Intervention for Deep Venous Thrombosis and Pulmonary Embolus

Transcription

1 Intervention for Deep Venous Thrombosis and Pulmonary Embolus Michael R. Jaff, DO Paul and Phyllis Fireman Endowed Chair in Vascular Medicine Massachusetts General Hospital Professor of Medicine Harvard Medical School Boston, Massachusetts USA

2 Michael R. Jaff, D.O. Conflicts of Interest Consultant Abbott Vascular (non-compensated) AOPA Boston Scientific (non-compensated) Cardinal Health Cordis Corporation (non-compensated) Janacare, Inc Medtronic (non-compensated) Micell, Inc Novella (DSMB) Primacea Valiant Volcano Equity Access Closure, Inc Embolitech I.C.Sciences, Inc Janacare, Inc MC10 Northwind Medical, Inc. PQ Bypass, Inc Primacea Sano V, Inc. Vascular Therapies, Inc 2 Board Member 2 -VIVA Physicians (Not For Profit 501(c) 3 Organization) -Intersocietal Accreditation Commission -CBSET January 2016

3 Current Management of DVT Diagnosis of DVT Anticoagulation IVC Filter: Contraind. to Anticoag. Protection during Lysis Distal (Calf Vein) Iliac/CFV Serial DUS to Exclude Propagation Circulation 2004;110 [Suppl I]:I-27-I-34 Pharmacologic Lysis (no contraind.) Mechanical Thrombectomy (+ Lysis) Iliac Stent (if residual stenosis) Surgical Thrombectomy Failed Lysis Contraind. to Lysis Failed Thrombectomy 3

4 So, Why Consider Intervention? Here is your challenge: There are so many physicians who believe that they are experts in the management of DVT Their perception? Patients do quite well with standard anticoagulation And now with NOACs???? We can keep patients out of the hospital (Who would argue with that?) Why incur the risks associated with intervention? Why incur the costs associated with intervention? Is this all trumped up to generate another procedure for interventionists? 4

5 Goals of endovascular therapy for DVT More rapid lysis via local administration of drug Relieve acute pain and edema Prevent PE and recurrent thrombosis Prevent post-thrombotic syndrome Restore vessel patency Preserve valve function Correct underlying anatomic lesions

6 Indications for Endovascular Venous Intervention Phlegmasia cerulea dolens Extensive or proximal DVT: IVC, iliofemoral Young, highly-functional pts high risk of PTS Symptomatic IVC filter occlusion Early intervention is best, but benefit may still be derived months after acute occlusion High risk for fatal PE Propagation of DVT despite conventional therapy High likelihood of underlying anatomic lesion May-Thurner syndrome (MTS) Compression by pelvic tumor Prior pelvic DVT

7 Percutaneous mechanical thrombectomy: Advantages vs. CDT Shorter treatment time to patency? Potentiator of thrombolytic therapy for subacute or chronic thrombus? Application when to lysis contraindicated? Cheaper? Safer?

8 The ATTRACT Trial Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis NHLBI-funded, Phase III, open-label, multicenter RCT Pharmacomechanical Catheter-Directed Thrombolysis 692 patients with symptomatic, acute proximal DVT 28 U.S. Centers, currently enrolling PI = Dr. Suresh Vedantham (Washington University) Study Chair = Dr. Samuel Z. Goldhaber (Harvard)

9 The ATTRACT Trial Symptomatic Proximal DVT (iliac, common femoral, femoral vein) PCDT plus rtpa AND Standard DVT Therapy Standard DVT Therapy 9

10 209 patients with symptomatic, first iliofemoral DVT Randomized to conventional treatment alone or additional catheter-directed thrombolysis Primary endpoints Villalta Score at 24 months Iliofemoral patency at 6 months 10 Lancet 2012;379:31-8

11 CaVent Study--Demographics 11 Lancet 2012;379:31-8

12 CaVent Study--Outcomes 20 Bleeding Events 3 major (rectus sheath hematoma, compartment syndrome, access site hematoma) 5 clinically relevant No deaths, PE, intracerebral hemorrhage Lancet 2012;379:31-8

13 J Vasc Surg 2012;55:

14 SVS/AVF Guidelines Guideline Grade Recommendation Quality of Evidence Early Thrombus Removal in the following scenarios: --First episode of acute iliofem DVT --Symptoms <14 days --Low Bleeding Risk --Ambulatory, good functional capacity, acceptable life expectancy Early Thrombus Removal in Phlegmasia Cerulea Dolens Percutaneous Techniques Preferred as Thrombus Removal Strategy Pharmacomechanical thrombolysis preferred to Catheter-Directed Thrombolysis 2-Weak 1-Strong 2-Weak 2-Weak C-Low/very low A-High C-Low/very low C-Low/very low J Vasc Surg 2012;55:

15 15

16 Highlights from the AHA Guidelines Iliofemoral Deep Venous Thrombosis Defined as complete or partial thrombosis of any segment of the iliac vein or the common femoral vein, with or without involvement of other lower extremity veins or inferior vena cava. Circulation 2011

17 Intervention for Deep Venous Thrombosis Deep Venous Thrombosis Anticoagulation does not prevent development of post-thrombotic venous insufficiency Morbidity of post-thrombotic venous insufficiency is significant and costly Consider endovenous intervention for iliofemoral DVT, advanced symptoms, and low bleeding risk Experienced interventionist is critical 17

18 J Thromb Thrombolysis 2016;41:68-81

19 What About PE?

20 J Thromb Thrombolysis 2016;41:68-81

21 What Are The Goals of Thrombolytic Therapy for Acute PE? J Thromb Thrombolysis 2016;41:68-81

22 This is What You Have to Deal With The Contraindications to Lytic Therapy Chest 2012;141 22

23 So, How To Decide?

24 Pulmonary Embolism Response Team (PERT) ED / ICU / Floor Team Pulmonary Vascular Medicine/Cardiology Cardiac Surgery 24

25 Intervention for Deep Venous Thrombosis and Pulmonary Embolus Michael R. Jaff, DO Paul and Phyllis Fireman Endowed Chair in Vascular Medicine Massachusetts General Hospital Professor of Medicine Harvard Medical School Boston, Massachusetts USA