interventions in the chronic setting with post-thrombotic …...european venous centre;...

1 European Venous Centre; Aachen-Maastricht

Prof. Cees H.A. Wittens, MD PhD Head of Venous Surgery Maastricht University Medical Center Uniklinik Aachen

Interventions in the chronic setting with post-thrombotic syndrome

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European Venous Centre; Aachen-Maastricht

Venous hypertension:

Deep venous insufficiency ( < 90 mmHg)

Deep venous obstruction !! (> 200 mmHg)

DVO

Internal causes

External causes

DVT

May-Thurner

Ext. compression

Cancer

Lymphocele

Fibrosis

Aneurysm

ICV atresia

Immobility

Thrombofilia

Pregnancy

Treatment of DVO

Pressure results CFV:

0

10

20

30

40

50

60

70

80

90

100

0 5 10 15 20 25

Pre

ssu

re (

mm

Hg

)

Time (min)

Pressure CFV (healthy)

0

10

20

30

40

50

60

70

80

90

100

0 5 10 15 20 25

Pre

ssu

re (

mm

Hg

)

Time (min)

Pressure CFV (iliac obstruction)

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Diagnostics

Clinical examination has to be performed

groin and abdominal wall: especially in

patients with: Venous ulcers

also in:

C 4,5

Venous claudication

Fast recurrent Varicosities

10-15 % will show signs

of central venous obstruction!!

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V European Venous Centre; Aachen-Maastricht

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Diagnostics

Due to changed therapeutic

options there is a need to

change diagnostics in venous

ulcer disease

Complete venous roadmap !!

Full duplex examination

MRV

CTV

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Diagnostics

Literature search showed no

comparable results because

there are no reporting standards

for deep venous pathology

registration

LOVE score

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Scoring systems

LOwer extremity VEnous pathology

scoring system

Each segment:

Post thrombotic leasions

Residual lumen 0 % (occlusion)

10-50 %

50-90 %

90-100%

Collaterals

External compression

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Treatment options

Conservative: Compression

Anticoagulation

Invasive: PTA alone (obsoleet)

PTA + stenting

Bypass

+ or -

○ Endophlebectomy

○ AV fistulae

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Indications for treatment:

Improve QoL!!

Skin problems

Venous claudication !

Swollen legs

Pain

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V E C European Venous Centre; Aachen-Maastricht

Cook

Veniti

OptiMed Sinus Venous

Sinus XL flex

New Venous stents

Bard

BS

Medtronic

Bolton

Aachen-Maastricht Experience:

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Patency rates of 314 patients

PTS (n=237)

○ Percutaneous procedure

PTS (n=77)

○ Hybrid procedure

Recanalization and stenting

Endophlebectomy

AV fistula

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Patency rate after stenting (n = 237)

for PTS (percutaneous):

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Improved inflow measures

○ Endophlebectomy (CFV involvement)

○ AV fistula

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Indications for Endophlebectomy

Patency rate for PTS (Hybrid (n= 77)

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Clinical improvement

VCSS Baseline 8,0 ±3,8 (2-21)

6 months 5,3 ±3,6 (0-18)

12 months 4,8 ±3,7 (0-15)

Villalta Baseline 10,8 ±4,8 (4-22)

6 months 5,2 ±4,3 (0-15)

12 months 6,2 ±3,9 (0-21)

Venous claudication Baseline 62 (55,6%)

12 months 16 (11,1%)

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VEINES-QOL/Sym overall

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QoL patency overall

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Treatment options: miscellaneous

Improved inflow measures / timing

○ AV fistulae

Surgical

Percutaneous (future)

○ Postoperative pneumatic compression !!

Improved anticoagulation

○ Oral “Heparines”

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Conclusion:

PTA and Stenting in PTS: ○ Good patency (>90%)

○ QoL increase (>24 point (>6=clinical relevant)

○ In failure no significant QoL loss

In Europe (850 Million inhabitants)

○ > 1.600.000 people have a significant

deep venous outflow obstruction.

All stent companies join forces

○ Support research (standardization in diagnostics,

treatment and outcome)

○ Create awareness

Major impact if this treatment become routine

21 European Venous Centre; Aachen-Maastricht

Prof. Cees H.A. Wittens, MD PhD Head of Venous Surgery Maastricht University Medical Center Uniklinik Aachen

Interventions in the chronic setting with post-thrombotic syndrome

V E C

interventions in the chronic setting with post-thrombotic …...european venous centre;...

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