Sclerotherapy and thrombophilia: How to do it? Saturday 29 March 2014 Pascal Giordana Nice, France.

Slides:



Advertisements
Similar presentations
Venous Thrombo-embolism In Pregnancy
Advertisements

Venous Thromboembolism: Risk Assessment and Prophylaxis
LHD Logo Venous Thromboembolism Reducing the Risk DATE.
Does competence of the terminal and/or pre-terminal valve influence the modalities of foam sclerotherapy for the treatment of trunk varices ? By Claudine.
Basic Clinician Training Module 5
STROKE & PREGNANCY By Judith Barnaby, Stroke CNS Reviewed by Dr. Bayer, Stroke Neurologist, St. Michael’s Hospital.
Results: 1.Progression of thrombus length and volume (40% vs. 28%; P
Venous Thromboembolism Prevention August Venous Thromboembloism Prevention 2 Expected Practice  Assess all patients upon admission to the ICU for.
Prophylaxis of Venous Thromboembolism
Venous Thromboembolism (VTE) Prophylaxis Policy Mary-Anne Davies Patient Safety Specialist Accreditation Coordinator.
Venous Thromboembolism
RecommendationsRecommendations Risk Recommendation Ambulation (all pts) IPC/GCS or, UFH 5000 SQ q 12 hrs or, Enoxaparin 40mg SQ daily IPC/GCS or, UFH 5000.
Thrombophilia. Now considered a multicausal disease, with an interplay of acquired and genetic thrombotic risk factors Approximately half of venous thromboembolic.
NEW ORAL ANTICOAGULANTS
Increasingly, women who are asymptomatic present in pregnancy with a known thrombophilia, typically detected because of screening following identification.
ANAESTHESIA AND ANTICOAGULANTS
Regional Anesthetics and Anticoagulation Marie Sankaran Raval M.D. Boston Medical Center Department of Anesthesiology Nina Zachariah M.D.
Thrombophilic states. Thrombophilic state is characterized by a shift in the coagulation balance in favour of hypercoagulability – i.e. easier and oftener.
Below the Knee DVT and Pregnancy Related Thrombosis Robert Lampman, MD Morning Report July 2009.
CHEST-2012: High Points and Pearls Alan Brush, MD, FACP Chief, Anticoagulation Management Service Harvard Vanguard Medical Associates.
DPT 732 SPRING 2009 S. SCHERER Deep Vein Thrombosis.
Chapter Two Venous Disease Coalition Pathogenesis and Consequences of VTE VTE Toolkit.
Chronic Venous Disease Treatment - Part II Vein closure and rerouting of blood through normal veins with Ultrasound Guided Foam Sclerotherapy S. Lakhanpal.
The EINSTEIN DVT Study 'Xarelto' for the Acute and Continued Treatment of Symptomatic Deep Vein Thrombosis.
Hypercoagulable States Basic Clinician Training Module 4 Introduction Hypercoagulable States Test Your Knowledge.
The EINSTEIN EXT Study 'Xarelto' for the Long-Term Prevention of Recurrent Venous Thromboembolism.
Management thrombophilia. introduction Twenty percent of maternal deaths in the United States during that period were attributed to PE. Inherited thrombophilias.
WARFARIN AN OVERVIEW.
Prevention Of Venous Thromboembolism In The Cancer Surgical Patient A K Kakkar Barts and the London School of Medicine and Thrombosis Research Institute,
Semuloparin for Thromboprophylaxis in Patients Receiving Chemotherapy for Cancer Agnelli G et al. N Engl J Med 2012;366(7): George D et al. Proc.
APPROACH TO BLEEDING DISORDERS. History of Bleeding Spontaneous vs. trauma/surgery-induced Ecchymoses without known trauma Medications or nutritional.
Venous Thromboembolism
7th ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines.
DEFINING THE DURATION OF ANTICOAGULATION. HOW LONG TO TREAT A DVT?
Oral Rivaroxaban for Symptomatic Venous Thrombroenbolism Group /06/11.
Prevention of Venous Thromboembolism 8 th ACCP Guidelines Chest 2008.
The Role of Thromboprophylaxis in Elective Spinal Surgery The Role of Thromboprophylaxis in Elective Spinal Surgery VA Elwell, N Koo Ng, D Horner & D Peterson.
Hypercoagulable Syndromes. Risk Factors For Venous Thrombosis ACQUIREDINHERITEDMIXED/UNKNOWN Advancing ageAntithrombin Deficiency  Homocysteine ObesityProtein.
Complicanze trombotiche nel mieloma multiplo Mauro Berrettini S.C. Medicina Generale-DH Oncologico Ospedale di Orvieto Mediterranean School of Oncology.
Pulmonary Embolism Treatment in Cancer - Is It Different 34th Brazilian Thoracic Conference 6th ALAT Congress 5th Brazil-Portugal Congress Brazilia/DF.
MANAGEMENT OF POST-ENDOVENOUS ABLATION VENOUS THROMBOSIS Stephen F. Daugherty, MD, FACS Clarksville, Tennessee, USA.
Thrombophilia National Haemophilia Director
HICKMAN CATHETER Thrombotic complications associated with venous access devic Thrombotic complications associated with venous access devices Occlusion.
VTE Venous ThromboEmbolism. VTE – aims of this module To define the terms associated with VTE and offer maximum care to treat patients. To define the.
Thrombophilia. Definition –Tendency to develop clots due to predisposing factors that may be genetically determined.
VTE Prevention In Action Interactive Case Scenarios.
Charles J. Lockwood, M.D. The Anita O’Keefe Young Professor and Chair Department of Obstetrics, Gynecology and Reproductive Sciences Yale University School.
Deep vein thrombosis Pulmonary embolism Deep vein thrombosis Pulmonary embolism Venous Thromboembolism TreatmentTreatment …All the same?
Venous Thromboembolism Prophylaxis for Medical Inpatients Heather Hofmann, rev. 4/18/14 DSR2 Mini Lecture.
DVT & PE: How early can I mobilize a patient ??
Venous thromboembolic disease
Hematology Blueprint PANCE Blueprint. Coagulation Disorders.
Thrombophilia Made Simple for Obstetricians
Oral Rivaroxaban Compared with Subcutaneous Enoxaparin for Extended Thromboprophylaxis After Total Hip Arthroplasty: The RECORD1 Trial Eriksson BI, Borris.
1. Normal haemostasis Haemostasis is the process whereby haemorrhage following vascular injury is arrested. It depends on closely linked interaction.
Complications of sclerotherapy Saturday 09 March 2013 Pascal Giordana Nice, France.
Conclusions Results Methods Background Venous thrombo-embolism in patients undergoing neo- adjuvant chemotherapy and surgery for oesophago-gastric cancer.
Prevention of Venous Thromboembolism in Orthopedic Surgery Patients Copyright: American College of Chest Physicians 2012 © Antithrombotic Therapy.
Treatment of deep venous thrombosis and pulmonary embolism Anders Waage.
Bleeding Tendency Dr. Mervat Khorshied Ass. Prof. of Clinical and Chemical Pathology.
Venous Thromboembolism Prophylaxis for Medical Inpatients
Prothrombin complex concentrate
By: Dr. Nalaka Gunawansa
Dr Ferdous Mehrabian. Dr Ferdous Mehrabian Inherited thrombophilias in pregnancy Inherited thrombophilias is a genetic tendency to venous thrombosis.
Microfoam ablation of the long saphenous vein
HICKMAN CATHETER. HICKMAN CATHETER Thrombotic complications associated with venous access devices Occlusion of lumen Fibrin sheath formation Venous.
Drugs Affecting Blood.
Thrombophilia.
Thrombophilia in pregnancy: Whom to screen, when to treat
Presentation transcript:

Sclerotherapy and thrombophilia: How to do it? Saturday 29 March 2014 Pascal Giordana Nice, France.

expression of interest: No conflict

Thrombophilia is the term now used to describe predisposition to increase risk of venous and occasionally arterial thromboembolism due to hematological abnormalities. Thrombophilia and venous thromboembolism; international concensus (Int Angiol 2005; 24: 1-26) Cancer is associated with 4.1 fold increased the risk for VTE witch increases to 6.5 with treatment by chemotherapy. 72% of individuals with travel-related DVT have associated coagulation defects. Lebanon exhibits one of the highest general population frequencies for factor V Leiden mutation in the eastern Mediterranean region (7.4% in general population and 39.7% in patients with VTE).

Thrombophilia and venous thromboembolism; international concensus (Int Angiol 2005; 24: 1-26) 4.1 to 16.2 increase risk of VTE

1025 patients treated with foam sclerotherapy (818 GSV and 207 SSV) Persons with personal history of VTE or previous identified thrombophilia were excluded 11 thrombo embolics events occured: 10 DVT o 5 symptomatics (all distal) o 5 no symptomatic (not completly occlisive) 1 PE DVT were more frequent for SSV (2.42%) vs GSV (0.61%) Foam doesn’t lead to more VTE than other methods of treatment Surgery = 5.3% Radiofrequency = 0 to 16% Laser = 0 to 8% J.L. Gillet et Al: phlebology. 2009; 24:

European guidelines for sclerotherapy in chronic venous disorders (Rabe et al: Phlebology 2013) Thromboembolic events are very rare and uncommon.

Effects of detergent sclerosants on anticoagulation…

In vitro effects of detergent sclerosants on coagulation, platelets and microparticles (K. Parsi et al: Eur J Vasc Endovasc Surg 34, 731_740) STS at high concentration (> 0.3 %): destroyed platelets, microparticles and the clotting factors V, VII and X. It prolongs all clotting test [prothrombin time (PT), activated partial thromboplastine time (APTT), non-activated partial prothromboplastin time (NAPTT), Thrombin time (TT), factor Xa clotting time (XACT)and surface activated clotting time (SACT)]. Higher concentration of POL were required to achieve some anticoagulant activity when compared with STS. POL never achieved the same degree of prolongation when compared with STS. STS has more anticoagulant activity than POL in high concentration.

In vitro effects of detergent sclerosants on coagulation, platelets and microparticles (K. Parsi et al: Eur J Vasc Endovasc Surg 34, 731_740) Low concentrations sclerosant demonstrate pro-activity.

In vitro effects of detergent sclerosants on antithrombotic mechanisms (K. Parsi et al: Eur J vasc Endovasc surg 2009, 38; ) Effect on protein C:  STS caused a moderate reduction in protein C level at a concentration of 0.3%. It reduce the PC level down to 10% with higher concentration.  POL only caused a mild reduction in PC level.

In vitro effects of detergent sclerosants on antithrombotic mechanisms (K. Parsi et al: Eur J vasc Endovasc surg 2009, 38; ) Effect on protein S:  STS at concentration of 0.6% and more completely destroyed free PS  POL reduced PS levels by 60%

In vitro effects of detergent sclerosants on antithrombotic mechanisms (K. Parsi et al: Eur J vasc Endovasc surg 2009, 38; ) Effect on AT:  STS significantly destroyed AT at concentration above 0.3%  POL reduced AT level down to 60%

In vitro effects of detergent sclerosants on antithrombotic mechanisms (K. Parsi et al: Eur J vasc Endovasc surg 2009, 38; ) Effect on APC and APCR:  STS prolonged APTT potentiating the anticoagulant activity of APC.  POL had the opposite effect increasing APCR.

The lytic effects of detergent sclerosants on Erythrocytes, platelets, endothelials cells and micro_particles are attenuated by albumin and other plasma components in vitro (K. Parsi et al: Eur J Vasc Endovasc Surg (2008) 36, ) Sclerosant at therapeutic concentrations lyse blood cells and endothelial cells in vitro. The effect is strongly reduced by serum albumin possibly contributing toward the low incidence of thromboembolic complications of sclerotherapy. The plasma components appeared to neutralize the lytic effects of sclerosants. STS was 50 fold and POL was 163 fold less hemolytic in blood than in saline. The displacement of blood from the vessel lumen decreased the exposure of the sclerosant to the plasma components and increases the exposure of the endothelial lining of the vessel lumen to the active agent.

An Investigation of coagulation cascade activation and induction for fibrinolysis using foam sclerotherapy of reticular veins (S. Guillen Fabi et al: Dermatol Surg 2012; 38: ) The objective was to evaluate the effect of foam bubbles on coagulation and fibrinolysis after foam sclerotherapy with STS. Patients were treated with up to 30 ml of foam STS. Blood was drawn immediately and 15 min after the procedure. There was no significant difference in coagulation or fibrinolysis, as measured according to platelet count and concentrations of clotting factor and fibrinogen after sclerotherapy with STS.

In practice…

Sclérothérapie chez le patient thrombophile connu. Etude prospective randomisée contrôlée de 105 cas (Hamel Desnos C. et al : phlébologie 2010,63, 1p ) 105 thrombophilics patients in combination with thromboprophylaxis in two randomized arms using low molecular weight heparin (LMWH) or warfarin. 75 with factor V Leiden mutation 18 with prothrombin A mutation 7 high level of factor VIII 5 combinations of these After randomization: 51 received Warfarin (1 mg once a days during 4 weeks after the last treatment) 54 received LMWH (nadroparin 4000 UI one injection at the same time with the sclerotherapy). A control (clinical examination and ultrasound screening) was realized after 3 or 4 weeks

Sclerotherapy of varicose veins in patients with documented thrombophilia: a prospective controlled randomized study of 105 cases (Hamel Desnos C. et al: Phlebology 2009; 24: )

Results: No episodes of symptomatic deep vein thrombosis or PE occurred No instances of DVT were revealed by ultrasound monitoring Conclusion: sclerotherapy, in combination with thromboprophylaxis, can performed safely in these tree most common thrombophilia. Prophylaxis by LHWM is easier to use than Warfarin Antithrombotic prophylaxis do not change the efficacy of the treatment. Sclérothérapie chez le patient thrombophile connu. Etude prospective randomisée contrôlée de 105 cas (Hamel Desnos C. et al : phlébologie 2010,63, 1p )

Conclusion: European guidelines for sclerotherapy in chronic venous disorders (Rabe et al: Phlebology 2013) Recommendation 2: we recommend to consider the following absolute and relative contraindications (Grade 1c):  Absolute contraindication: acute DVT or PE, long lasting immobility and confinement to bed.  Relative contraindication: High thromboembolic risk (history of thromboembolic events, known severe thrombophilia, hyper coagulate state and active cancer).

European guidelines for sclerotherapy in chronic venous disorders (Rabe et al: Phlebology 2013) Recommendation 9: in patients with a high risk of thromboembolism such as those with history of spontaneous DVT or known severe thrombophilia we recommend:  Use of pharmacological thromboprophylaxis in line with current guidelines recommendations (Grade 1c)  Implement physical prophylaxis (compression, movement) (Grade 1c)  Avoid the injection of large volumes of foam (Grade 1c)  Decide on a case-by-case basis (perform a benefit-risk assessment based on the particular indication) (Grade 1c)