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Endovascular management of Chronic thromboembolic pulmonary Disease and
Post thrombotic syndrome
Riyaz Bashir MD, FACC Director Vascular and Endovascular medicine
Professor of medicine Temple University Hospital
786
Operable 64%
In-operable 36%
CTEPH Patients
57% - Treated with Pulmonary Thromboendarterectomy
(Circulation . 2011; 124:1973-1981.)
Eur Heart J. Published online September 23, 2017. doi:10.1093/eurheartj/ehx530
Outcomes of BPA – Japanese Experience
Eur Heart J. Published online September 23, 2017. doi:10.1093/eurheartj/ehx530
Outcomes of BPA – Japanese Experience
Eur Heart J. Published online September 23, 2017. doi:10.1093/eurheartj/ehx530 Eur Heart J | Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: [email protected].
Challenges of BPA Reperfusion Pulmonary Edema
47 Yr. Old Male Self Employed Painter S/P Splenectomy Perfusion Scan Non-Selective pulmonary Angiogram
Technical Procedure of BPA
• Right Femoral vein access
• 7Fr Long sheath (70cm)
• 6Fr Guiding Catheter (Multipurpose, JR 4)
• Cross the lesion with a Radi wire
• BPA over a RADI Wire
Echocardiographic Changes
Pre BPA 6 min walk distance – 360 m
PVR – 6.8 WU
Post BPA 6 min walk distance – 449 m
PVR - 4.0
TEMPLE CTEPH TEAM
Paul Forfia Anjali Vaidya Arslan Mirza Yousi Toyoda Chandra Dass Riyaz Bashir
Temple’s Early Experience with Balloon Pulmonary Angioplasty
Temple BPA Experience
32 patients
63 sessions
194 Vessels
191 Surgical Thromboendarterectomies
0
5
10
15
20
25
30
35
40
45
50
FY2013
FY2014
FY2015
FY2016
FY2017
FY2018
FY2019
1
10 13
34 37
46 48
3
13 15
30
PTE
0
2
4
6
8
10
12
14
Pre-BPA 1 monthPost-BPA
3 MonthPost-BPA
6 MonthPost-BPAN
um
be
r o
f C
TEP
H P
atie
nts
(N
=13
)
New York Heart Association (NYHA) Functional Class Before and After BPA Based on Six Minute Walk Test
NYHA IV (<300 m)
NYHA III (300-376 m)
NYHA II (377-450 m)
NYHA I ( >450 m)
6 MWD increased from 342 ± 113 m to 429 ±151 m
2019 – At CTEPH Centers of Excellence
1. PTE is the first line of therapy for CTEPH – Potentially curative.
2. BPA is a reasonable option in patients who have in-operable disease or are very poor surgical risk
Post Thrombotic Syndrome May Thurner Syndrome
PRE stent Post Stent
Eliahou R et al. Radiographics 2012;32:E33-E49
Post hysterectomy venogram
showing decompression of IVC
and IVC filter (arrow).
IVC venogram: filling defect in the IVC and compression of filter from external compression
CT angiogram of chest and abdomen demonstrating large leiomyoma with compression of the IVC and IVC filter (blue arrow).
Uterine Fibroids
CONCLUSION
• Venous CTO stenting of the iliofemoral and caval vessels leads to significant improvement in functional capacity
• Ongoing CTRACT Trial – level 1 Evidence
C-TRACT Trial Referral - Mobile App
• Open Apple App Store or Google Play Store
• Using the search feature, type “C-TRACT.” - Android users must use caps and hyphen
• Locate the “C-TRACT Referral Tool” App.
• Click “GET” or “Install” from search screen
• You are ready to refer patients to C-TRACT!
C-TRACT App Icon
Temple University
Venous Thromboembolism Program
215-316-0232
CAD STEMI Stroke (LVO) Large Vessel VTE
CV cause of M & M #1 #2 #3
Pathogenesis Thrombus/stenosis Thrombus/stenosis Thrombus/stenosis
Standard of Care Endovascular Endovascular ? Endovascular
Challenges 1. Resistance to interventional therapies
2. Systems/processes 3. Technology
1. Resistance to interventional therapies
2. Systems/Processes
3. Technology
1. Resistance to interventional therapies
2. Systems and processes
3. Technology - Volume of thrombus
2019
VTE – Challenge Burden of Thrombus
Courtesy of W. Jaber, Brent Keeling and Omar Lattouf
Acute ST elevation Myocardial infarction
Acute Stroke Acute Pulmonary Embolism
Safety of BPA
• Zero procedure related mortality
• Two patients had mild hemoptysis one required brief intubation
• One patient mild radiographic reperfusion edema
Case
• 53 yr. female • Severe left leg swelling and venous claudication • Severe post thrombotic syndrome
• Venous Duplex: • Chronic DVT left common femoral and iliac veins
• PMHX: • Heterozygous Factor 5 Leiden mutation • 1989 – after starting oral contraceptives • Developed left iliofemoral DVT complicated by phlegmasia cerulea Dolens treated with
systemic thrombolysis. • One recurrence on anticoagulation
Stenting • Need to extend into IVC
• Need to cover CFV stenosis
• Avoid stenting across the Profunda vein
Complete resolution of swelling and Claudication
Treatment of CTEPH
Mahmud, et al J A CC VO L. 7 1, N O . 21, 2018 MA Y 29, 201 8 : 24 6 8 – 86
PTE
BPA