Deep Vein ThrombosisDeep Vein Thrombosis
DVT facts, statistics, DVT facts, statistics, and therapeutic optionsand therapeutic options
MICHAEL A ARATA MDMICHAEL A ARATA MD
INTERVENTIONAL RADIOLOGYINTERVENTIONAL RADIOLOGY
MEMORIAL UNIVERSITY MEDICAL CENTERMEMORIAL UNIVERSITY MEDICAL CENTER
SAVANNAH, GEORGIASAVANNAH, GEORGIA
DVT facts, statistics, DVT facts, statistics, and therapeutic optionsand therapeutic options
MICHAEL A ARATA MDMICHAEL A ARATA MD
INTERVENTIONAL RADIOLOGYINTERVENTIONAL RADIOLOGY
MEMORIAL UNIVERSITY MEDICAL CENTERMEMORIAL UNIVERSITY MEDICAL CENTER
SAVANNAH, GEORGIASAVANNAH, GEORGIA
DVT Overview DVT Overview
I.I. PrevalencePrevalence
II.II. Risk FactorsRisk Factors
III.III. Clinical PresentationClinical Presentation
IV.IV. Causes of Limb SwellingCauses of Limb Swelling
V.V. Treatment Strategies Treatment Strategies
VI.VI. Clinical Experience-Case ReviewClinical Experience-Case Review
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The Problem of DVT: StatisticsThe Problem of DVT: Statistics
• DVT occurs in approx. 2 million Americans DVT occurs in approx. 2 million Americans each year. Approx 1/3 develop PEeach year. Approx 1/3 develop PE
• The combined annual incidence for DVT is The combined annual incidence for DVT is approximately 2.5%-5% of the adult populationapproximately 2.5%-5% of the adult population
• DVT recurs in 5-10% of patients the year after DVT recurs in 5-10% of patients the year after anticoagulationanticoagulation
• DVT recurs in 30% of patients eight years after DVT recurs in 30% of patients eight years after anticoagulationanticoagulation
1996 American Heart Association Scientific Statement on DVT1996 American Heart Association Scientific Statement on DVT
Risk Factors for DVTRisk Factors for DVT Age >40 years Age >40 years Cancer Cancer Obesity Obesity Previous or family history of DVT/PE Previous or family history of DVT/PE Recent surgeryRecent surgery Paralysis or immobilityParalysis or immobility Contraceptives/Hormone replacement therapy Contraceptives/Hormone replacement therapy Pregnancy Pregnancy Serious illness: CHF, MI, sepsis Serious illness: CHF, MI, sepsis Coagulation disordersCoagulation disorders
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DVT: Clinical PresentationDVT: Clinical Presentation
Calf pain/tenderness Calf pain/tenderness SwellingSwelling Calor, rubor Calor, rubor Cyanosis or pallorCyanosis or pallor Superficial venous dilatation Superficial venous dilatation Loss of pulses in severe DVTLoss of pulses in severe DVT
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Causes of Limb Swelling: Causes of Limb Swelling: Acute Acute
DVTDVT Arterial ischemiaArterial ischemia Superficial phlebitis Superficial phlebitis Joint effusion Joint effusion Hematoma Hematoma Baker’s cystBaker’s cyst
Arthritis Arthritis Fracture Fracture Cellulitus Cellulitus Dermatitis Dermatitis
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Causes of Limb Swelling: Causes of Limb Swelling: ChronicChronic
Post-phlebitic syndrome Post-phlebitic syndrome Chronic venous insufficiencyChronic venous insufficiency Venous obstruction Venous obstruction
Other Other Heart failure Heart failure RSD RSD Hypoproteinemia- cirrhosisHypoproteinemia- cirrhosis MedicationMedication
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DVT Treatment Strategies: DVT Treatment Strategies: Timing Timing
Sooner is Better!Sooner is Better!
< 3 Weeks Good < 3 Weeks Good < 1 Week Better < 1 Week Better < 3 Days Best< 3 Days Best
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Rationale for Early Treatment Rationale for Early Treatment of DVTof DVT
Early treatment increases probability of Early treatment increases probability of maintaining normal valve functionmaintaining normal valve function– Damaged valves lead to venous insufficiencyDamaged valves lead to venous insufficiency
Decrease recurrent DVT riskDecrease recurrent DVT risk– Restore normal venous flowRestore normal venous flow– Clear thrombogenic substrateClear thrombogenic substrate
Decrease risk for PEDecrease risk for PE– Asymptomatic PE occurs in majority of patients Asymptomatic PE occurs in majority of patients
with DVTwith DVT
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Delayed Complications: Delayed Complications: Post-Phlebitic SyndromePost-Phlebitic Syndrome
Post-Phlebitic Syndrome -- spectrum Post-Phlebitic Syndrome -- spectrum symptoms seen after DVTsymptoms seen after DVT– painpain– edemaedema– pigmentationpigmentation– ulcerulcer
Occurs in 50 to 70% cases proximal DVTOccurs in 50 to 70% cases proximal DVT Prevalence estimated to be as high as 2 Prevalence estimated to be as high as 2
percent in the general populationpercent in the general population
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Delayed Complications: Delayed Complications: Post-Phlebitic SyndromePost-Phlebitic Syndrome
Post-Phlebitic Syndrome - Result of Post-Phlebitic Syndrome - Result of venous hypertensionvenous hypertension
Venous hypertensionVenous hypertension– Venous insufficiency- valve damageVenous insufficiency- valve damage– Venous occlusion- Chronic DVT/ Venous occlusion- Chronic DVT/
ScarringScarring
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DVT Treatment Strategies: DVT Treatment Strategies: Historical Standard Historical Standard
Primary intention-Prevent PEPrimary intention-Prevent PE AnticoagulationAnticoagulation
– Heparin, Warfarin, LMWH Heparin, Warfarin, LMWH
IVC Filter PlacementIVC Filter Placement Catheter-Directed ThrombolyticsCatheter-Directed Thrombolytics
– Select casesSelect cases
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Vascular ThrombosisVascular Thrombosis
Technology has revolutionized fieldTechnology has revolutionized field Lysis/thrombectomy STD of careLysis/thrombectomy STD of care
– MIMI– Acute strokeAcute stroke– Acute limb ischemiaAcute limb ischemia– Massive PEMassive PE– DVT- effort thrombosis/SVC syndromeDVT- effort thrombosis/SVC syndrome
Why Not LE DVT?Why Not LE DVT?
Large clot burdenLarge clot burden– Systemic lysis-not effectiveSystemic lysis-not effective
– Initial revascularization devices Initial revascularization devices inadequateinadequate
Catheter directed lysis more effectiveCatheter directed lysis more effective– Costly-ICU stayCostly-ICU stay
– Poor Patient tolerancePoor Patient tolerance
Treatment Strategies: Treatment Strategies: Investigational Investigational
New treatments to rapidly remove thrombus: New treatments to rapidly remove thrombus:
Mechanical ThrombectomyMechanical Thrombectomy– Physical removal of clot burdenPhysical removal of clot burden– Often used in combination with lyticsOften used in combination with lytics
Power Pulse Spray Power Pulse Spray – Accelerated thrombolysis delivered by AngioJet Accelerated thrombolysis delivered by AngioJet
systemsystem
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Clinical Experience: Mechanical Clinical Experience: Mechanical Thrombectomy for DVTThrombectomy for DVT
Experience as reported by K. Kasirajan, MDExperience as reported by K. Kasirajan, MD– 17 patients with extensive DVT treated with AngioJet17 patients with extensive DVT treated with AngioJet
» 7 of 17 patients had <50% thrombus removal 7 of 17 patients had <50% thrombus removal
» 9 patients thrombolytics used achieving <90% thrombus 9 patients thrombolytics used achieving <90% thrombus removal removal
Conclusion: PMT with adjunctive thrombolytic is less Conclusion: PMT with adjunctive thrombolytic is less invasive, low risk option in patients with extensive DVTinvasive, low risk option in patients with extensive DVT
Kasirajan K, Gray B, Ouriel K, Jvasc Inter Radiol 2001 Feb;12(2):179-85Kasirajan K, Gray B, Ouriel K, Jvasc Inter Radiol 2001 Feb;12(2):179-8516
Clinical Experience: Mechanical Clinical Experience: Mechanical Thrombectomy for DVTThrombectomy for DVT
44 patient retrospective study 44 patient retrospective study – DVT- mechanical thrombectomy using AngioJetDVT- mechanical thrombectomy using AngioJet
Key Findings Key Findings – 54.5% of patients received thrombolysis 54.5% of patients received thrombolysis
administered pre-AngioJet administered pre-AngioJet – 56.8% of patients received adjunctive 56.8% of patients received adjunctive
thrombolysis thrombolysis – No major complications were related to the use of No major complications were related to the use of
AngioJetAngioJet
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: S1617
Clinical Experience: Mechanical Clinical Experience: Mechanical Thrombectomy for DVTThrombectomy 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 TreatmentResponse to AngioJet Treatment
18Kasirajan 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%
Clinical Experience: Mechanical Clinical Experience: Mechanical Thrombectomy for DVTThrombectomy for DVT
ReportedReported Conclusions:Conclusions:
– AngioJet Mechanical thrombectomy is a AngioJet Mechanical thrombectomy is a safe adjunct or alternative to safe adjunct or alternative to thrombolysis for DVTthrombolysis for DVT
– Debulking with AngioJet may result in Debulking with AngioJet may result in elimination or reduction of lytic doseelimination or reduction of lytic dose
– A sufficiently powered study is A sufficiently powered study is warranted to assess effectswarranted to assess effects
19Kasirajan 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
AngioJetAngioJet®® Xpeedior Xpeedior®® 120 120
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Clinical Experience:Clinical Experience:Power Pulse SprayPower Pulse Spray
ReportedReported Conclusions:Conclusions:
– 25 lower extremities25 lower extremities
– Thrombolytic success 100%Thrombolytic success 100%
–Same day treatment 52%Same day treatment 52%–Procedure complete after Power Pulse Procedure complete after Power Pulse
Spray 80%Spray 80%
21Arata M, Pappas J, Personal experience
Deep Vein ThrombosisDeep Vein Thrombosis
Mechanical Thrombectomy Mechanical Thrombectomy Case ExamplesCase Examples
Mechanical Thrombectomy Mechanical Thrombectomy Case ExamplesCase Examples
This program was developed for educational purposes only. The AngioJet System is not indicated for use in the venous system.
Initial VenogramInitial Venogram
IVC Filter
Initial popliteal venogram demonstrating DVT
Initial femoral venogram demonstrating DVT
Initial iliocaval venogram demonstrating DVT
Sequential Venograms Following Sequential Venograms Following AngioJet ThrombectomyAngioJet Thrombectomy
Sequential venograms performed following thrombectomy passes
Completion VenogramCompletion VenogramCompletion LE venogram Completion pelvic venogram Completion cavogram
Deep Vein ThrombosisDeep Vein Thrombosis
Power Pulse Spray Power Pulse Spray Case ExamplesCase Examples
Power Pulse Spray Power Pulse Spray Case ExamplesCase Examples
This program was developed for educational purposes only. The AngioJet System is not indicated for use in the venous system.
Initial VenogramInitial Venogram
Initial thrombus
Venogram demonstrating focal
femoral DVT
F/U Overnight LysisF/U Overnight Lysis
Venogram following overnight lysis demonstrating marked DVT progression
Venogram following overnight lysis demonstrating caudal progression of DVT
Thrombectomy VideoThrombectomy Video
Video of thrombectomy and PPS
Power Pulse SprayPower Pulse SprayLE venogram following PPS
demonstrating complete lysis Pelvic venogram following iliac stenting
Initial VenogramInitial VenogramInitial popliteal venogram
demonstrating DVT
Initial femoral venogram demonstrating DVT
Initial iliocaval venogram demonstrating DVT
Following Power Pulse SprayFollowing Power Pulse SprayCompletion popliteal
venogram
Completion femoral venogram
Completion pelvic venogram
SummarySummary
DVTDVT– Major healthcare problemMajor healthcare problem
– Management focus- decades oldManagement focus- decades old»Prevent propagationPrevent propagation
AnticoagulationAnticoagulation IVC filterIVC filter
– Revolution in vascular technologyRevolution in vascular technology
SummarySummary
Power Pulse SprayPower Pulse Spray–Same day treatment-cost effectiveSame day treatment-cost effective
–Preliminary results superior to lysisPreliminary results superior to lysis
–Potentially saferPotentially safer
–Substantially more patient friendlySubstantially more patient friendly