Venous Thrombosis. Magnitude of the Problem. DVT 2 Million PE 600,000. Death 60,000. Estimated Cost of VTE Care $1.5 Billion/year.

Transcription

1

2 Venous Thrombosis Magnitude of the Problem DVT 2 Million Postthrombotic Syndrome 800,000 PE 600,000 Death 60,000 Silent PE 1 Million Pulmonary Hypertension 30,000 Estimated Cost of VTE Care $1.5 Billion/year Goldhaber SZ, et al. Lancet 1999;353:

3 Etiology valvular damage

4 Modality Indications Time Frame Anticoagulants All Immediately Pharmacologic lysis Percutaneous mechanical thrombectomy (PMT) PTA/stenting Open surgical thrombectomy Acute Iliofemoral DVT Acute Iliofemoral DVT Chronic iliac vein stenosis Acute Iliofemoral DVT, not lytic candidate, or poor results after lysis/pmt As early as possible Early Following successful venous patency Early (Days)

5

6

7 Phlegmasia Cerulia Dolens

8 Peripheral Vascular Diseases: 2 nd Ed. Young, Olin, et al. 1996

9 AGENT Alteplase (rt-pa) Reteplase (r-pa) INFUSION mg/hr U/hr Tenectaplase (TNK) mg/hr

10 Case Study 1: Acute Iliofemoral DVT

11

12

13 Placed patient in prone position and examination of right popliteal vein

14 Introducer sheath placement in popliteal vein under ultrasound guidance

15 Initial Venogram

16 Initial Venogram

17 First Venogram post PPS (30 minutes)

18 Left Iliac Vein Stenosis Biliary Endoprosthesis placement and post-stenting balloon angioplasty

19 Completion venogram

20 Completion venogram

21 Pre - thrombectomy

22 Post thrombectomy 4 days later Procedural time 2 hours No ICU stay

23 Case Study 2: Massive IVC thrombus post IVC filter 63 year old male presents with SOB and chest pain (from Texas!) History of PE, 2 DVT s, and IVC filter placement (1999) V/Q scan high probability for Pulmonary Embolus

24 IVC Filter in Place

25 Large IVC Thrombus Above Filter IVC Filter

26 IVC Filter Placed Above Thrombus Via Jugular Approach IVC Filter

27

28 Thrombectomy P-PS Technique

29 Thrombectomy P-PS Technique

30 Thrombectomy P-PS (tpa)

31 IVC Filter Post P-PS (30 min) No residual thrombus

32 Gooseneck Snare Removal of IVC Filter

33 Gooseneck Snare Removal of IVC Filter

34 Removal of IVC Filter

35 Removal of IVC Filter

36 Removal of IVC Filter

37 Removal of IVC Filter

38 Removal of IVC Filter

39 Removal of IVC Filter

40 Before After 30 Min P-PS

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

66

67

68

69

70

71

72 Etiology

73 SVC - Syndrome

74

75

76 BEFORE AFTER

77 Pulmonary Embolism Annual incidence Over 600,000 cases in the United States 1 1 episode per 1000 patients 2,3 Cause of Death # of annual deaths 4 PE Up to 200,000 1,4 AIDS 18,017 Breast Cancer 40,870 Causes or contributes to 15% of all hospital deaths 5 PE is seen in 40-50% of patients with symptomatic proximal DVT 6 ; recurrent PE is a substantial risk 1. Wood. Major pulmonary embolism: review of a pathopahysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest 2002;121: Tapson. Acute pulmonary embolism. N Engl J Med 2008;358(10): Silverstein et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch intern Med 1998;158: American Heart Association Fact Sheet Dalen JE et al. Natural history of pulmonary embolism. Prog Cardiovasc Dis. 1975;17: Huisman MV et al. Unexpected high prevelance of silent pulmonary embolism in patients with deep venous thrombosis. CHEST 1989;95:

78 Treatment Anticoagulation (UFH, LMWH, Fondaparinux) Systemic thrombolysis Catheter-directed thrombolysis Mechanical and pharmacomechanical interventions Surgical embolectomy

79 Pulmonary Embolism Patient risk stratification (per AHA 2011 guidelines) Massive PE Submassive PE Minor/Nonmassive PE High risk Moderate risk Low risk Sustained hypotension (systolic BP <90 mmhg for 15 min) Inotropic support Pulselessness Persistent profound bradycardia (HR <40 bpm with signs or symptoms of shock) Systemically normotensive (systolic BP 90 mmhg) RV dysfunction Myocardial necrosis Systemically normotensive (systolic BP 90 mmhg) No RV dysfunction No myocardial necrosis RV dysfunction RV/LV ratio > 0.9 or RV systolic dysfunction on echo RV/LV ratio > 0.9 on CT Elevation of BNP (>90 pg/ml) Elevation of NTpro-BNP (>500 pg/ml) ECG changes new complete or incomplete RBBB anteroseptal ST elevation or depression anteroseptal T-wave inversion Jaff et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: A scientific statement from the American Heart Association. Circulation 2011;123(16):

80 Patients with right heart dysfunction defined as RV D /LV D > 0.9 have a significantly higher chance of adverse events within 30 days. Quiroz R, Kucher N, Schoepf J, et. al. Circulation. 2004;109: Adverse event rate: 54% if RV D /LV D ratio < % if RV D /LV D ratio 0.9 OR : 4.02 (p=0.041) 85

81 Circulation. 2005;112:e28-e32 86

82

83 Recommendations for Catheter Embolectomy and Fragmentation for PE Recommendations Depending on local expertise, either catheter embolectomy and fragmentation or surgical embolectomy is reasonable for patients with massive PE and contraindications to fibrinolysis Catheter embolectomy and fragmentation or surgical embolectomy is reasonable for patients with massive PE who remain unstable after receiving fibrinolysis For patients with massive PE who cannot receive fibrinolysis or who remain unstable after fibrinolysis, it is reasonable to consider transfer to an institution experienced in either catheter embolectomy or surgical embolectomy if these procedures are not available locally and safe transfer can be achieved Either catheter embolectomy or surgical embolectomy may be considered for patients with submassive acute PE judged to have clinical evidence of adverse prognosis (new hemodynamic instability, worsening respiratory failure, severe RV dysfunction, or major myocardial necrosis) Catheter embolectomy and surgical thrombectomy are not recommended for patients with low-risk PE or submassive acute PE with minor RV dysfunction, minor myocardial necrosis, and no clinical worsening Circulation 2011, 123: Level of Evidence Class IIa; Level of Evidence C Class IIa; Level of Evidence C Class IIa; Level of Evidence C Class IIb; Level of Evidence C Class III; Level of Evidence C

84 Mechanical Fragmentation Hydrodynamic Ultrasound-Accelerated Fibrinolysis Suction Embolectomy

85 Case Study Massive PE 90

86

87

88

89

90 Hemodynamics- Massive PE

91

92

93

94 Ekosonic Control Unit Ekosonic Mach4 Endovascular Device 5.4 fr Intelligent side-hole drug delivery catheter Ultrasound MicroSonic Core

95

96 Slide courtesy : Dr.Goswami Prairie Heart

97

98

99

100

101