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![Acute DVT
What’s New in Venous Disease?
RecommendationsRecommendations
“In […patients] with extensive
DVT…operative venous
thrombectomy may be used to
reduce acute symptoms and post-
thrombotic morbidity…”
…GRADE 2B…
2008](https://image.slidesharecdn.com/surgicaltreatmentacutedvt-150305074651-conversion-gate01/85/Surgical-treatment-acute-dvt-45-320.jpg)
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Similar to Surgical treatment acute dvt
Surgical treatment acute dvt
- 1. Surgical Treatment forAcute Deep Vein Thrombosis Anthony J. Comerota, MD, FACS, FACC Director, Jobst Vascular Institute Adjunct Professor of Surgery, University of Michigan
- 2. Surgical Treatment forAcute Deep Vein Thrombosis Venous Thrombectomy in Patients with Iliofemoral DVT
- 3. Long-term: Clinical Statusand QOL •95% Venous Insufficiency •15% Venous Ulceration •Venous claudication developed in almost 50% •Limited ambulation in 15% •Marked hemodynamic impairment •Markedly reduced QOL Delis KT et al Ann Surg 2004;239(1):118 Akesson H Eur J Vasc Surg 1990 Observations at 5 Years Iliofemoral DVT: Anticoagulation Alone
- 4. Intramuscular Pressures (mmHg) IliofemoralDVT Days Intramuscular Pressure (mmHg) Anterior & Deep Posterior Compartments (Mean) Qvarfordt P et al Ann Surg 1983;197:450 • 12 Patients with iliofemoral DVT • Venous thrombectomy • Intramuscular pressures (wick) (Surrogate for venous pressure) Pre-Op (Mean) Post-Op (Mean) 40 30 20 10 0 Reduction of pressure to normalReduction of pressure to normal after thrombus removalafter thrombus removal
- 5. Extensive DVT Rx’edwith anticoagulation alone…Extensive DVT Rx’ed with anticoagulation alone… ……obstructs venous returnobstructs venous return ……causes valve reflux, leading to…causes valve reflux, leading to… ……venous hypertension, which...venous hypertension, which... ……activates theactivates the cellular and metabolic pathwayscellular and metabolic pathways leading to chronic venous diseaseleading to chronic venous disease ……Producing avoidable and costlyProducing avoidable and costly post-thrombotic morbiditypost-thrombotic morbidity Basis for Argument Venous Thrombectomy
- 6. Strategy of thrombusremoval – Eliminates obstruction – Preserves valve function Iliofemoral DVTIliofemoral DVT
- 7. Venous ThrombectomyVenous Thrombectomy -History -- History - • Early initial enthusiasm • Disappointment with results (Lansing and Davis reports) • Surgeons stopped performing procedure • Recent enthusiasm – Better understanding principles – Randomized trials – Improved technique – Improved anticoagulation
- 8. Iliofemoral DVT Strategy ofthrombus removal – Venous thrombectomy – Catheter directed thrombolysis …for iliofemoral DVT ACCP 2008 2008
- 9.
- 10. Long-Term Results Venous Thrombectomy 76%41months6051984-9910 PatencyFollow-upNo.YearsReports Iliac Vein Patency (mean) (mean) 63%45 months1984-99 CompetenceFollow-upNo.YearsReports Femoral-Popliteal Competence (mean)(mean) 8
- 11. Venous ThrombectomyVenous Thrombectomy -Randomized Trial -- Randomized Trial - • Randomized trials: Scandinavian centers • Iliofemoral DVT: N=63 • Randomized: Venous thrombectomy + AVF + Anticoagulation vs. Anticoagulation alone • Endpoints: – Patency – Post-thrombotic morbidity – Complications • Follow-up: 6 months, 5 years, 10 years Plate G et al J Vasc Surg 1984 Eur J Vasc Surg 1990 Eur J Endovas Surg 1997
- 12. • Infrequent -both groups • One recurrent, symptomatic PE (anticoag.) • 3 wound complications • No significant bleeding complication • 13% early reocclusion (thrombect.) Early Complications Plate G et al, J Vasc Surg 1984 Venous ThrombectomyVenous Thrombectomy - Randomized Trial -
- 13. Anticoag.Thrombectomy 6.7 mmHg3.2 mmHg*ExercisePressure (iliac) 15%4%Venous Claudication 37%17%Varicose Veins 78%54%Swelling 7%42%Asymptomatic 26%52%N Valve fct. (fempop) 35%76%Normal Iliac (venogram) *successful thrombectomy Plate G et al, J Vasc Surg 1984 Venous ThrombectomyVenous Thrombectomy - Randomized Trial - Results: 6 Months (N=51) -
- 14. Anticoag.Thrombectomy 60 mmHg43 mmHgAVP 27%11%SevereCVI 18%37%Asymptomatic 37%7%Reflux + obstruction 6%40%N Valve fct. (fempop) 50%78%Patent iliac* Plate G et al, Eur J Vasc Endovasc Surg 1990 *radionuclide phlebography Venous ThrombectomyVenous Thrombectomy - Randomized Trial - Results: 5 Years (N=41) -
- 15. 14% 43% 33% 78% Anticoag.Thrombectomy 63 mmHg55 mmHgAVP 18%8%SevereCVI 24%54%N Clinical Score N Valve fct. Femoral Popliteal 41%84%Patent iliac* Plate G et al, Eur J Vasc Endovasc Surg 1990 *radionuclide phlebography Venous ThrombectomyVenous Thrombectomy - Randomized Trial - Results: 10 Years (N=30) -
- 16.
- 17. Venous ThrombectomyVenous Thrombectomy -PreOp -- PreOp - • Know full extent of thrombosis • Image vena cava • Therapeutic anticoagulation • Arrange for complete imaging (leg through vena cava)
- 18. Venous ThrombectomyVenous Thrombectomy -Operative -- Operative - • Prep entire leg • Expose CFV, SFJ, FV, profunda • Infrainguinal thrombectomy first • Catheter based infrainguinal thrombectomy if massage/compression not successful • Iliocaval thrombectomy with fluoroscopic guidance • Correct iliac vein stenosis • Construct AVF
- 19. Femoral Vein Exposure VenousThrombectomy
- 20. Clot with VenousHypertension Venous Thrombectomy
- 21.
- 22.
- 23. Dual Catheter Technique VenousThrombectomy
- 24. Dual Catheter Technique VenousThrombectomy
- 25. Dual Catheter Technique VenousThrombectomy
- 26. Comerota AJ, GaleS J Vasc Surg 2006;43:185-91. Infrainguinal Balloon Catheter Passage Venous Thrombectomy
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- 32. Correct Iliac VeinStenosis Venous Thrombectomy
- 33. Comerota AJ, GaleS J Vasc Surg 2006;43:185-91. Caval Clot Venous Thrombectomy
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- 36. •Small anastomosis •↑ venousvelocity •No ↑ pressure •Permanent Arteriovenous Fistula Venous Thrombectomy
- 37.
- 38. AV Fistula andDistal Catheter Venous Thrombectomy
- 39. Posterior Tibial VeinInfusion Catheter Venous Thrombectomy
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- 41. Venous ThrombectomyVenous Thrombectomy -PostOp -- PostOp - • Leg infusion of heparin • Long-leg compression • Ambulation • Pre-discharge venogram • Long-term anticoagulation
- 42. Infrainguinal Phlebogram –Pre Discharge Venous Thrombectomy
- 43. 3 Years PostOp Venous Thrombectomy •Hairdresser •No edema •Minimal symptoms •N valve function
- 44. January 2006 “Contemporary” VenousThrombectomy
- 45. Acute DVT What’s Newin Venous Disease? RecommendationsRecommendations “In […patients] with extensive DVT…operative venous thrombectomy may be used to reduce acute symptoms and post- thrombotic morbidity…” …GRADE 2B… 2008
- 46. “After venous thrombectomy,we recommend the same intensity and duration of anticoagulant therapy as those who do not undergo venous thrombectomy” …GRADE 1C… Acute DVT What’s New in Venous Disease? RecommendationsRecommendations 2008
- 47. • More comprehensiveprocedure than initially reported • Follows principles of good vascular surgical technique • Should be offered to all active patients with extensive, symptomatic DVT who cannot be Rx'ed with catheter-based methods • Significantly reduces postthrombotic morbidity Contemporary Venous Thrombectomy SummarySummary
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