What is the real place of venous echo Doppler in aircrew member flying rehabilitation after a thromboembolism event?

Transcription

1 89 th ASMA ANNUAL SCIENTIFIC MEETING DALLAS- May 6-10, 2018 What is the real place of venous echo Doppler in aircrew member flying rehabilitation after a thromboembolism event? S BISCONTE (1), V MARICOURT (2), A DIARD (2), N HUIBAN (3), J MONIN (4), S NGUYEN (1), O MANEN (4) (1) Aeromedical Center, Robert Picqué Military Hospital, Bordeaux, France (2) Angiologist, Bordeaux, France (3) Aeromedical Center, Saint Anne Military Hospital, Toulon, France (4) Aeromedical Center, Percy Military Hospital, Clamart, France

2 Disclosure Information 89 th Annual Scientific Meeting Sébastien BISCONTE I have no financial relationships to disclose. I will not discuss off-label use and/or investigational use in my presentation The opinions or assertions expressed here in are the private views of the authors and are not to be considered as official or as reflecting the views of the French Military Health Service.

3 Venous Thromboembolism Venous thromboembolism (VTE) is a blood clot that starts in a vein. 2 types: Deep vein thrombosis (DVT) is a clot in a deep vein, usually in the leg Pulmonary embolism (PE) occurs when a DVT clot breaks free from a vein wall, travels to the lungs and blocks some or all of the blood supply. Blood clots in the thigh are more likely to break off and travel to the lungs than blood clots in the lower leg or other parts of the body. 3 rd leading vascular diagnosis after heart attack and stroke 300, ,000 each year in USA.! Place of venous ultrasonography

4 Venous Thromboembolism in aviation medicine VTE! Flight safety - Leg pain and edema - Dyspnea, tachypnae, chest pain - Syncope, death Flight! VTE - Increase risk of VTE due to Virchow s triad per 1,000 passengers/years times highter than in the healthy population - Aircrew members? Kuipers S et al. The absolute risk of venous thrombosis after air travel: a cohort study of 8,755 employees of international organizations. PLoS Med 2007; 4:

5 !Place of venous ultrasonography! primary noninvasive diagnostic method!several types: compression ultrasound, duplex ultrasound, color doppler imaging alone In complement of a complete medical examination 2 medical questions for rehabilitation after a VTE Vascular sequelae Recurrence risk Hereditary or acquired factors Temporary or permanent Strong, moderate or weak Diagnosis Treatment and follow-up Return to fly

6 Doppler ultrasound: gold standard for diagnosis First line exploration! Quality criteria: Morphological test: diagnosis A complete anatomic exploration Deep vein system: inferior vena cava! foot Superficial vein system Bilateral analysis Thrombus characteristics: Superior limit, diameter in compression, extension Gravity diagnosis: phlegmatia coerulae (ischemia by artery compression) Sometimes: fast echo in two points for proximal DVT diagnosis. in a second time: complete Doppler ultrasound Gold standard now: Only one complete test! For the flight surgeon: complete and conscientious analysis

7 Thrombosis diagnosis and differential diagnosis

8 Thrombosis diagnostic

9 Vein thrombosis localisation Proximal DVT (80%): Common iliac vein External iliac vein Common femoral vein Fermoral vein Popliteal vein Sensitivity: 97-98% Specificity: 97-98% Distal DVT(20%): Anterior tibial vein Posterior tibial vein Peroneal vein Sensitivity: 70% Specificity: 60% 10-25% of distal DVT! proximal DVT in 7 days!pe +++!PE + Superficial vein system Long saphenous vein Short saphenous vein Sensitivity? Specificity? Extension?! CONTINUUM! Duration of anticoagulant therapy

10 Duration of anticoagulant therapy Two elements for the decision : - localisation: proximal or distal DVT not - Provoked or unprovoked factors, reversible or Distal DVT: - 3 months - Minimum of 6 weeks in case of reversible provoked factor - more than 3 months in case of cancer, pregnancy or permanent increased risk factors Proximal DVT: unprovoked: 6 months case by case decision for cancer or pregnancy Treatment = Anticoagulation therapy and class 3 compression stockings Place of Doppler ultrasound during treatment?! Seems to be logical. Evolution? Efficiency?!But no!! Whatever the result : no treatment duration modification! Only one case: no clinical improvement

11 When it s time to discuss flying rehabilitation European regulation for civil aircrew Implementing Rules: MED.B.010 «Applicants with an established history or diagnosis of arterial or venous thrombosis shall be referred to the licencing authority» Acceptable means of compliance French regulation for military aircrew Anticoagulation therapy = Unfit Nothing specific about Thromboembolism But all diseases with a risk for flight safety = unfit - case by case Evaluation after presentation at the national commission Is the anticoagulation therapy the only problem? - What about delay before rehabilitation? - what sort of medical exams could we perform? - What are the elements of discussion?! Place of venous echo Doppler? IMPLEMNETING RULES TO CIVIL AVIATION AIRCREW: COMMISSION REGULATION (EU) No 1178/2011 of 3 November 2011 Acceptable Means of Compliance (AMC) and Guidance Material (GM) to Part ATCO.MED Medical requirements TO CIVIL AVIATION AIRCREW: 15 decmber 2011 IMPLPEMNETING RULES TO AIR TRAFFIC CONTROLLER :COMMISSION REGULATION (EU) 2015/340 of 20 February 2015 Acceptable Means of Compliance (AMC) and Guidance Material (GM) to Part ATCO.MED Medical requirements for air traffic controllers.13 March 2015 Instruction ministérielle 800 du 20 février 2012

12 When it s time to discuss flying rehabilitation After the end of the anticoagulation treatment use administrative delay to make sure there is no recurrence without treatment In case of long-term treatment: after the recommended curative treatment (6 months) Place of venous echo Doppler? Recurrence risk? Vascular evaluation Sequelae? Postthrombotic syndrome?

13 Place of doppler ultrasound: Reccurence risk? Risk factors for venous thromboembolism recurrence: Unprovoked proximal DVT +++ Proximal vs distal DVT Initial length of tretment Initial thombosis characteristics and treatment Obesity Male sex Patient characteristics Positive d-dimer testing Hereditary thrombophilia Active cancer Antiphospholipid antibody Pregnancy and puerperium Etiology Persistence of residual thrombosis?! Fahrni et al. Assessing the risk of recurrent venous thromboembolism a practical approach Vasc Health Risk Manag 2015; 11: Carrier et al. Residual vein obstruction to predict the risk of recurrent venous thromboembolism in patients with deep vein thrombosis: a systematic review and meta-analysis. J Thromb Haemost. 2011;9:

14 Place of doppler ultrasound: Vascular evaluation 1/ Mapping of vascular sequelae +++ to ensure the disappearance of the thrombus Optimal treatment = cure - to make the difference between a recurrence and a sequelae 2/ Search for a local abnormality increasing recurrence risk - compression, 3/ General vascular check-up - Distal thrombosis, contralateral thrombosis - Varicose veins: link with VTD? 220,000 patients Follow-up duration: 7.5 years DVT: HR x 5.3 PE: HR x 1.73 Chang et al. Association of Varicose Veins With Incident Venous Thromboembolism and Peripheral Artery Disease. JAMA 2018 Feb 27;319(8):

15 Place of doppler ultrasound: Vascular evaluation Prognostic elements for a postthrombotic syndrome? Definition: the development of symptoms and signs of chronic venous insufficiency following deep vein thrombosis 20-50% Clinical diagnosis: Villalta s score Diagnosis, severity and prognosis score 5-9 :Mild PTS 10-14: moderate PST 15: severe PST No link between ultrasonic abnormalities and risk of PTS PTS without vascular sequelae Vascular sequelae without PTS! No place in prognosis for venous echo Doppler Arany Soosainathan and al. Scoring systems for the post-thrombotic syndromej Vasc Surg 2013;57:254-61

16 Take home message Important place of the initial venous echo Doppler Complete analysis For flight rehabilitation: Search sequelae and general vascular check-up after treatment No place of ultrasonic control during treatment No link between echo Doppler and PTS Evaluation of recurrence risk: Provoked/unprovoked ++++ Treatment, etiology, patient characteristics ++++ Less important of ultrasonic results

17 Thank you for your attention