The Conservative and Active Management of Post Thrombotic Syndrome

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1 The Conservative and Active Management of Post Thrombotic Syndrome Stephen Black Consultant Vascular Surgeon Clinical Lead for Venous and Lymphoedema Surgery Guys and St Thomas Hospital London

2 How important is DVT v AAA DVT 1/1000 incidence 70,000 DVTs in UK per annum Most serious complication : PE PE kills 24,000-32,000 p.a. AAA In men: 0.25/1000 age /1000 age 70 Most serious complication : Rupture raaa kills 12,000 p.a. 1-Prandoni-Annals of Internal Medicine 1996; 125:1-7 2 European Heart Journal doi: /eurheartj/ehu

3 What is the primary physicians thought Accurate diagnosis process? Treat patient in a safe manner Shift patient out of clinic/er/bed/hospital as efficiently as possible Most initial concern directed towards avoiding PE They do NOT see patients long term Follow up focused on anticoagulant control and VTE recurrence - less interested in leg swelling and pain which affect daily living

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5 VTE Recurrence VS Restoration of function

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8 Who gets it? One third of all DVTs Iliofemoral Up to 60% of these patients will get PTS 1 in 1000 people in UK 1/3 Iliofemoral US 330,000

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10 Stockings Dressings Anticoagulants Conservative Options Multiple Meta-analysis of the available literature Most focused on prevention Treatment options poorly studied

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13 Three Broad Patient Groups Acute Post Thrombotic Chronic Post Thrombotic Non-Occlusive Non Thrombotic (NIVL) The stents sole role is to maintain an adequate lumen

14 Figure 15 Treatment Pathway

15 "Becoming an expert in almost anything requires literally years of work. People will do this only if they have some initial success, enjoy the work, and are supported by the social climate. Expertise is not solely a cognitive affair." ~ Earl Hunt

16 Belen Quintana Prakash Saha Laurence Boss Theatre Team Our Team Outpatient Team Inpatient Team Intreventional Radiology: Ilyas Shazd, Narayan Karunanithy, Tarun Saburwhal, Irfan Ahmad

17 May-Thurner/Cockett Syndrome

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20 Original options limited Wallstent Arterial Stents - small diameters High radial force does not imply crush resistance

21 It is principally about Radius

22 New Dedicated Venous Stents Optimed Cook Veniti Bard Medtronic Boston Scientific

23 Strength and coverage for venous disease Newtons

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28 Post Procedure IVUS

29 Residual compression at the left common iliac vessel crossing Arterial stent -open cell structure Venous Stent - open cell structure IVUS image IVUS image Braided stainless steel stent Venous Stent closed cell structure IVUS image IVUS image

30 Flexibility leg in foetal position

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39 Valve Reconstruction Valvuloplasty Kistner (malleti) Neovalve - Malleti O. Maleti a, M. PerrinReconstructive Surgery for Deep Vein Reflux in the Lower Limbs: Techniques, Results and Indications Eur J Vasc Endovasc Surg (2011) 41, 837e848

40 Stent Choice Placement Errors Mistakes Technical Patency Flow Inflow!!! CFV Clotting APLS Behcet s Anti-coagulation

41 Number of Patients Deep venous reconstruction programme Total patients seen 444 Total patients having intervention Acute DVT Chronic PTS

42 Day 1 Day 4 Day 7 Day 10 Day 14 Day 21 Day 28 % Red Cell Stain % Fibrin Stain % Collagen Stain McGuiness et al., Thromb & Haem (2001) Saha et al., Circulation (2013) HUMAN MOUSE A i ii B 100 *** *** i 90 ii i ii *** i ii i i ii i i ii ii C Day 100 *** 90 *** *** 80 *** ii i ii i ii Day i ii D *** ii 50 i 40 *** i ii i ii *** Day

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44 April 2012 and November 2015 TABLE 1

45 Outcomes Primary patency was defined as a patent stent with <50% diameter reduction Primary assisted patency was defined as a stent that had not occluded but had a re-intervention based on imaging findings and/or symptoms Secondary patency included stents that blocked and were successfully reopened Ulcer healing or changes in Venous Disability Score and Villalta Score were used as a measure of clinical outcomes before and after intervention QOL scores now measured on all patients before and after intervention by Belen

46 ACUTE PATEINTS 88% of CDT patients had a venous stent

47 Complications No stent related mortality Major bleeding complications: No strokes No GI haemorrhage 4/66 (6%) patients required >2 units blood transfusions One patient had an iatrogenic arterio-venous fistula One patient presented with a presumed infective thrombus One patient needed a brachial artery cut-down for failed cannulation in IR

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49 CHRONIC PATEINTS Ulcer healed in 6/14 patients (43%)

50 Complications No stent related mortality Major bleeding complications: No strokes No GI haemorrhage 1 large groin haematoma requiring exploration 1 large hamatoma in rectus femoris muscle 1 spinal haematoma resulting in paraplegia 3/6 (50%) patients developed infection of their PTFE fistula graft that required removal

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52 Technical considerations 6 month outcomes in chronic patients 2014 Primary patency 50% Secondary patency 68% 2016 Primary patency 69% Secondary patency 87%

53 EVAR 1 at 10 years Greenhalgh et al, NEJM 2010

54 Conclusions Medical management does not treat PTS Dedicated stents potentially improve treatment First generation of stent design The stent alone is not the panacea Know each device and technical issues We need long term patient outcome data to support use We do not have data yet to know if this is durable?