AGGRESSIVE THERAPIES
Surgeon General's Workshop on Deep Vein Thrombosis
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Thomas W. Wakefield MD
S. Martin Lindenauer Professor
Section of Vascular Surgery
University of Michigan
SLIDE 2: Goals of Therapy for Venous Thromboembolism (VTE)
- Prevent Extension or Recurrence of Deep Venous Thrombosis (DVT)
- Prevent Pulmonary Embolism (PE)
- Minimize Early and Late Squeal of the Thrombosis
Anticoagulants Accomplish #1, #2 Anticoagulants in General do not Accomplish #3
Organize, Fibrose, Recanalize, Embolize; Stimulate
Inflammatory Response in the Vein Wall and Valve
Approximately Half will Completely Recanalize within 6 to 9 months
Symptomatic Recurrent Thromboembolic Events in 5% to 15%
Occult Events even more Prominent (up to 50%)
Thrombus Propagation in 26% to 38% by Serial Ultrasound scans
SLIDE 4: Post-Thrombotic Syndrome (CVI)
Varicose Veins to Severe Pain, Swelling, and Ulceration
- 23% after 2 years
- 28% after 5 years
- 29% after 8 years
Especially with Ipsilateral Recurrent DVT
Thrombolytic Medication
Mechanical Devices
Pharmacomechanical Approaches
Operative Thrombectomy
“Thrombolytic therapy remains controversial particularly due to the risk of bleeding and is not indicated for the routine treatment of VTE”
Thrombectomy (n31) vs Anticoagulation (n32)
Clinical Success - 6 months
40% vs 7% Asymptomatic
76% vs 35% Iliofemoral Patency
52% vs 26% Femoropopliteal Patency
Thrombectomy (n13) vs Anticoagulation (n17)
Follow-up - 10 years
83% vs 41% Patency
78% vs 43% No Popliteal Reflux
SLIDE 8: Thrombolysis with Catheter-Directed Urokinase
Table. Dissolving the DVT with thrombolytic drugs has been evaluated with a number of quality of life scales and has been associated with improvements in many aspects of quality of life, leading to a decrease in long-term symptoms of pain and swelling. Three large studies have demonstrated that excellent opening up the venous system can be achieved with administration of dissolving agents directly into the thrombus.
SLIDE 9: Quality of Life Measures
Mean scale scores comparing patients who had either partial or complete lysis with lytic therapy vs. patients who had heparin treatment
Dissolving the DVT with thrombolytic drugs has been evaluated with a number of quality of life scales and has been associated with improvements in many aspects of quality of life, leading to a decrease in long-term symptoms of pain and swelling. Three large studies have demonstrated that excellent opening up the venous system can be achieved with administration of dissolving agents directly into the thrombus. A recent small randomized trial of dissolving medicine versus blood thinning medicine alone has confirmed this observation
Need Level 1 Evidence Comparing Standard
Anticoagulation to Thrombus Dissolution using Thrombolysis and/or Venous Thrombectomy
We know all DVTs are Not Alike!!!
Mechanical Devices
Catheters (Venturi Effect)
Mechanical Catheters with Balloons
Ultrasound
Early Removal of Thrombus Conveys Significant Benefits
The Earlier the Removal, the Better the Outcome
However, the Therapy is Complicated with Bleeding risk and the Value of such Therapy is Not Defined
National Organizations have Identified the Need for Studies
Society for Interventional Radiology American Venous Forum
Thrombolytic Therapy/Embolectomy for Cardiogenic Shock
? Right Ventricular Dysfunction without Hemodynamic Instability
Thrombolytics + Anticoagulants vs. Anticoagulants for Submassive PE
Thrombolytics Reduced Need to Escalate Therapy
SLIDE 14: Pulmonary Embolectomy
Useful in Situations of Massive PE with Thrombolysis Failure (approx 8%)
Lowers Mortality Rate (p = 0.07)
Lowers Recurrent PE rate (p<.05)
Lowers Fatal Bleeding Episodes
Indications
Complication of Anticoagulation
Contraindication to Anticoagulation
Failure of Anticoagulation
VTE Prophylaxis
Protection from PE >95% when using wire-based filters over 20 yrs
Filters Placed Infrarenal, Suprarenal, even in SVC
Retrievable Filters (3 Types) Now Becoming Predominant
If Left to become Permanent, Long-term Fate Unknown
Percutaneous Technique
Fluoroscopy, Ultrasound (External, IVUS)
SLIDE 16: Ambulation/Stockings
Rate and Severity of Postthrombotic Syndrome after Proximal DVT can be decreased by 50% by the use of Compression Stockings
Walking with Good Compression does not Increase the Risk of PE, while significantly Decreasing the Incidence and Severity of the Postthrombotic Syndrome
Thank you
