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Ambulatory Venous Hypertension

Obstruction and valve incompetence. …Highest venous pressure …Most severe morbidity. Ambulatory Venous Hypertension. Components. Obstruction Valve incompetence. Iliofemoral DVT. Contraindication to Lysis. Yes. No. Surgical Thrombectomy + AVF. Catheter-directed Thrombolysis. Success.

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Ambulatory Venous Hypertension

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  1. Obstruction and valve incompetence …Highest venous pressure …Most severe morbidity Ambulatory Venous Hypertension Components • Obstruction • Valve incompetence

  2. Iliofemoral DVT Contraindication to Lysis Yes No Surgical Thrombectomy + AVF Catheter-directed Thrombolysis Success No Anticoagulation Yes

  3. Venous Thrombectomy vs. Anticoagulation Randomized Trial • 63 patients: iliofemoral DVT • Thrombectomy + AVF vs. Anticoagulation • Follow-up: 6 mos, 5 yrs, 10 yrs • Patency • Valve function • Venous hemodynamics • Clinical evaluation Plate G et al, J Vasc Surg 1984

  4. Venous Thrombectomy vs. Anticoagulation Results: 5 years (n=41) Thrombectomy Anticoag. Patent iliac* 78% 50% N Valve fct. (fempop) 40% 6% Reflux + obstruction 7% 37% Asymptomatic 37% 18% Severe CVI 11% 27% AVP 43 mmHg 60 mmHg *radionuclide phlebography Plate G et al, Eur J Vasc Endovasc Surg 1990

  5. Acute DVT Thrombolytic Therapy: ACCP 2004 “…There is no evidence that supports the use of thrombolytic agents for the initial treatment of DVT….” Recommend against the routine use of catheter-directed thrombolysis (Grade 1C) …Treatment..[with lytic Rx] .. Be confined to patients requiring limb salvage. (Grade 2C) Buller H, et al Chest 2004;126:401S

  6. Catheter-Directed Lysis Iliofemoral DVT Improvement in Quality of Life • Significantly better QOL with lysis Physical function Stigma Health distress Post thromb Sx • Successful lysis correlated w/QOL • Lytic failures and heparin Rx similar Comerota AJ et al J Vasc Surg 2000

  7. Catheter-Directed Lysis Iliofemoral DVT Improvement in Quality of Life • 35 consecutive patients • Iliofemoral DVT • Randomized • Follow-up 1week/6mos • Clot lysis • Venous reflux • Cath-dir SK (pulse spray) • vs. • Anticoagulation alone Elsharawy M, et al Eur J Vas Surg. 2002; 24:209

  8. Catheter-Directed Lysis Iliofemoral DVT Randomized Trial: Outcome at 6 months Anticoag (n=17) Lysis (n=18) P-valve Patency 12% 72% <0.001 Reflux 41%* 11% 0.04 LOS 6d 7d 0.4 *Underestimate 20 occlusion Elsharawy M, et al Eur J Vas Surg. 2002; 24:209

  9. Postthrombotic Syndrome Elastic Stockings (30-40 mmHg) Postthrombotic Syndrome Control Stocking RRR P-value Brandjes DP 47% 21% 55% <.01 (n=194) Lancet 1997;349:759 Prandoni P 49% 24% 51% <.01 (n=170) Patho Hemst Thromb 2002;32(suppl 2):72

  10. A Strategy of Thrombus Removal for Venous Thromboembolism: We Owe it to Our Patients

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