard n=103 vein patency >80% @4y Engelberger n = 87 95% free from PTS @ 1yr

Comparison (CDT + AC) v (AC alone) Comerota- less PTS -68 pts Prospective Abu Rahma- less symptoms Elsharawy-better valvular fn; less reflux CAVENT IF patency 64% in CDT v 36% in AC

All trials open to criticism

Courtesy G O’Sullivan

Which Patients are not?

Why Not?

The main consideration is the risk of bleeding from treatment

Clash of treatment objectives

VTE Recurrence

VS

Restoration of function

- Post Thrombotic

Limbs - Location

Rest Hyperemic

Iliofemoral 6.3 mmHg 8.9 mmHg

Femoral-popliteal 4.4 mmHg 7.3 mmHg

Popliteal 1.5 mmHg 3.1 mmHg

Controls 1.0 mmHg 2.7 mmHg

Hemodynamics of Venous Obstruction

Arm - Foot Pressure Gradient

ILIOFEMORAL SHOULD BE OUR FOCUS!

Labropolos J Vasc Surg 1997

Level defined by Haematology - what is

proximal?

One third of all DVTs Iliofemoral

Up to 60% of these patients will get PTS

1 in 1000 people in UK – 1/3 Iliofemoral

US – 330,000

Who gets it?

May-Thurner/Cockett Syndrome

Courtesy N Baekgaard

Stent

Mechanical Thrombectomy

Trellis

Angiojet

EKOS

Angiovac

Clearlumen

i

ii

ii i

i

ii

ii

i

ii

i

ii

i

ii

i

ii i

i

i

i

i

i

ii

i

ii

ii

ii

ii

ii

Da

y 1

D

ay 4

D

ay 7

D

ay 1

0

Day 1

4

Day 2

1

Da

y 2

8

1 4 7 10 14 21 280

10

20

30

40

50

60

70

80

90

100

Day

% R

ed C

ell

Sta

in

1 4 7 10 14 21 280

10

20

30

40

50

60

70

80

90

100

Day

% F

ibrin S

tain

1 4 7 10 14 21 280

10

20

30

40

50

60

70

Day

% C

olla

gen S

tain

A B

C

D

***

***

***

***

*** ***

***

***

***

***

McGuiness et al., Thromb & Haem (2001)

Saha et al., Circulation (2013)

T1: 710 (ms)

%MTR=41.0

%MTR/cm3=30.0

ADC: 0.55x10-3 mm2/s

Pre-intervention thrombus MRI characterisation

T1 [x10-3 (s)]

0

1.0

2

0.5

1.5

No signal

Left CFV

D E F

T1: 428 (ms)

Left EIV

No signal

T1 map MR Venogram

A B C

%MTR: 50.0

%MTR/cm3=57.0

ADC: 0.13x10-3 mm2/s

MR Venogram

Thrombus

Example 1

LYSABLE

LYSABLE

Prediction

Pre-intervention thrombus MRI characterization

T1 [x10-3 (s)]

0

1.0

2

0.5

1.5

T1: 557 (ms)

T1: 782 (s)

% MTR: 26.0

%MTR/cm3: 203.0

ADC:1.7x10-3 mm2/s

% MTR: 44.0

%MTR/cm3: 38.0

ADC: 1.3x10-3 mm2/s

Left CFV

Signal

No signal

D E F

A

CIV

C B

T1 map MR Venogram MR Venogram

Signal T1: 1015 (ms)

THR

Example 2

UNLYSABLE

NEEDS STENT

LYSABLE

Prediction

%MTR: 22

MTR (%/cm3)=196

%MTR: 23

MTR (%/cm3)=143.6

Pre-intervention thrombus MRI characterization

2.0

T1 [x10-3 (s)]

0

1.0

0.5

1.5

Left EIV

Left CFV

T1: 852 (ms) Signal

T1: 823 (ms) Signal

ADC: 1.6x10-3 mm2/s

ADC: 2.8x10-3 mm2/s

Example 3

UNLYSABLE

NEEDS STENT

UNLYSABLE

Prediction

T1 map MR Venogram MR Venogram

Post operative0

5

10

15

Vill

alta S

core

Acute Venous Disease - GSTT

0 1 2 3 4 5 6 7 8 9 10 11 120

20

40

60

80

100

Primary Patency

Primary Assisted Patency

Secondary Patency

Time follow-up

Patients

(%

)

78%

92% 94%

Pre-op VDS Post-op VDS0

1

2

3

VD

S S

core

P<0.001

Belen Quintana

Prakash Saha

Nathalie Dubant

Vanessa Harvey

Theatre Team

Outpatient Team

Inpatient Team

Our Team

Irfan Ahmad

Tarun Saburwhal

Narayn Karunanithy

Athanasios Diamantopoulos

Kostas Katsanos

Panos Gkoutzios

Leo Motzon

Ilyas Shazad

Ander Cohen

Karen Breen

Vickie Macdonald

Beverley Hunt

The principle has to be early restoration of normal function

Methods of determining clot age will help

Long-term outcomes remain unknown

Quality of life improvement is key

We don’t understand the incidence or cost of PTS

You need a good team

Conclusions

ACKNOWLEDGMENTS

Academic Department of Vascular Surgery,

St. Thomas’ Hospital, KCL, London

Mr Prakash Saha Prof Alberto Smith

Mr Bijan Modarai Mr Matt Waltham

Mr Steven Grover

Mr Ashish Patel

Mr Adnan Bajwa

Mr Oliver Lyons

Department of Haematology, GSTT, London

Dr Ander Cohen

Dr Karen Breen

Dr Vickie MacDonald

Prof Beverley Hunt

Division of Imaging Sciences,

KCL, London

Dr Marcelo Andia

Dr Alkystis Phinikaridou

Dr Ulrike Blume

Dr Andrea Wiethoff

Prof Tobias Schaeffter

Prof Rene Botnar