Surgeon General's Workshop on Deep Vein ThrombosisAGGRESSIVE THERAPIES1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 Thomas W. Wakefield MD SLIDE 2: Goals of Therapy for Venous Thromboembolism (VTE)
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
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
SLIDE 14: Pulmonary Embolectomy Useful in Situations of Massive PE with Thrombolysis Failure (approx 8%) Lowers Mortality Rate (p = 0.07) 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 |
