Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
Improved clinical outcomes –Evidence on venous thrombectomyfollowed by stenting
Michael K. W. Lichtenberg, MD, FESCVascular Centre Arnsberg, Germany
Venous Centre Arnsberg, Germany
Disclosure
Speaker name:
Michael Lichtenberg
I have the following potential conflicts of interest to report:
Consulting (CR Bard, Veniti, Volcano, Biotronik, Terumo, Boston, Straub
Medical,Veryan, TVA medical, Spectranetics, Cook, Optimed)
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
I do not have any potential conflict of interest
X
X
Venous outflow obstruction
webs, spurs, chords
Venous diseaseWestern Europe
1. Wikipedia, 2016: Western Europe [https://en.wikipedia.org/wiki/Western_Europe]2. Coon WW, Willis III PW, Keller JB. Venous thromboembolism and other venous disease in the Tecumseh Community Health. Circulation. 1973;48:839-846.3. Oguzkurt L, Ozkan U, Ulusan S, Koc Z, Tercan F. Compression of the left common iliac vein in asymptomatic subjects and patients with left iliofemoral deep vein thrombosis. J Vasc IntervRadiol. 2008;19:366-371.4. Maurins U, Hoffmann BH, Lösch C, Jöckel K-H, Rabe E, Pannier F. Distribution and prevalence of reflux in the superficial and deep venous system in the general population - results from the Bonn Vein Study, Germany. J Vasc Surg. 2008;48:680-87.5. Ananikian PP, Nanian AM, Galstian SM, Pogoisan BS. Clinical aspects, diagnosis and treatment of varicose veins of the lower limbs associated with extravasal compression of the external iliac vein. Kardiologiia. 1984 Feb;24(2):97-100.6. Raju S, Neglén P. High prevalence of nonthrombotic iliac vein lesions in chronic venous disease: A permissive role in pathogenicity. J Vasc Surg. 2006;44:136-44.7. Marston W, Fish D, Unger J, Keagy B. Incidence of and risk factors for iliocaval venous obstruction in patients with active or healed venous leg ulcers. J Vasc Surg. 2011;53:1303-1308.
*UK, DE, IT, ES, FR, NL
Country: Western Europe Population ≥ 18 Years Age 1 2016 Projection
Incidence 2 Annual Patients Annual Treatable Patients
DVT 0,25% 833.237 61% 3 508.274
CEAP Classification Prevalence 4 Affected Population Treatable Patients
C0 No Disease 9,7% 32.396.246 N/A 0
C1 Reticular Veins 59,0% 196.643.879 N/A 0
C2 Varicose Veins 14,3% 47.627.814 22,00% 5 10.478.119
C3 Edema 13,4% 44.694.821 21,80% 6 9.743.471
C4 Skin Pigmentation 2,9% 9.532.229 21,80% 6 2.078.026
C5 Healed Ulcers 0,6% 2.066.427 21,80% 6 450.481
C6 Active Ulcers 0,1% 333.295 60,00% 7 199.977
CVD (C2-C6): 104.254.585 23.458.348
% Obstuctive Component
Venous Outflow Obstruction
333.294.710
Acute
% Obstuctive Component
Chronic
PTS is high with conservative therapy
Catheter-directed thrombolysis plus anticoagulation versus anticoagulation alone in the treatment of proximal deep vein thrombosis - a meta-analysis
Vasa 2015 May;44(3):195-202
Iliofemoral patency
after 6 months
Persistent
obstruction within
iliac vein
Vasa 2015 May;44(3):195-202
Standard Treatment vs. CDT
Enden T, et al: CaVenT Study
– Follow-Up 24 months:
– Number needed to treat: 7
Lancet. 2012 Jan 7;379(9810):31-8.
Long-Term Results using Catheter-directed Thrombolysis in 103 Lower Limbs
with Acute Iliofemoral Venous Thrombosis
N. Bækgaard, R. Broholm, S. Just, M. Jørgensen, L.P. Jensen
European Journal of Vascular and Endovascular Surgery , Volume 39, Issue 1, Pages 112-117 (January 2010)
All patients with patent veins and normal valve functionshowed no sign of dermal pigmentation, ulceration or venousclaudication at follow-up 1 major
bleeding
complication
• 2. Indications for early thrombus removal
• 2.1. We suggest a strategy of early thrombus removal in selected patientsmeeting the following criteria:
• (a) a first episode of acute iliofemoral deep venous thrombosis
• (b) symptoms <14 days in duration
• (c) a low risk of bleeding
• (d) ambulatory with good functional capacity and an acceptable lifeexpectancy (Grade 2C)
Young and active patient
Descending ileofemoral
thrombosis
May-Thurner Syndrome
Phlegmasia, descending IVC
thrombosis
Bowel cancer
Stenosis of right iliac vein
With thrombus
Lymphocele compression
23 y female
patient
65 y male
patient80 y female
patient
Indication for proximal venous thrombectomy
CDT with
high risk
CDT with
high risk
21 y, female, descending DVT in May – Thurnersyndrome. Transpopliteal access, 10 F Aspirex®
8 F: blood volume aspiration up to 75 ml/min
10 F: blood volume aspiration up to 130 ml/min
AngioJet®EKOS® Peripheral
Infusion SystemTrellis™ System
M. Lichtenberg (Hrsg.), C. Tiefenbacher, M. Katoh, P. Minko, E. Minar, C. Wissgott, A. Storck, B. Hailer: Thrombektomie: medikamentös, mechnisch, operativ. Uni-med Verlag,
2013
Early Clot RemovalMany Choices
6 – 10
French
Aspirex® (Rotational thrombectomy) Indigo System ® (Penumbra)
PEARL* Venous Registry†
CaVenT‡
CDT Standard
Onset of DVT
Symptoms
Acute 67% (≤14 days) 66% (≤10 Days ) 100% ≤21 days
Chronic 33% (>14 days) 16% (>10 Days ) NA
Acute & Chronic
NA 19% NA
Primary Lytic TPA Urokinase TPA NA
CDT Drip Times (mean) 17 hrs 48 hrs 57.6 hrs (2.4 days) NA
Procedure Times
CDT (N=29)
40.9 hrs NA NA NA
CDT+PPS/RL (N=172)
22.0 hrs NA NA NA
PPS/RL (N=115)
2.0 hrs NA NA NA
Bleeding Complications4.5% (major &
minor combined)11% (major); 16% (minor)
22% (major & minor combined)
0%
PEARL Comparison Treatment of Lower Extremity DVT
*Garcia,MJ, et al. J Vasc Interv Radiol 2015; 26:777-785†Mewissen MW, Seabrook GR. Radiology 1999:211:39-49 ‡Enden , Haig Y. Lancet 2012:379:31-38
Two center retrospective data analysis for DVT thrombectomy with the Aspirex® catheter
43 Aspirex thrombectomy procedures for
iliofemoral DVT
Technical success analysis
Safety analysis
Dr. Thomas Heller Dr. Michael Lichtenberg
Ileofemoral DVT therapy with Aspirex catheter
• May-Thurner syndrom: 43.1 years, 66 % female• Cancer patients with more phlegmasia symptoms• Duration of symptoms: 1 day – 3 months • Hemodynamic technical success in cath lab with Aspirex
and stent implantation: 97 % (42/43 patients)• No prolonged lytic therapy• Stent rate 100 % in Arnsberg patients / 95 % Rostock• IVUS 100 %• Stent rate 1,25 / patient• Complications: No bleeding, PE
25 years, female, nonsmoking patient.Back pain during last weeks
6 – 10
FrenchVeniti Vici
ConclusionDVT thrombectomy
• Is effective in venous thrombus removal
• Even in more organized thrombus
• Restores vein patency in upper and lower limb
• Has low risk and less side effects with PMT
• No ICU stay
• „End it in the Angiolab“
• PMT will be the standard treatment
Treat the underlying reason with a
dedicated iliac vein stent
THANK YOU FOR YOUR ATTENTION