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
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 50 0.78/1000 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:10.1093/eurheartj/ehu283 3-www.uhce.ox.ac.uk/Atlases/Trends/England/Pulmonary%20embolism_England.pdf 4-www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/99/9906.htm#n23
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
VTE Recurrence VS Restoration of function
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
Stockings Dressings Anticoagulants Conservative Options Multiple Meta-analysis of the available literature Most focused on prevention Treatment options poorly studied
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
Figure 15 Treatment Pathway
"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
Belen Quintana Prakash Saha Laurence Boss Theatre Team Our Team Outpatient Team Inpatient Team Intreventional Radiology: Ilyas Shazd, Narayan Karunanithy, Tarun Saburwhal, Irfan Ahmad
May-Thurner/Cockett Syndrome
Original options limited Wallstent Arterial Stents - small diameters High radial force does not imply crush resistance
It is principally about Radius
New Dedicated Venous Stents Optimed Cook Veniti Bard Medtronic Boston Scientific
Strength and coverage for venous disease Newtons
Post Procedure IVUS
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
Flexibility leg in foetal position
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
Stent Choice Placement Errors Mistakes Technical Patency Flow Inflow!!! CFV Clotting APLS Behcet s Anti-coagulation
Number of Patients Deep venous reconstruction programme Total patients seen 444 Total patients having intervention 220 80 60 Acute DVT Chronic PTS 40 20 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
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 80 70 i ii 60 50 *** i ii 40 30 20 i i ii i i ii ii C 10 0 1 4 7 10 14 21 28 Day 100 *** 90 *** *** 80 *** 70 60 ii 50 40 i ii 30 20 i ii 10 0 1 4 7 10 14 21 28 Day i ii D 70 60 *** ii 50 i 40 *** i ii i ii 30 20 10 *** 0 1 4 7 10 14 21 28 Day
April 2012 and November 2015 TABLE 1
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
ACUTE PATEINTS 88% of CDT patients had a venous stent
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
CHRONIC PATEINTS Ulcer healed in 6/14 patients (43%)
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
Technical considerations 6 month outcomes in chronic patients 2014 Primary patency 50% Secondary patency 68% 2016 Primary patency 69% Secondary patency 87%
EVAR 1 at 10 years Greenhalgh et al, NEJM 2010
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?