Interventional Treatment VTE: Radiologic Approach Hae Giu Lee, MD Professor, Dept of Radiology Seoul St. Mary s Hospital The Catholic University of Korea
Introduction Incidence High incidence: 250,000-1,000,000/year in US In Korea: increased in incidence Aging society Malignancy High detection rate Risk Factors DVT of lower extremities Old age, Debilitating state, Malignancy, Major surgery Hypercoagulability, Pregnancy, Contraceptive, Hormonal therapy Antiphospholipid antibody syndrome, Inflammatory bowel disease, SLE, Varicose vein, Previous DVT, Central venous catheter
Introduction Post-thrombosis syndrome Pain, swelling, skin discoloration, heaviness, venous claudication & ulceration Iliofemoral DVT High incidence & worse prognosis Rarely recanalize via endogenous processes Persistent outflow obstruction-high venous pressure Higher incidence of recurrent DVT than infrainguinal thrombosis Damaged venous valve & obstruction Rapid progression in recurrent thrombosis Incidence: 1 yr - 17.3%, 8 yr 29% Severity of DVT & Occ. of PTS: low correlation Worse life quality Complications of DVT Br J Radiol 2009;82:198, Arch Intern Med 2002;62:1144, Arch Intern Med 2004;164:17, J Vasc Surg 2009;49:704
Introduction Complications of DVT Pulmonary thromboembolism Majority of DVT Pts No or weak relation with DVT extent & clot amount Life threatening Br J Radiol 2009;82:198, Arch Intern Med 2002;62:1144, Arch Intern Med 2004;164:17, J Vasc Surg 2009;49:704
Dx D-dimer Screening Introduction US Screening Compression & Color Doppler Imgaging Venography CT & MR venography Pelvis & Abdomen: Extent Adequacy of outflow DVT of lower extremities
Introduction Venous valve Rest Systolic Diastolic
Introduction Pathology after DVT 3 days 1 wk 2 wks 4 wks Ann Surg 1987;205:312
Introduction Chronic change: 4 wks after Tx Surgical Thrombectomy Thrombolysis J Vasc Surg 2000;31:1193-205
Introduction Vascular change: DVT 10 years earlier No venous obstruction
Indications Acute thrombosis < 10 days Response Favorable prognosis Chronic lesions Poor response Sometimes amenable An experimental study Residual thrombus Organized & recanalized thrombus at 4 wks Re-endothelialization at 4 wks Combined reflux Incompetent valve Combined lesions Stenosis Obstruction Systemic disease Vasc Surg 2000;31:1193
Treatment Goals Prevention of PE Prevention of DVT propagation Provision of early symptom relief Prevention of PTS DVT of lower extremities Tx Anticoagulant Conventional Tx-systemic Catheter-directed thrombolysis Mechanical thrombectomy Combined JVIR 2006;17:613
Treatment Anticoagulation Post-thrombosis syndrome Fails to prevent PTS in significant proportion Life quality Significant disability QOL impairment Socioeconomic Condition Surgery: contemporary tech. AVF Improved patency Less venous pressure Less edema & PTS Conventional & Surgical Tx Eur J Vasc Endovasc Surg 2007;33:351, JVIR 2006;17:613
Treatment Catheter-directed thrombolysis Decreases incidence of PTS Early thrombosis removal Normal valvular function 72% vs 12%(anticoagulation) Interventional Tx Improved QOL Faster Sx relief than anticoagulation Hours to days PE & PE related death: 0.9% & 0.1% Radiology 1999:211:39, JVIR 2005;16:815, J Vasc Surg 2000;32:130, JVIR 2006;17:613
Treatment Catheter-directed thrombolysis Thrombolysis with UK + Stenting 1 st Patency, 1yr & 2yr: 95% 2 nd Patency, 1yr & 2yr: 100% Disadvantage High dose of thrombolytic agent Prolonged procedure time: Esp. chronic Bleeding Mostly vascular access Major bleeding 8-11%, Intracranial bleeding 0.2% Possible lack of long term benefits Interventional Tx Radiology 1999:211:39, J Vasc Surg 2009;49:704, JVIR 2005;16:815
Treatment Interventional Tx Group 1: Anticoagulation, Group 2: Thrombolysis Ann Surg 2001;233:752
Treatment Mechanical thrombectomy Embolic complications Often inadequate Hemolytic complications anemia and renal dysfunction Relative short procedure time Interventional Tx Eur J Vasc Endovasc Surg 2007;33:351 JVIR 2001; 12:147 164
Amplatz device Treatment Rotational blender-like impeller Mechanical thrombectomy 100,000 to 150,000 rpm Aspirate & re-circulate macerated thrombus Results Removal of thrombus: 75-83% 6 month patency: 77% Procedural related desaturation No clinically significant PE Eur J Vasc Endovasc Surg 2007;33:351
Treatment Arrow-Trerotola device Rotational design 4 helically arranged nitinol wires 3000 rpm Re-circulates macerates thrombus Mechanical thrombectomy Thrombolytic therapy & angioplasty with stents Technical & clinical success: 100% 16-month: 92% Valve & intimal damage No reports Eur J Vasc Endovasc Surg 2007;33:351
Treatment AngioJet device High-velocity saline jet (350-450 km/hr) Zone of negative pressure around the catheter tip Advantages Less vessel trauma Mechanical thrombectomy Ability to aspirate thrombus Results Without preprocedural thrombolytic therapy ½ Pts: removal of 50% thrombus & 77% of patency Another study 65% of Pts: complete removal Eur J Vasc Endovasc Surg 2007;33:351
Treatment Trellis catheter Hybrid catheter Isolates thrombosed vein segment between two occluding balloons Thrombolytics infusion between occluding balloons Dispersion wire into the catheter spiral configuration 1500 rpm 15-20 min: thrombus aspiration Advantages Mechanical & pharmacologic therapies Infusate aspiration: Avoid systemic thrombolysis Rapidity Prevent PE by occluding balloon Results Procedure time: 91 min Complete lysis(>95%): 14% 1st patency in 2 days: 86% Mechanical thrombectomy Eur J Vasc Endovasc Surg 2007;33:351, JVIR 2007;18:715
Treatment Ultrasound-accelerated Thrombolysis US + Catheter-directed thrombolytics Mechanical thrombectomy Infusion catheter with ultrasound transducers Clot fibrin fragmentation Results Complete lysis:70% Overall lysis: 91% Infusion time: 22.0 hrs Eur J Vasc Endovasc Surg 2007;33:351, JVIR 2008; 19:521
Treatment Korean style Thrombolysis with UK 30,000-120,000 U/Hr for 4 hr-overnight Thromboaspiration with 8-9F vascular sheath Contraindication of thrombolysis Refused thrombolysis Occasionally combined balloon maceration Mostly within 2 hrs Blood loss Incomplete removal of thrombus Combination Thrombolysis with thromboaspiration Common in Korea Temporary IVC filter placement Most cases Rethrombosis Intervention US or CT follow-up