Deep%20Vein%20Thrombosis

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Deep Vein Thrombosis

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

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DVT Overview

1. Prevalence
2. Risk Factors
3. Clinical Presentation
4. Causes of Limb Swelling
5. Treatment Strategies
6. Clinical Experience-Case Review

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The Problem of DVT Statistics

• DVT 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 population
• DVT recurs in 5-10 of patients the year after
  anticoagulation
• DVT 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 gt40 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

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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

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Causes of Limb Swelling Acute

• Arthritis
• Fracture
• Cellulitus
• Dermatitis

• DVT
• Arterial ischemia
• Superficial phlebitis
• Joint effusion
• Hematoma
• Bakers cyst

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Causes of Limb Swelling Chronic

• Post-phlebitic syndrome
• Chronic venous insufficiency
• Venous obstruction
• Other
• Heart failure
• RSD
• Hypoproteinemia- cirrhosis
• Medication

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DVT Treatment Strategies Timing

• Sooner is Better!
• lt 3 Weeks Good
• lt 1 Week Better
• lt 3 Days Best

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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

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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

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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

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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

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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

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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 lt50 thrombus removal
• 9 patients thrombolytics used achieving lt90
  thrombus removal
• Conclusion PMT with adjunctive thrombolytic is
  less invasive, low risk option in patients with
  extensive DVT

Kasirajan K, Gray B, Ouriel K, Jvasc Inter
Radiol 2001 Feb12(2)179-85
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Clinical Experience Mechanical Thrombectomy for
DVT

• 44 patient retrospective study
• DVT- mechanical thrombectomy using AngioJet
• Key Findings
• 54.5 of patients received thrombolysis
  administered pre-AngioJet
• 56.8 of patients received adjunctive
  thrombolysis
• No major complications were related to the use of
  AngioJet

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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Clinical Experience Mechanical Thrombectomy for
DVT

• Response to AngioJet Treatment

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50
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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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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

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
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Clinical ExperiencePower Pulse Spray

• Reported Conclusions
• 25 lower extremities
• Thrombolytic success 100
• Same day treatment 52
• Procedure complete after Power Pulse Spray 80

Arata M, Pappas J, Personal experience
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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
Initial popliteal venogram demonstrating DVT
Initial femoral venogram demonstrating DVT
Initial iliocaval venogram demonstrating DVT
IVC Filter
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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 cavogram
Completion pelvic venogram
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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
Venogram demonstrating focal femoral DVT
Initial thrombus
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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 pelvic venogram
Completion popliteal venogram
Completion femoral 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