Ambulatory Venous Hypertension Components Obstruction Valve incompetence Obstruction Valve...
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Ambulatory Venous HypertensionComponents
•Obstruction
•Valve incompetence
•Obstruction and valve incompetence…Highest venous pressure…Most severe morbidity
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Iliofemoral DVT
Contraindication to Lysis
Yes No
Surgical Thrombectomy + AVF
Anticoagulation
Catheter-directedThrombolysis
Success
Yes
No
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• 63 patients: iliofemoral DVT• Thrombectomy + AVF vs. Anticoagulation• Follow-up: 6 mos, 5 yrs, 10 yrs
• Patency– Valve function– Venous hemodynamics– Clinical evaluation
Plate G et al, J Vasc Surg 1984
Venous Thrombectomy vs. Anticoagulation
Randomized TrialRandomized Trial
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Anticoag.Thrombectomy
60 mmHg43 mmHgAVP
27%11%Severe CVI
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
Venous Thrombectomy vs. Anticoagulation
Results: 5 years (n=41)
*radionuclide phlebography
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Acute DVT
“…There is no evidence that supports the use of thrombolytic agents for the initial treatment of DVT….”
Thrombolytic Therapy: ACCP 2004Thrombolytic Therapy: ACCP 2004
Buller H, et alChest 2004;126:401S
Recommend against the routine use of catheter-directed thrombolysis (Grade 1C)
…Treatment..[with lytic Rx] .. Be confined to patients requiring limb salvage. (Grade 2C)
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Catheter-Directed Lysis Iliofemoral DVT
• Significantly better QOL with lysisPhysical function StigmaHealth distress Post thromb Sx
• Successful lysis correlated w/QOL
• Lytic failures and heparin Rx similar
Improvement in Quality of LifeImprovement in Quality of Life
Comerota AJ et alComerota AJ et alJ Vasc SurgJ Vasc Surg 2000 2000
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• 35 consecutive patients• Iliofemoral DVT• Randomized
• Follow-up 1week/6mos–Clot lysis–Venous reflux
Cath-dir SK (pulse spray)vs.
Anticoagulation alone
Elsharawy M, et alEur J Vas Surg. 2002; 24:209
Catheter-Directed Lysis Iliofemoral DVT
Improvement in Quality of LifeImprovement in Quality of Life
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Elsharawy M, et alEur J Vas Surg. 2002; 24:209
0.4 7d 6dLOS
0.04 11%41%*Reflux
<0.001 72%12%Patency
P-valve Lysis (n=18)
Anticoag(n=17)
*Underestimate 20 occlusion
Catheter-Directed Lysis Iliofemoral DVT
Randomized Trial: Outcome at 6 monthsRandomized Trial: Outcome at 6 months
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Postthrombotic SyndromeElastic Stockings (30-40 mmHg)
Lancet 1997;349:759
<.0151%24%49%
<.0155%21%47%
P-valueRRRStockingControl
Postthrombotic Syndrome
Brandjes DP
Prandoni P
(n=194)
(n=170)Patho Hemst Thromb 2002;32(suppl 2):72
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A Strategy of Thrombus Removal for Venous Thromboembolism:
We Owe it to Our Patients