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Ambulatory Venous Hypertension Components Obstruction Valve incompetence Obstruction Valve incompetence Obstruction and valve incompetence …Highest venous pressure …Most severe morbidity …Highest venous pressure …Most severe morbidity
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Iliofemoral DVT Contraindication to Lysis Yes No Surgical Thrombectomy + AVF Surgical Thrombectomy + AVF Anticoagulation Catheter-directed Thrombolysis Catheter-directed Thrombolysis 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 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 Trial
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Anticoag. Thrombectomy 60 mmHg 43 mmHg AVP 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 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 2004 Buller H, et al Chest 2004;126:401S Buller H, et al Chest 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 lysis Physical functionStigma Health distressPost thromb Sx Successful lysis correlated w/QOL Lytic failures and heparin Rx similar Significantly better QOL with lysis Physical functionStigma Health distressPost thromb Sx Successful lysis correlated w/QOL Lytic failures and heparin Rx similar Improvement in Quality of Life Comerota AJ et al J Vasc Surg 2000 Comerota AJ et al J Vasc Surg 2000
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35 consecutive patients Iliofemoral DVT Randomized Follow-up 1week/6mos –Clot lysis –Venous reflux 35 consecutive patients Iliofemoral DVT Randomized Follow-up 1week/6mos –Clot lysis –Venous reflux Cath-dir SK (pulse spray) vs. Anticoagulation alone Cath-dir SK (pulse spray) vs. Anticoagulation alone Elsharawy M, et al Eur J Vas Surg. 2002; 24:209 Elsharawy M, et al Eur J Vas Surg. 2002; 24:209 Catheter-Directed Lysis Iliofemoral DVT Improvement in Quality of Life
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Elsharawy M, et al Eur J Vas Surg. 2002; 24:209 Elsharawy M, et al Eur J Vas Surg. 2002; 24:209 0.4 7d 6d LOS 0.04 11% 41%* Reflux <0.001 72% 12% Patency P-valve Lysis (n=18) Lysis (n=18) Anticoag (n=17) Anticoag (n=17) *Underestimate 2 0 occlusion Catheter-Directed Lysis Iliofemoral DVT Randomized Trial: Outcome at 6 months
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Postthrombotic Syndrome Elastic Stockings (30-40 mmHg) Lancet 1997;349:759 <.01 51% 24% 49% <.01 55% 21% 47% P-value RRR Stocking Control 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
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