H. Arjomand, MD, FACC, FSCAI, FSVM Henry Ford Hospital

Detroit, MI

Philadelphia

“The Thinker” (Rodin Museum)

Seacoast of Maine & New Hampshire

Detroit

Acute Venous Thromboembolism (VTE)Outline

Clinical case examples Overview of acute VTE types:

Deep Venous Thrombosis (DVT) Pulmonary Embolism (PE)

Prognostic markers and outcome Dose regimen of Novel Oral Anticoagulants

(NOAC) Brief discussion on role of endovascular

therapy

Clinical Case Patient:

38 y/o woman without any prior medical history; no know prior DVT;

Symptom: Painful (heaviness) swelling of left arm of 12-18

hrs duration Exam:

significant Lt UE swelling, tenderness Doppler:

Lt axillary & subclavian vein thrombosis

Paget-Schroetter Syndrome (PSS)Clinical Profile (1)

Spontaneous thrombosis of UE veins AxilloSubclavian Vein Thrombosis (ASVT): Primary (Spontaneous) - rare Secondary: due to indwelling UE venous

catheters for venous access, pacemakers, or cancer - common

First postulated by Paget in 1875; described as a cause of acute pain and swelling of the arm by Schroetter in 1884

Occurs in physically active individuals after unusually strenuous use of the arm and shoulder

Paget-Schroetter Syndrome (PSS)Clinical Profile (2)

Presence of underlying compressive anomaly of thoracic outlet Usually bilateral → risk of thrombosis of both arms

Sx: dull, aching pain in the shoulder or axilla swelling of the arm and hand

Embolic complications can occur in 1/3 of pts Dx:

Venous Doppler, CT/CTA, MRI/MRA, Venogram Tx:

Anticoagulation +/- Endovascular (CDT, PMT, ….) +/- Surgical Tx of thoracic outlet abnormality

Venous ThromboembolismOutcome/Risk Over Time *

Acute Venous Thromboembolism (VTE)

DVT: Highly prevalent, with incidence of one in 1,000 3rd most common cardiovascular disease in the

US In those treated with effective anticoagulation

PE can still occur in as many as 20% Proximal DVT in iliofemoral venous segments

is associated with significant complications Post-thrombotic syndrome (PTS) may occur in

60% of patients months to years after an acute episode of DVT despite anticoagulation

Post-Thrombotic Syndrome (PTS)

Limb pain, heaviness, tightness, numbness; edema (worsens with activity); decreased stamina; varicosities; and “Stasis Ulcers”

Acute VTE - Treatment Options Anticoagulation therapy alone Thrombolytic therapy:

Systemic Catheter-Directed Thrombolysis (CDT)

Endovascular therapy: EndoWave Ultrasound-Assisted CDT

○ Ekos Peripheral Infusion System Percutaenous Mechanical Thrombectomy (PMT)

○ Angiojet Rheolytic System

Isolated Pharmacomechanical Thrombolysis○ Trellis-8 Peripheral Infusion System

VTE – Treatment Options

EKOS

Angiojet

ACCP - Antithrombotic Therapy for VTE2012

NOAC – Dose Regimen Rivaroxaban:

15 mg by mouth twice daily for three weeks followed by 20 mg once daily

Apixaban: 10 mg twice daily for seven days followed by 5

mg twice daily Edoxaban:

60 mg once daily (30 mg once daily in patients with a creatinine clearance of 30-50 mL/minute or low body weight ≤60 kg)

Dabigatran: 150 mg twice daily

Pulmonary Embolism (PE)Clinical Case

Patient: 78 y/o woman with h/o HTN, ↑ Chol, COPD

Symptom: SOB, chest pain, & Rt LE swelling

Lab: Elevated D-dimer, Troponin & BNP

Doppler: Rt LE (femoral) DVT

Chest CT Echo

Piazza, G. et al. Circulation 2006;114:e28-e32

Pulmonary Embolism (PE)The pathophysiology of right ventricular dysfunction secondary to acute PE

Pulmonary Embolism (PE)Clinical Case (2)

Hypotensive, hypoxic Was offered systemic thrombolysis

refused due to concern about ICH Was offered endovascular options:

Refused due to concern about the risk! Treated with Levophed for hypotension &

shock Underwent IVC filter placement

Concern of inability to tolerate additional PE

Pulmonary Embolism (PE)Clinical Case (2)

Underwent IVC filter placement Concern of inability to tolerate additional PE

Had prolonged hospitalization Survived to hospital discharge

Had significant residual respiratory compromise

= Massive PE

Summary (1)

VTE is very common, and contributes to significant long-term morbidity and mortality

No significant advances in outcome over the past decade

Emerging treatment options: Novel oral anticoagulants (NOAC) Newer endovascular options Potential improvement of CV outcome;

hopefully

Summary (2)

Appropriate therapy has the

potential of improving outcome of

patients with VTE

Clinical Case Patient:

26 y/o woman without any prior medical history; no know prior DVT; no trauma

Symptom: persistent painless swelling of left thigh for

several years Exam:

significant asymmetry of thigh circumference (Left >>> Right)

Doppler: normal bilateral LE venous Doppler

CTA of Abdomen and Pelvis (1)

Cil B E et al. Radiology 2004;233:361-365

CTA of Abdomen and Pelvis (2)

Cil B E et al. Radiology 2004;233:361-365

Iliac Venogram (1)

Cil B E et al. Radiology 2004;233:361-365

Iliac Venogram (2)Lt Iliac Vein Stent

Cil B E et al. Radiology 2004;233:361-365

Specific VTE SyndromesClinical Pearle

Persistent edema of the left leg may be due to

“May-Thurner Syndrome”

May-Thurner Syndrome (MTS)Clinical Profile (1)

Originally described in 1957 Autopsy study involving 430 cadavers

Occurs in younger pts, usually 20-50 yrs old, mostly women

Also known as: Iliac vein compression syndrome Cockett syndrome Iliocaval compression syndrome

May-Thurner Syndrome (MTS)Clinical Profile (2)

Compression of Lt common iliac vein by the overlying Rt common iliac artery Lt LE edema Asymmetric feet appearance

Persistent venous compression → intimal injury → stenosis → predisposes to thrombosis

May-Thurner Syndrome (MTS)Clinical Profile (3)

Occurs in 4-5% of pts undergoing evaluation for LE venous disorders

Progressive disease with substantial long-term disabling complications

Without associated thrombosis, many cases are probably not recognized on LE venous Doppler

Dx: clinical profile, CTA/CTV, Venogram Tx: Endovascular; rarely surgical

Catheter-directed thrombolysis (CDT) Iliofemoral Venous Thrombosis

No large-scale randomized trial Recommended in recent ACCP guidelines for

treatment for VTE Advantage:

Lower risk (by 50%) of post-thrombotic syndrome (from 60% to 30%)

Shorter hospital stay (esp with newer treatment modalities: ultrasound-assisted CDT, PMT,…)

Sharifi M, et al. Cathet Cardiovasc Interv 2009;75:S43.

Isolated Pharmacomechanical ThrombolysisTrellis-8 Peripheral Infusion system

Total of 1,409 limbs treated in 1,304 patients: Patency: 95% Majority of cases (> 83%) were completed in

less than two hours in the single-setting Reduced dose of thrombolytic drugs by 30% No bleeding complications

Pulmonary Embolism (PE)Thrombolysis (1)

Regimen: tPA - 100 mg intravenously over 2 hrs

Indications: Accepted:

○ Persistent hypotension (SBP <90 mmHg or a drop in SBP of ≥40 mmHg from baseline )

Potential:○ Right ventricular dysfunction○ Free-floating right atrial or ventricular thrombus○ Patent foramen ovale (PFO)

33

14

0

10

20

30

40

n = 48 n = 91

Death (%)

PFO (+)

Konstantinides et al. Circulation 1998;97:1146

PFO (-)

P = 0.015

Outcome of Patients with Acute PE & PFO

Patients with Major Acute PE (n = 139)

33

14

Kucher, N. et al. Circulation 2006;113:577-582

ICOPER Study:International Cooperative Pulmonary Embolism Registry

Patients with massive PE:Reperfusion Tx: 35No reperfusion Tx: 73

A.Overall mortality (P=0.40)

B.Cardiovascular mortality (P=0.34)

52 y/o man with Bilat Proximal DVT, SOB & ↓BP while on i.v. heparin

Prior to Thrombolysis After Thrombolysis (24 hrs later)

Kucher, N. et al. Circulation 2006;113:577-582

ICOPER Study:International Cooperative Pulmonary Embolism Registry

Patients with massive PE:IVC Filter: 11No IVC Filter: 97

A. Overall mortality (P = 0.006)

B. Cardiovascular mortality (P=0.005)

Venous Thromboembolism (VTE) IVC Filters - Indications

Accepted: Absolute contraindication to anticogulation Failure of anticoagulation/acute Proximal DVT Following surgical embolectomy Peri-procedural (with CDT or PMT)

Potential: Compromised pulm vascular bed; would poorly

tolerate another embolic event Proximal DVT in pts with poor cardiopulm reserve VTE in pts with increased risk of bleeding

Percutaenous Mechanical Thrombectomy (PMT) in Patients with Massive/Submassive PE

51 pts with acute PE & hemodynamic compromise, treated Angiojet Rheolytic System Technical success: 92% Major bleeding: 8% In-hospital mortality: 16% Long-term outcome: no CV mortality at

3-yr follow-up

Chechi T, et al. Cathet Cardiovasc Interv 2009;73:506-513.