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Endovascular Management of Acute and Chronic Deep Vein

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Endovascular Management of Acute and Chronic Deep Vein Powered By Docstoc
					European Venous Congress 2011
Maastricht
Thursday 3rd March


“Thrombus Removal and Oncology
Patients”

Gerry O’Sullivan FRCR FRCPI
Galway, Ireland
gerard.osullivan2@hse.ie
Pre Trellis phlegmasia right leg              24 hours post TrellisTM




                                                                Puncture site




                 Bladder Ca, iliac vein DVT
Oncology patients have a higher
incidence of Venous Thrombo-
embolism (VTE)

• Virchows triad
  – Sticky blood (pro coagulant factors released
    from tumours, raised platelet count)
  – Slow flow (immobility or extrinsic compression
    from tumour or node)
  – Damaged wall (tumour invading vein)
How do patients present?
• Oncology patients usually present with a
  swollen limb
• Sadly, most physicians think this is due to
  a low albumin or lymphoedema
• In my experience gross third spacing gives
  rise to oedema everywhere and a solitary
  swollen limb is usually due to a venous
  problem
Swollen limb: How to investigate?

• Ultrasound
• Everybody gets one
• High rate of false negative if above the
  groin
• I prefer CT (and to a lesser extent MR)
All patients get a CTPA and CTV
•   Tumours/Nodes
•   IVC anomalies
•   Size of main veins
•   Acute v chronic
•   Iliac vein compression syndrome
•   Need for IVC filter- MY indications:
    – IVC thrombus
    – PE on CTPA if large volume - get an echo!
    – Dilated right ventricle    - get an echo!
Interventional Treatment Options- VTE

• Systemic thrombolysis- high rate of bleeding problems
    – In 2009 really only indicated for massive PE
         • Ref LOHAN, Emergency Radiology 2007

• Catheter-directed thrombolysis (CDT)- it localises in the area of the thrombus,
   but systemic absorption occurs to a considerable extent
         • Ref Semba/Dake JVIR 1994

• Ultrasound assisted thrombolysis- EKOSTM
    – US waves fragment the thrombus and allow lysis to penetrate deeper- shortens
      duration of thrombolysis by approximately 1 day

• Mechanical Thrombectomy
    – Egg beater-rotating nitinol cage- TrerotolaTM
    – Bernoulli effect- PossisTM Angiojet

• Isolated Pharmaco-Mechanical Thrombolysis (IPMT)
    – TRELLISTM
    – Combination of isolated catheter directed thrombolysis and mechanical
      dispersion
              – JVIR 2007 18:715-724 O’Sullivan
Catheter directed thrombolysis
•   Semba/Dake- Stanford University 1994
•   Catheter directed thrombolysis
•   Landmark paper
•   Great results
    – But…
       • Time consuming-averages 2-3 DAYS
       • Risk of bleeding
       • Some contra-indications
       • Needs ITU bed
                                     JVIR 1994;191:487-494
“Accelerated” catheter directed
thrombolysis
• 1. EKOSTM- US fragmentation of thrombus
    enables more thrombus to become exposed to
    thrombolysis- shortens thrombolysis possibly to
    1- 2 days instead of 3 days
•   2. In conjunction with TRELLISTM
    – Use Trellis for above knee veins
    – Use CDT for below knee veins
    – Enables treatment to be shortened to less than 24h
“Mechanical” methods


• TrellisTM-Mixture of thrombolytic agent
  (tPA), blending device, suction device,
  balloons at either end-hence ISOLATED
  THROMBOLYSIS
• PossisTM-Bernoulli effect
• EKOSTM(shortens duration of t’lysis but not
  a single session Rx- still need HDU bed)
    TRELLIS-8 Infusion          System TM:

    Isolated Thrombolysis
• Targeted delivery of
    thrombolytic agents
•   Treatment area isolated
    within occluding balloons
•   Mechanical dispersion of
    infused thrombolytic
    agents
•   Aspiration following
    treatment
Contra-
indications
for CDT
may NOT
apply for
IPMT
              JVIR 2007, 18:715-724
Factors to consider pre Treatment

• Is this thrombus or compression?
    – CRITICAL- much easier if not thrombosed
•   Any contra-indications to Rx?
•   Can they move limb?
•   Have they any hope of EVER moving limb?
•   Life expectancy if their limb was working again?
•   Will they be able to lie prone for 2 hours?
•   Will they be able to lie still?
•   Which site of access?
If thrombosed:4 basic scenarios
• Ilio-femoral DVT with clear IVC and patent popliteal vein-
  this is the easiest and quickest- Trellis only
• IVC thrombus and ilio-femoral (but not popliteal vein)
  DVT- will need an IVC filter but possible to treat in a
  single session with Trellis
• All calf veins acutely thrombosed, DVT up to iliacs, IVC
  clear- Rx CDT 48-72h or Trellis popliteal vein upwards
  and CDT for 24h afterwards
• IVC, ilio-femoral, popliteal and below knee DVT- this will
  need an IVC filter, Trellis and 24-48 h Catheter Directed
  Thrombolysis
Catheter Directed Thrombolysis in
Cancer patients?

• CDT works, but it takes time, and it is not
    without risk
•   Overall not a great option in cancer patients
•   In my current practice I only use CDT for
    – extensive ilio-femoral-popliteal DVT involving calf
     veins in combination with Trellis (to deal with the
     above knee thrombus)
Acute DVT in Ovarian Ca

• 60 year old lady
• Ovarian CA, but systemically well
• Proven DVT on CDUS 6 weeks previously
• Failed 6 weeks worth of conventional
  treatment (LMWH, then Coumadin)
• Phelgmasia Cerulea Dolens
Swollen, blue
useless
left leg
LEFT LEG PRONE VIEWS- ASCENDING VENOGRAPHY




    SFV            CFV                Iliac veins
LEFT LEG PRONE VIEWS




                       Iliac venogram
                       Catheter tip in L EIV
                       No forward (cephalad) flow



                       Glidewire advanced through into
                       IVC
                       IVC confirmed no clot
                       180 Amplatz wire
                       10F sheath into popliteal V
                    TrellisTM:
                    80cm shaft length
Isolating segment   30cm treatment length
with balloons       10mg tPa making up 12cc N saline
                    1 run of about 8 mins
                    Total time from skin prep
                    so far of ~ 45 mins
Slurry aspiration- removes tPa and minor thrombus
CFV, EIV, CIV at 1 hour 10 mins. Post TrellisTM
Post PTA and then WallstentsTM 16mm#90mm; 14mm#90mm




TOTAL TIME
FROM POPLITEAL VEIN PUNCTURE
TO FINISH: 1 hour, 47 minutes
Successful result
•   SINGLE SESSION!!!
•   tPa largely confined to treated segment
•   No need indwelling sheaths etc etc
•   No need of ICU bed
•   Post Trellis
    – Pneumatic compression boots overnight
    – In oncology patients, life long Low Molecular Weight
      Heparin
    – US day 1 mandatory
             Pre and 3 months later




Patient lived >3 years post this episode!
So….
•   TrellisTM works
•   It is quick
•   It is efficient
•   It is very safe
•   All disposable, no ancillary machinery
•   Does it clear as well as 24 or 48h traditional
    lysis?
    – With addition of a suction thrombectomy to finish-
      probably yes…………..
Detachable hub sheath- a fantastic help in aspiration!
Options:
10F sheath from IVC filter kit
Terumo “Destination” 7F 90 cm- goes thru a 10F sheath
Pronto extraction catheter
NOW THAT’S WHAT I’M TALKIN ABOUT!!!!!!!
Case 2


 • 65 year old female
 • Recently diagnosed Colon Cancer
 • No prior Rx
 • Massively swollen dusky left leg
Prone position
Popliteal venous puncture
Patent popliteal and femoral vein in the thigh
Absolute obstruction to flow of contrast above this
Wire into IVC
Confirm in IVC by injection ontrast
Trellis inserted, upper balloon in very distal IVC
6 mins TrellisTM, 10mg tPA- complete thrombus clearance
-underlying stenosis remains
Stent deployment- 2 x 14mm diameter EV3 self expanding stents
Upper stent still had residual stenosis post PTA so a second stent inside it
Skin to skin
48 minutes

Perfect in line flow

Huge symptomatic relief
by morning
         Case 3



•   35 year old lady
•   Metastatic endometrial sarcoma
•   Severely swollen L leg
•   CDUS- extensive acute DVT
•   This was early in my experience and I did not
    get a CTV/CTPA
TIME 1037h
Prone view left leg
Severe extrinsic compression
With acute thrombus below this level
Note ureteric obstruction which could
not be stented on this side
Post first pass Trellis
16mm Wall stent
Tight extrinsic compression from tumour
12mm balloon angioplasty
Post 2nd pass TrellisTM
and insertion 16 and
14mm WallstentsTM-
Total time < 90 minutes
Perfect in line flow from
back of knee to IVC
Pre Rx   At 145 days
       Case 4
• Lung cancer
• Previously treated with radiotherapy for
  SVCO
• Presented with facial oedema, hoarseness,
  bloodshot eyes
• CT scan showed mediastinal
  nodes/tumour compressing SVC
Ultrasound

• Both IJVs
• Both EJVs
• Both SCVs
  – ALL THROMBOSED

  – How else can we get into the neck veins???
Less than 24 hours later
2010
January issue
Pre Trellis swollen left leg   Post Trellis- equal sized legs
Malignant venous stenting
Galway experience 2005-2010
• The study was carried out in a tertiary care university
    teaching hospital with a large cancer population.
•   56 cases of stenting for malignant lower limb venous
    obstruction performed at our institution over a 5 year
    period were reviewed.
•   Using computed tomography, all patients with histology
    proven malignancy and lower extremity swelling, unilateral
    (n=35) and bilateral (n=21), were evaluated.
•   Follow-up was by colour Doppler ultrasound where feasible
    to confirm patency and thereafter follow-up was clinical.
•   Inclusion criteria were unresolved leg oedema, malignancy
    and life expectancy greater than 2 weeks.
•   Patients with a life expectancy less than 2 weeks were
    excluded.
Simplified scoring system for
assessment of leg swelling in cancer
patients
Inability to weight bear,
Inability to walk
Inability to put on shoes (not sandals)
                           3 points each.

Blisters
Skin discoloration 5 points each.

Total score is 19.
For example:

Discoloured --no
Blisters --   no
Can’t weight bear- yes 3
Can’t walk- yes- 3
Can’t wear shoes-yes 3
Results:
• Mean score pre-treatment was 13.33 , mean score at 3 and
  7 days post treatment was 6.55 and 3.46 respectively.
• There is a significant reduction in patient symptomatic
  score between pre-procedure scoring and 3 days post-
  procedure (See graph).
• The vast majority of patients experienced profound and
  prolonged relief from their symptoms.
• The mean survival length post- procedure was 147.44 days.
   –   30 patients received stenting only,
   –   21 received stenting & Trellis®,
   –   3 received stenting & Trellis® & CDT,
   –   2 received stenting & CDT.
   –   5 patients required one additional stenting procedure.
Isolated Pharmaco-Mechanical
Thrombolysis
Galway TrellisTM 2005-11
• 88 patients, 101 Trellis episodes (both limbs or repeat
    Rx)
•   Venous 86
•   Arterial 2
•   M:F equal
•   Age 4-71
•   Underlying malignancy in 51%
•   Median tpa dose 12mg
•   Median time 34 mins per segment
•   Median time 111 mins skin to skin- (last 4 <50 minutes)
In the same time period
• 21 patients treated by Catheter Directed Thrombolysis
    –   8   combined with Trellis
    –   4   acute on chronic
    –   4   ankle to groin
    –   3   IVC and bilateral legs to below knee level DVT
• 1 death from v tach 8 hours into CDT with a thrombosed
    IVC filter- small PE found
•   2 serious bleeds- 1 compartment syndrome, 1 big fall in
    Hb 11 to 5
•   Other patients did well- 3 haematomas not requiring Rx;
    HB falls by ~ 0.7g/d
•   Median ICU stay 63 hours
•   Median tpa dose 71 mg
Results: IPMT with TrellisTM
• Technically successful – i.e. clearance of >95%
    of thrombus with in line flow from periphery in
    96/101
•   Two patients needed catheter directed
    thrombolysis afterwards- DVT older than 21 d
•   Primary patency at Day 1 96/101
•   Primary assisted patency 78/84 at 3 months
•   Longest follow up 4 years
Complications:
• One death on table
   – PE one week before; marked SOB thought to be due to Farmers
     lung or Asthma
   – Undiagnosed severe Right Ventricular Hypertrophy (on post
     mortem)
   – Farmers lung (on post mortem)
   – On table MI but no new PE

   Lesson learned:
   Retrievable filters
   1.    Unexplained shortness of breath
   2.    Positive CTPA
   3.    IVC thrombus
Failures
• 1. acute stent thombosis with advanced malignancy-
  patient refused further Rx, died at 3 weeks
• 2. prior seminoma with Radiotherapy to
  retroperitoneum; IVC to knee thrombosis; lost to follow
  up for 2 months, when patient returned thrombosed
  from SFV to mid IVC- not especially symptomatic;
  attempted, could not get through
• 3. Two patients with advanced malignancy who basically
  lay in bed for two weeks post procedure- entire leg
  rethrombosed
• 4. Two patients who developed bleeds post adjuvant
  CDT which then led to cessation of anticoagulation and
  rethrombosis of the entire segment
Lessons learned:
  • Overall IPMT is a VERY safe technique with low risks

  • Acute DVT only- less than 20 days really

  • Use a retrievable filter if you have PE/RV strain/IVC
    thrombus

  • Questionable benefit in treating if that limb is weak or
    stroked

  • Pneumatic compression boots very useful

  • Mobilise as quickly as possible (walk them to ward!!)
  • If DVT older than 20-30 days, WAIT, re scan in 6
    months, and then possibly primary stent
CVIR

Epub

Oct 2010
To summarise:
• Who to treat- above knee symptomatic DVT
  –    iliac
  –    ilio-femoral
  –   IVC
  –   SVC


• How to treat
  – IPMT using TrellisTM
  – CDT only if necessary
Thank you for your attention….

				
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