Joint Hospital Surgical Grand Joint Hospital Surgical Grand RoundRound
Yolanda HY ChanKwong Wah Hospital
Management ofManagement ofAcute Iliofemoral DVT:Acute Iliofemoral DVT:
Why not Anticoagulation alone?
Deep Venous Thrombosis
• Annual incidence– 1.0 to 1.6 per 1,000 persons per year
• Iliofemoral DVT– Complete / Partial thrombosis of iliac
vein +/- common femoral vein– 10 % of all DVT
The post-thrombotic syndrome: The forgotten morbidity of deep venous thrombosis
Kahn SRJ Thromb Thrombolysis 21(1), 41-48,2006
Iliofemoral DVT
• Extrinsic compression of iliac vein (80 %)– May-Thurner syndrome– Tumour– Irradiation– Retroperioneal fibrosis
• Extension of distal DVT• Idiopathic
Management of Acute DVT
Post-thrombotic Post-thrombotic syndrome (PTS)syndrome (PTS)
PhlegmasiaPhlegmasia
Post-Thrombotic Syndrome
Relationship between deep venous thrombosis and the post-thrombotic syndrome
Kahn SRArch Intern Med.2004;164:17-26
Post-Thrombotic Syndrome
• Despite adequate conventional therapy– Only 20 % of iliac vein completely
recanalized– Every fourth patient with proximal DVT
developed PTSAnn Intern Med 1996;125:1-7
Post-Thrombotic Syndrome
• 10 or more years after iliofemoral DVT, almost 90 % of patients were unable to work because of leg symptoms
J Surg Res 1977;22:483-488
Journal of Surgical Research
The Socioeconomic Effects of an Iliofemoral Venous ThrombosisO'Donnell TF Jr, Browse NL, Burnand KG, Thomas ML
Rationale for Thrombus Removal
Early relief of thrombus
– Eliminates luminal obstruction– Increases chance of preserving normal
valve function
↓ Post-thrombotic morbidity
Thrombus Removal in Acute DVT
Early removal ofthrombus
Thrombolysis Thrombectomy
Systemic SurgicalIntrathrombus
(Catheter-directed)
Catheter-directed Thrombolysis
Accelerates thrombolysis
Lessens overall dose of lytic agent
Reduces duration of infusion
(CDT)
Group 1(33)
Heparin (5 to 7 days)Warfarin (6 months)
Group 2(18)
Catheter-directed thrombolysis
+/- Angioplasty & Stenting
Extensive iliofemoral DVTAcute onset of symptoms within 14
days
Ann Surg 2001;233:752-760
Conclusion
• Patients with iliofemoral DVT are at high risk of post-thrombotic syndrome
• Early thrombus removal minimizes PTS
• Catheter-directed thrombolysis can reduce acute symptoms and prevent PTS
• Pharmacomechanical thrombolysis has the benefit of shortening treatment time
Management of Acute DVT
Gloviczki P, Wakefield TW, Comerota A, et alHandbook of venous disorders: Guidelines of the American venous
forum
Risks of CDT
• Major bleeding 8 %– Intracranial bleeding 0.02 %
• Pulmonary embolism– Symptomatic 0.9 %– Fatal 0.1 %
Society of interventional radiology position statement: Treatment of acute iliofemoral deep vein thrombosis with use of adjunctive catheter-directed intrathrombus
thrombolysisVedantham S, Millward SF, Cardella JF, et al
J Vasc Interv Radiol 2006;17:613-616
Indications for Intervention
Post-thrombotic syndrome
- Ambulatory- Reasonable life
expectancy- Proximal
thrombosis
Phlegmasia
- Severe symptoms
- Limb-threatening
Indications for thrombolysis in deep venous thrombosisGogalniceanu P, Johnston CJ, Khalid U, et al
Eur J Vasc Endovasc Surg 2009 Aug;38(2):192/198
Post-Thrombotic Syndrome
Relationship between deep venous thrombosis and the post-thrombotic syndrome
Kahn SRArch Intern Med.2004;164:17-26
Predictive factors of PTS
• Ipsilateral recurrence of DVT
• Iliofemoral location• Old age• Obesity• Failure of prompt recovery from acute
symptoms• Insufficient oral anticoagulant therapy
Post-thrombotic syndrome: Prevalence, prognostication and need for progress
Prandoni P, Kahn SRBr J Haematol 2009;145(3):286-295
Contraindications to CDT
• Bleeding disorders• Active internal bleeding• Recent GI bleeding or CVA• Recent major surgery (< 10 days)• Severe hypertension• Metastatic malignancy with CNS
involvementIliofemoral deep vein thrombosis: Conventional therapy versus lysis and percutaneous transluminal angioplasty
and stentingAbuRahma AF, Perkins SE, Wulu JT, et al
Ann Surg 2001;233:752-760
Management of Acute DVT
AnticoagulationAnticoagulation
• Lessen propagation of thrombus
• Prevent pulmonary embolism
Thrombus removalThrombus removal
• Provide early symptom relief
• Minimize PTS
Post-Thrombotic Syndrome
• The average cost of treating PTS was US $ 4,700
Ann Intern Med 1997;126(6):454-457