Surgical treatment acute dvt

Surgical treatment acute dvt

1. Surgical Treatment for Acute
Deep Vein Thrombosis
Anthony J. Comerota, MD, FACS, FACC
Director,
Jobst Vascular Institute
Adjunct Professor of Surgery,
University of Michigan

2. Surgical Treatment for Acute
Deep Vein Thrombosis
Venous Thrombectomy in
Patients with Iliofemoral DVT

3. Long-term: Clinical Status and QOL
•95% Venous Insufficiency
•15% Venous Ulceration
•Venous claudication developed in almost
50%
•Limited ambulation in 15%
•Marked hemodynamic impairment
•Markedly reduced QOL
Delis KT et al
Ann Surg 2004;239(1):118
Akesson H
Eur J Vasc Surg 1990
Observations at 5 Years
Iliofemoral DVT: Anticoagulation Alone

4. Intramuscular Pressures (mmHg)
Iliofemoral DVT
Days
Intramuscular
Pressure
(mmHg)
Anterior & Deep Posterior Compartments (Mean)
Qvarfordt P et al
Ann Surg 1983;197:450
•12 Patients with iliofemoral DVT
•Venous thrombectomy
•Intramuscular pressures (wick)
(Surrogate for venous pressure)
Pre-Op
(Mean)
Post-Op
(Mean)
40
30
20
10
0
Reduction of pressure to normalReduction of pressure to normal
after thrombus removalafter thrombus removal

5. Extensive DVT Rx’ed with anticoagulation alone…Extensive DVT Rx’ed with anticoagulation alone…
……obstructs venous returnobstructs venous return
… …causes valve reflux, leading to…causes valve reflux, leading to…
……venous hypertension, which...venous hypertension, which...
……activates the activates the cellular and metabolic pathwayscellular and metabolic pathways
leading to chronic venous diseaseleading to chronic venous disease
……Producing avoidable and costly Producing avoidable and costly
post-thrombotic morbiditypost-thrombotic morbidity
Basis for Argument
Venous Thrombectomy

6. Strategy of thrombus removal
–Eliminates obstruction
–Preserves valve function
Iliofemoral DVTIliofemoral DVT

7. Venous ThrombectomyVenous Thrombectomy
- History -- History -
•Early initial enthusiasm
•Disappointment with results
(Lansing and Davis reports)
•Surgeons stopped performing procedure
•Recent enthusiasm
–Better understanding principles
–Randomized trials
–Improved technique
–Improved anticoagulation

8. Iliofemoral DVT
Strategy of thrombus removal
–Venous thrombectomy
–Catheter directed thrombolysis
…for iliofemoral DVT
ACCP 2008
2008

9. “Contemporary” Venous
Thrombectomy

10. Long-Term Results
Venous Thrombectomy
76%41 months6051984-9910
PatencyFollow-upNo.YearsReports
Iliac Vein Patency
(mean) (mean)
63%45 months1984-99
CompetenceFollow-upNo.YearsReports
Femoral-Popliteal Competence
(mean)(mean)
8

11. Venous ThrombectomyVenous Thrombectomy
- Randomized Trial -- Randomized Trial -
•Randomized trials: Scandinavian centers
•Iliofemoral DVT: N=63
•Randomized:Venous thrombectomy + AVF + Anticoagulation
vs.
Anticoagulation alone
•Endpoints:
–Patency
–Post-thrombotic morbidity
–Complications
•Follow-up: 6 months, 5 years, 10 years
Plate G et al
J Vasc Surg 1984
Eur J Vasc Surg 1990
Eur J Endovas Surg 1997

12. •Infrequent - both groups
•One recurrent, symptomatic PE (anticoag.)
•3 wound complications
•No significant bleeding complication
•13% early reocclusion (thrombect.)
Early Complications
Plate G et al,
J Vasc Surg 1984
Venous ThrombectomyVenous Thrombectomy
- Randomized Trial -

13. Anticoag.Thrombectomy
6.7 mmHg3.2 mmHg*Exercise Pressure (iliac)
15%4%Venous Claudication
37%17%Varicose Veins
78%54%Swelling
7%42%Asymptomatic
26%52%N Valve fct. (fempop)
35%76%Normal Iliac (venogram)
*successful thrombectomy
Plate G et al,
J Vasc Surg 1984
Venous ThrombectomyVenous Thrombectomy
- Randomized Trial - Results: 6 Months (N=51) -

14. Anticoag.Thrombectomy
60 mmHg43 mmHgAVP
27%11%Severe CVI
18%37%Asymptomatic
37%7%Reflux + obstruction
6%40%N Valve fct. (fempop)
50%78%Patent iliac*
Plate G et al,
Eur J Vasc Endovasc Surg 1990
*radionuclide phlebography
Venous ThrombectomyVenous Thrombectomy
- Randomized Trial - Results: 5 Years (N=41) -

15. 14%
43%
33%
78%
Anticoag.Thrombectomy
63 mmHg55 mmHgAVP
18%8%Severe CVI
24%54%N Clinical Score
N Valve fct.
Femoral
Popliteal
41%84%Patent iliac*
Plate G et al,
Eur J Vasc Endovasc Surg 1990
*radionuclide phlebography
Venous ThrombectomyVenous Thrombectomy
- Randomized Trial - Results: 10 Years (N=30) -

16. Acute Post Op
Iliofemoral DVT

17. Venous ThrombectomyVenous Thrombectomy
- PreOp -- PreOp -
•Know full extent of thrombosis
•Image vena cava
•Therapeutic anticoagulation
•Arrange for complete imaging
(leg through vena cava)

18. Venous ThrombectomyVenous Thrombectomy
- Operative -- Operative -
•Prep entire leg
•Expose CFV, SFJ, FV, profunda
•Infrainguinal thrombectomy first
•Catheter based infrainguinal thrombectomy if
massage/compression not successful
•Iliocaval thrombectomy with fluoroscopic guidance
•Correct iliac vein stenosis
•Construct AVF

19. Femoral Vein Exposure
Venous Thrombectomy

20. Clot with Venous Hypertension
Venous Thrombectomy

21. Leg Compression
Venous Thrombectomy

22. Operative Technique
Venous Thrombectomy

23. Dual Catheter Technique
Venous Thrombectomy

24. Dual Catheter Technique
Venous Thrombectomy

25. Dual Catheter Technique
Venous Thrombectomy

26. Comerota AJ, Gale S
J Vasc Surg 2006;43:185-91.
Infrainguinal Balloon Catheter Passage
Venous Thrombectomy

27. Operative Technique
Venous Thrombectomy

28. Operative Technique
Venous Thrombectomy

29. Venous Balloon
Venous Thrombectomy

30. Venous Thrombectomy
Iliofemoral DVT

31. Completion Phlebogram
Venous Thrombectomy

32. Correct Iliac Vein Stenosis
Venous Thrombectomy

33. Comerota AJ, Gale S
J Vasc Surg 2006;43:185-91.
Caval Clot
Venous Thrombectomy

34. Specimen
Venous Thrombectomy

35. AV Fistula
Venous Thrombectomy

36. •Small anastomosis
•↑ venous velocity
•No ↑ pressure
•Permanent
Arteriovenous Fistula
Venous Thrombectomy

37. clamped
clamp
removed
Femoral Vein Pressure
Iliofemoral DVT

38. AV Fistula and Distal Catheter
Venous Thrombectomy

39. Posterior Tibial Vein Infusion Catheter
Venous Thrombectomy

40. Anticoagulation Catheter
Venous Thrombectomy

41. Venous ThrombectomyVenous Thrombectomy
- PostOp -- PostOp -
•Leg infusion of heparin
•Long-leg compression
•Ambulation
•Pre-discharge venogram
•Long-term anticoagulation

42. Infrainguinal Phlebogram – Pre Discharge
Venous Thrombectomy

43. 3 Years Post Op
Venous Thrombectomy
•Hairdresser
•No edema
•Minimal symptoms
•N valve function

44. January 2006
“Contemporary” Venous Thrombectomy

45. Acute DVT
What’s New in Venous Disease?
RecommendationsRecommendations
“In […patients] with extensive
DVT…operative venous
thrombectomy may be used to
reduce acute symptoms and post-
thrombotic morbidity…”
…GRADE 2B…
2008

46. “After venous thrombectomy, we recommend the same
intensity and duration of anticoagulant therapy as those
who do not undergo venous thrombectomy”
…GRADE 1C…
Acute DVT
What’s New in Venous Disease?
RecommendationsRecommendations
2008

47. •More comprehensive procedure than initially
reported
•Follows principles of good vascular surgical
technique
•Should be offered to all active patients with
extensive, symptomatic DVT who cannot be
Rx'ed with catheter-based methods
•Significantly reduces postthrombotic morbidity
Contemporary Venous Thrombectomy
SummarySummary