Interventional Treatment VTE: Radiologic Approach

Interventional Treatment VTE: Radiologic Approach

Hae Giu Lee, MDProfessor, Dept of Radiology

Seoul St. Mary’s HospitalThe 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

DVT of lower extremities

• High detection rate

• Risk Factors•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

Complications of DVT

• 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

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

• Pulmonary thromboembolism– Majority of DVT Pts– No or weak relation with DVT extent & clot amount– Life threatening

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

• Dx– D-dimer• Screening

– US


US• Screening• Compression & Color Doppler Imgaging

– Venography– CT & MR venography• Pelvis & Abdomen: Extent• Adequacy of outflow

Introduction

• Venous valve

Rest Systolic Diastolic

Introduction

• Pathology after DVT

Ann Surg 1987;205:312

3 days 2 wks1 wk 4 wks

Introduction

• Chronic change: 4 wks after TxSurgical

ThrombectomyThrombolysis

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– 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


• 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

Conventional & Surgical Tx

• QOL impairment• Socioeconomic Condition

• Surgery: contemporary tech.– AVF…– Improved patency– Less venous pressure– Less edema & PTS

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

– 72% vs 12%(anticoagulation)

– 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

• 1st Patency, 1yr & 2yr: 95% • 2nd Patency, 1yr & 2yr: 100%

– Disadvantage

Interventional Tx

– 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

Radiology 1999:211:39, J Vasc Surg 2009;49:704, JVIR 2005;16:815

TreatmentInterventional Tx

Group 1: Anticoagulation, Group 2: ThrombolysisAnn 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;33:351JVIR 2001; 12:147–164

Treatment

• Amplatz device– Rotational blender-like impeller• 100,000 to 150,000 rpm• Aspirate & re-circulate macerated thrombus

Mechanical thrombectomy

• 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


• Re-circulates macerates thrombus

– Thrombolytic therapy & angioplasty with stents• Technical & clinical success: 100%• 16-month: 92%

– Valve & intimal damage• No reports


Treatment

• AngioJet device– High-velocity saline jet (350-450 km/hr)

• Zone of negative pressure around the catheter tip

– Advantages• Less vessel trauma


• Less vessel trauma• 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


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


• 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%

Eur J Vasc Endovasc Surg 2007;33:351, JVIR 2007;18:715

Treatment

• Ultrasound-accelerated Thrombolysis– US + Catheter-directed thrombolytics• Infusion catheter with ultrasound transducers• Clot fibrin fragmentation


• 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– 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

Documents

Interventional Treatment VTE: Radiologic Approach