Joint Hospital Surgical Grand Joint Hospital Surgical Grand RoundRound

Yolanda HY ChanKwong Wah Hospital

Management ofManagement ofAcute Iliofemoral DVT:Acute Iliofemoral DVT:

Why not Anticoagulation alone?

Deep Venous Thrombosis

• Annual incidence– 1.0 to 1.6 per 1,000 persons per year

• Iliofemoral DVT– Complete / Partial thrombosis of iliac

vein +/- common femoral vein– 10 % of all DVT

The post-thrombotic syndrome: The forgotten morbidity of deep venous thrombosis

Kahn SRJ Thromb Thrombolysis 21(1), 41-48,2006

Iliofemoral DVT

• Extrinsic compression of iliac vein (80 %)– May-Thurner syndrome– Tumour– Irradiation– Retroperioneal fibrosis

• Extension of distal DVT• Idiopathic

Management of Acute DVT

Compression therapyCompression therapy + Anticoagulation+ Anticoagulation

Management of Acute DVT

Post-thrombotic Post-thrombotic syndrome (PTS)syndrome (PTS)

PhlegmasiaPhlegmasia

Post-Thrombotic Syndrome

Relationship between deep venous thrombosis and the post-thrombotic syndrome

Kahn SRArch Intern Med.2004;164:17-26

Post-Thrombotic Syndrome

• Despite adequate conventional therapy– Only 20 % of iliac vein completely

recanalized– Every fourth patient with proximal DVT

developed PTSAnn Intern Med 1996;125:1-7

Post-Thrombotic Syndrome

• 10 or more years after iliofemoral DVT, almost 90 % of patients were unable to work because of leg symptoms

J Surg Res 1977;22:483-488

Journal of Surgical Research

The Socioeconomic Effects of an Iliofemoral Venous ThrombosisO'Donnell TF Jr, Browse NL, Burnand KG, Thomas ML

Rationale for Thrombus Removal

Early relief of thrombus

– Eliminates luminal obstruction– Increases chance of preserving normal

valve function

↓ Post-thrombotic morbidity

Thrombus Removal in Acute DVT

Early removal ofthrombus

Thrombolysis Thrombectomy

Systemic SurgicalIntrathrombus

(Catheter-directed)

Catheter-directed Thrombolysis

Catheter-directed Thrombolysis

Accelerates thrombolysis

Lessens overall dose of lytic agent

Reduces duration of infusion

(CDT)

Catheter-directed Thrombolysis

Group 1(33)

Heparin (5 to 7 days)Warfarin (6 months)

Group 2(18)

Catheter-directed thrombolysis

+/- Angioplasty & Stenting

Extensive iliofemoral DVTAcute onset of symptoms within 14

days

Ann Surg 2001;233:752-760

Ann Surg 2001;233:752-760

Pharmacomechanical Thrombolysis

Power-Pulse Angiojet

Pharmacomechanical Thrombolysis

Trellis-8 device

Pharmacomechanical Thrombolysis

Conclusion

• Patients with iliofemoral DVT are at high risk of post-thrombotic syndrome

• Early thrombus removal minimizes PTS

• Catheter-directed thrombolysis can reduce acute symptoms and prevent PTS

• Pharmacomechanical thrombolysis has the benefit of shortening treatment time

Management of Acute DVT

Gloviczki P, Wakefield TW, Comerota A, et alHandbook of venous disorders: Guidelines of the American venous

forum

Thank YouThank You

Risks of CDT

• Major bleeding 8 %– Intracranial bleeding 0.02 %

• Pulmonary embolism– Symptomatic 0.9 %– Fatal 0.1 %

Society of interventional radiology position statement: Treatment of acute iliofemoral deep vein thrombosis with use of adjunctive catheter-directed intrathrombus

thrombolysisVedantham S, Millward SF, Cardella JF, et al

J Vasc Interv Radiol 2006;17:613-616

Indications for Intervention

Post-thrombotic syndrome

- Ambulatory- Reasonable life

expectancy- Proximal

thrombosis

Phlegmasia

- Severe symptoms

- Limb-threatening

Indications for thrombolysis in deep venous thrombosisGogalniceanu P, Johnston CJ, Khalid U, et al

Eur J Vasc Endovasc Surg 2009 Aug;38(2):192/198

Post-Thrombotic Syndrome

Relationship between deep venous thrombosis and the post-thrombotic syndrome

Kahn SRArch Intern Med.2004;164:17-26

Predictive factors of PTS

• Ipsilateral recurrence of DVT

• Iliofemoral location• Old age• Obesity• Failure of prompt recovery from acute

symptoms• Insufficient oral anticoagulant therapy

Post-thrombotic syndrome: Prevalence, prognostication and need for progress

Prandoni P, Kahn SRBr J Haematol 2009;145(3):286-295

Contraindications to CDT

• Bleeding disorders• Active internal bleeding• Recent GI bleeding or CVA• Recent major surgery (< 10 days)• Severe hypertension• Metastatic malignancy with CNS

involvementIliofemoral deep vein thrombosis: Conventional therapy versus lysis and percutaneous transluminal angioplasty

and stentingAbuRahma AF, Perkins SE, Wulu JT, et al

Ann Surg 2001;233:752-760

Catheter-directed Thrombolysis

Management of Acute DVT

AnticoagulationAnticoagulation

• Lessen propagation of thrombus

• Prevent pulmonary embolism

Thrombus removalThrombus removal

• Provide early symptom relief

• Minimize PTS

Post-Thrombotic Syndrome

• The average cost of treating PTS was US $ 4,700

Ann Intern Med 1997;126(6):454-457

Catheter-directed Thrombolysis

Catheter-directed Thrombolysis