Implications from the ACCP 2012 Consensus Guidelines for the Management of Thrombosis: a case based approach
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1 Implications from the ACCP 2012 Consensus Guidelines for the Management of Thrombosis: a case based approach Prof. I. Baumgartner Head Clinical and Interventional Angiology
2 About the ACCP guidelines Widely considered the gold standard for thrombosis prevention and therapy: Since 1986 every few years, authoritative reviews consists of 24 articles, 801 pages, 600 recommendations Electronically freely accessible Dealing with oral and parenteral anticoagulants & antiplatelet drugs, prevention & treatment of VTE, perioperative management of antithrombotic therapy, and antithrombotic therapies for cardiovascular diseases
3 42-year old male (JR) 1994 proximal DVT (right leg) and symptomatic PE - after surgery (knee operation) 6-months OAC ACCP 2012
4 9 th ACCP Guidelines (2012) on VTE treatment Duration of anticoagulant treatment following DVT/PE Condition Proximal DVT or PE First provoked proximal DVT or PE First unprovoked proximal DVT or PE Recommendation Grade Minimum 3 months (1B) 3 months (1B if if surgical, 2B if non-surgical and low or moderate bleeding risk [BR]) Extended if BR low or moderate (2B), 3 months if BR high (1B)
5 9 th ACCP Guidelines (2012) on VTE treatment Why 3 months rather than 6 or 12 months? Prof. I. Baumgartner, Angiology
6 42-year old male (JR) 1994 proximal DVT (right leg) with submassive PE - after surgery (knee operation) 3-months OAC (ACCP 2012) 2002 superficial vein thrombosis (right leg) 6-months OAC ACCP 2012 Postthrombotic syndrome chronisch venous insufficiency ulcer varicosis superficial vein thrombosis Recommendation: stockings after DVT (2B)
7 9 th ACCP Guidelines (2012) on VTE treatment Superficial vein thrombosis (SVT) A prospective study of 844 pts with acute SVT of 5 cm: 4% symptomatic PE, 10% proximal DVT, 13% additional distal DVT
8 9 th ACCP Guidelines (2012) on VTE treatment Superficial vein thrombosis Prof. I. Baumgartner, Angiology
9 42-year old male (JR) 2/2003 unprovoked, proximal DVT (left leg) extended OAC ACCP 2012
10 9 th ACCP Guidelines (2012) on VTE treatment Duration of anticoagulant treatment following DVT/PE (I Recurrence) has to be based on etiology and bleeding risk (BR)
11 42-year old male (JR) poor compliance superficial vein thrombosis (GSV, SSV) - start OAC without LMWH proximal progression SVT (right leg) - INR 2.9, switch to LMWH once daily bilaterale PE with recurrent DVT (external iliac vein, right leg) LMWH, twice daily, IVC filter
12 42-year old male (JR) poor compliance superficial vein thrombosis (GSV, SSV) - start OAC without LMWH proximal progression SVT (right leg) - INR 2.9, switch to LMWH once daily bilaterale LE with recurrent DVT (external iliac vein, right leg) LMWH, twice daily, IVC filter
13 42-year old male (JR) 10/2007 recurrent, unprovoked, proximal DVT (right leg) ACCP 2012 Diagnosis of recurrent DVT: Recommendation: proximal CUS or highly sensitive D-dimer (grade 1B) Recommendation: abnormal but nondiagnostic CUS venography (1B) or - serial proximal CUS (2B) - sensitive D-dimer test with serial proximal CUS if positive (2B)
14 42-year old male (JR) poor compliance superficial vein thrombosis (GSV, SSV) - start OAC without LMWH proximal progression SVT - INR 2.9, switch to LMWH once daily bilaterale LE with recurrent DVT (external iliac vein, right leg) LMWH, twice daily, IVC filter
15 9 th ACCP Guidelines (2012) on VTE treatment Once or twice daily dosing of LMWH same for DVT
16 42-year old male (JR) poor compliance superficial vein thrombosis (GSV, SSV) - start OAC without LMWH proximal progression SVT - INR 2.9, LMWH once daily (compliance?) bilaterale LE with recurrent DVT (external iliac vein, right leg) LMWH, twice daily, IVC filter
17 Cavafilter... ACCP 2012
18 9 th ACCP Guidelines (2012) on VTE treatment IVC filters for the initial treatment of VTE same for DVT same for DVT
19 IVC filter do not eliminate risk of PE and increase risk of DVT Circulation 2005;112:416-22
20 .. IVC filter do not alter combined frequency of DVT and PE (i.e. recurrent VTE) and mortality. Circulation 2005;112:416-22
21 42-year old male (JR) ascending iliofemoro-caval DVT INR 2.1 (compliance?) new INR target 3-4 ACCP 2012
22 9 th ACCP Guidelines (2012) on VTE treatment Intensity of anticoagulant effect
23 9 th ACCP Guidelines (2012) on VTE treatment Thrombus removal in acute iliofemoral DVT * * Patients with DVT that involves the iliac and common femoral veins are at highest risk of PTS, recurrent VTE and, therefore, are the subset with greatest potential to benefit from thrombus removal strategies.
24 CaVenT Study multicentre, open-label, RCT of efficacy and safety of additional CDT with alteplase in first-time acute iliofemoral DVT co-primary effect variables: iliofemoral 6 mo and frequency of 24 mo ARR of 24 mo 14 4% [95% CI ] ; NNT 7 [95% CI 4 502] Lancet. 2012; 379(9810):31-8
25 Acute-on-chronic ascending iliofemoral DVT history of bilateral femoral DVT acute DVT of IVC bilateral acute iliac DVT chronic changes
26
27 Pharmacomechanical (PMT) thrombus removal (15-hour EKOS CDT [t-pa 20 mg], thrombusaspiration [Angiojet] and stenting) Prof. I. Baumgartner, Angiology
28 Pharmacomechanical (PMT) thrombus removal (clinical 24 hours) before after
29 The Bern DVT Experience fixed-dose EKOS thrombolysis (CDT) regimen: t-pa 20 mg/15 hours N = 52 Acute (symptoms 14 days) N = 33 Subacute orchronic (symptoms >14 days) N = 19 Clot lysis 50% 87.9% 47.4% Different to CaVent Additional interventional treatment (n=52) Mechanical thrombectomy 27% Stenting 71%
30 The Bern DVT Experience fixed-dose EKOS thrombolysis (CDT) regimen: t-pa 20 mg/15 hours Complications (n=52) Complications None 83% Bleeding complications Minor, n=5 9.6% Major, n=1 1.9% Other complications Painful intervention 3.8% Transient foot drop 1.9%
31 The Bern DVT Experience Patency and 12 months Ilio-femoral DVT: primary patency Ilio-femoral DVT: secondary patency Ilio-femoral DVT: secondary sustained clinical success 83% 96% 85% analysis time analysis time analysis time clinical outcome in 6 months
32 9 th ACCP Guidelines (2012) on VTE treatment Conclusions In patients with acute VTE*, we suggest prophylactic dose of fondaparinux or LMWH in SVT for 45 day (2B) either 3 months or extended OAC in acute VTE* (1B or 2B) INR target 2-3 (1B) anticoagulant therapy alone over CDT (2C) patients who are most likely to benefit* from CDT are likely to choose CDT over anticoagulation alone (*DVT that involves the iliac and common femoral vein) against use of an IVC filter in addition to anticoagulants (1B) *acute proximal DVT and PE
33
34 Thank you for your attention Prof. I. Baumgartner, Angiology
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