Surgical approach for DVT. Division of Vascular Surgery Department of Surgery Seoul National University College of Medicine

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1 Surgical approach for DVT Seung-Kee Min Division of Vascular Surgery Department of Surgery Seoul National University College of Medicine

2 Treatment Options for Venous Thrombosis Unfractionated heparin & oral anticoagulation LMWH Alternative anticoagulants Thrombolysis Venous thrombectomy IVC interruption Pulmonary embolectomy

3 Goals of DVT Treatment Rutherford (ed): Vascular Surgery (2000)

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6 Clinical spectrum of acute DVT Anticoagulation therapy Proper treatment?

7 Anticoagulation only is not ENOUGH! Akesson et al (1990) ; Acute Iliofemoral DVT treated with anticoagulation only, 5 yr F/U 95 % ambulatory venous HT 90 % chronic venous insufficiency (CVI) Sx 15 % venous ulcer 15 % venous claudication Anticoagulation only = Inadequate Therapy

8 Strategy of thrombus removal Rationale for thrombus removal Pathophysiology of CVI ; ambulatory venous HT = venous valvular incompetence + luminal obstruction Thrombus removal elimination of luminal obstruction preservation of valve function Post-thrombotic syndrome avoided Method Surgical venous thrombectomy Catheter-directed thrombolysis Percutaneous pharmaco-mechanical thrombectomy

9 Flowchart of invasive treatment of DVT Liapise et al, European Manual of Medicine: Vascular Surgery

10 Treatment algorithm for iliofemoral DVT Comerota & Paolini. EJVES 2007;33:351-60

11 1. Catheter-directed Thrombolysis Aim To restore venous patency To preserve venous valve function Technique Ipsilateral popliteal vein or contralateral femoral vein approach Multisided-hole catheter Position the system directly into the thrombus Pulsed spray injection Thrombolytic agent Urokinase rtpa

12 2. Percutaneous mechanical thrombectomy Amplatz device Arrow-Trerotola device AngioJet device Trellis catheter (Segmental pharmacomechanical thrombolysis) EKOS LysUS system (Ultrasound-accelerated thrombolysis)

13 3. Iliofemoral Venous Thrombectomy Indications Phlegmasia cerulea dolens Impending venous gangrene Contraindication to thrombolysis treatment Good Prognostic Factor Young patient Symptom onset < 7 days, preferably < 72 hrs No systemic predisposing condition (malignancy, CHF)

14 Operative risks for thrombectomy General Anesthesia Perioperative fatal pulmonary embolism Rethrombosis Bleeding Valvular injury

15 Accurate preoperative evaluation is essential! Accurate preoperative evaluation General status of the patient Hypercoagulability ; acquired or congenital Imaging studies Duplex USG / CT venography Proximal and distal extent of the thrombi Underlying anatomic cause iliac vein compression syndrome, intraluminal web, stricture, chronic thrombosis sequelae Associated vascular anomali duplication, left-sided IVC, malformation

16 Technique of Venous Thrombectomy Exposure and prevention of clot embolization Groin incision CFV exposure & venotomy ; regional thrombus removal IVC occlusion balloon or IVC filter Evacuation of iliac vein thrombus Iliac thrombectomy balloon Intraop. Venography Removal of any residual thrombus Ouriel & Rutherford (eds): Atlas of Vasc Surg Clearance of thrombus below the venotomy site Milking technique ; compression along the leg from ankle Separate venotomy incision below knee, if needed.

17 Prevention of PE during thrombectomy Fatal pulmonary embolism during procedure mainly due to undetected IVC thrombus IVC control before thrombectomy!! Prevention Positive pressure ventilation or Valsalva maneuver Preop. IVC filter placement Double balloon technique Hallett et al (ed): Comprehensive Vasc Endovasc Surg. 2009

18 Temporary AVF formation End-to-Side anastomosis GSV branch - CFA The AVF is left open for 2 ~ 4 weeks Until venous re-endothelialization has occurred Fistula closure ; by endovascular or open CFA GSV branch Ouriel & Rutherford (eds): Atlas of Vasc Surg

19 Result of Venous Thrombectomy

20 Technical advances in venous thrombectomy Technique Old Contemporary Pretreatment phlebography / CT scan Occasionally always Venous thrombectomy catheter No Yes Operative fluoroscopy / phlebography No Yes Correct iliac vein stenosis No Yes Arteriovenous fistula No Yes Infrainguinal thrombectomy No Yes Intraoperative thrombolysis No Yes Full post op anticoagulation Occasionally Yes Catheter-directed anticoagulation No Yes Intermittent pneumatic compression No postop Yes Comerota & Paolini. EJVES 2007;33:351-60

21 Infrainguinal balloon catheter venous thrombectomy Comerota & Gale. JVS 2006;43:185-91

22 Intraoperative thrombolysis Vigorous irrigation with heparin-saline solution UK or rt-pa injection Comerota & Gale. JVS 2006;43:185-91

23 Axillo-Subclavian venous thrombosis Paget-Schroetter syndrome, effort thrombosis Venous manifestation of thoracic outlet compression Affects young, healthy, physically active individuals Symptom; sudden onset of severe & uniform selling of U/E Treatment Thrombolytic therapy first Confirm extrinsic compression or stricture If no stenosis, imaging studies with provocative maneuvers If vein compression(+), operative therapy is recommended ; first rib resection and subtotal scalenectomy If (-), anticoagulation for 3 ~6 months (+/- first rib resection)

24 Thank you for your attention.