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