南口博纪教授-NEW-IR-for-DVT.ppt

1、南口博纪教授-NEW-IR-for-DVTWakayama Medical Univ.Hospital800 Beds1500 Outpatients/dayAngiography 2700/year in all 600/year in IRWakayama 和歌山970,000 in Wakayama Pref.370,000 in Wakayama City高野山KoyasanA.D.816 1,200years old temple白浜Shirahama Adventure WorldBig Panda Family北京北京Acute DVTLymphedemaAfter Hyster

2、ectomyHematomaOverdose of VKAChronic DVTPost-thrombotic Synd.Chief Complaints:Leg SwellingIRRed,Fever,PainfulWhite,pitting edemaBlue,anemiaSkin Ulcer,Infectionhistory of DVTIntroductionVenous Thromboembolism(VTE)=Pulmonary Embolism(PE)+Deep Vein Thrombosis(DVT)PE in 70%of DVT casesDVT in 3070%of PE

3、cases PHLEGMASIA CERULEA DOLENSPE incidence:JAPAN-62/million,USA-500/millionVTE increasing in JAPAN:Westernization of Lifestyle,Aging Population,Greater rate of DiagnosisPE:High mortality 10-30%Over 100,000 deaths/year in USAEarly Diagnosis and Treatment(including inhibition of DVT progression and p

4、revention of PE recurrence)are therefore very important!Treatment of DVT has recently advanced significantlyDespite the use of standard anticoagulant therapy,DVT recurs frequently and often leads to the development of post-thrombotic syndrome(PTS)Catheter-based techniques have been used in the manag

5、ement of DVT for many years,but are undergoing now strict evaluation in RCTs to determine whether they improve patient outcomes70 FAcute DVT2001.1Greenfield filterMicrocath.via jugularExtravasation!From Jugular vein=Retrograde approachVascular Injury may occurWaste of TimeG.OSullivan2 days later,Pop

6、 V approach(1st case)Now 86 years old,alive,no symptoms27 limbs,CDT with UK(1.4 million16.0 million IU)for 30 hr(1574 hr)Technical&clinical success 85%,No major complications.Rationale for Thromboreductive Therapies Consequences of DVTPTS develops in 2550%with proximal DVTPTS causes chronic symptoms

7、(swelling,pain,heaviness,fatigue.)Severe PTS may experience venous claudication,stasis dermatitis,skin changes(hyperpigmentation,fibrosis,skin ulcer)Recurrent ipsilateral DVT:2 to 6-fold increased risk of PTSTherefore,adequate anticoagulation should be a key PTS prevention measure,but it is clear th

8、at despite anticoagulation many DVT patients will still develop PTS.Rajasekhar A:J Thromb Thrombolysis 2015;39,315.IVC filter indicationsNot reportedPREPIC studyPermanent IVC filter&Anticoaglants(AC)vs AC only for Proximal DVT with/without PE,f/uAcute phase:PE preventableChronic phase(8 years):Recur

9、rent DVT is higher!(p0.042)Use retrievable IVC filter&retrieve ASAP!Decousus H,NEJM,338,1998.PREPIC Study Group.Circulation 112,2005.PREPIC 2 studyPE patients:Retrievable IVC filter&AC vs AC onlyAC for 6 months,Filter retrieval 3 months3 months,Recurrent PE in 6 cases vs 3 cases6 months,Recurrent PE

10、 in 7 cases vs 4 cases6 months,Recurrent DVT in 1 case vs 2 casesNo need for IVC filter under adequate ACsStill Controversial!Mismetti P,JAMA 313,2015.Retrievable(optional)filter in almost all cases before Thrombolysis1.IVC filterGunther tulipOptEaseALNTo Prevent iatrogenic PE due to Thrombolysis an

11、d/or ThrombectomyCatheter-directed intrathrombus thrombolysis(CDT)for DVTImage-guided,Catheter-directed,intra-thrombus drug infusion has been safe and effective Advantages:(1)Achieve a high intra-thrombus drug concentration and Avoid bypass of the drug via collaterals(2)Reduce drug dose,treatment ti

12、me and complicationsRequired EquipmentOur standard IR protocol typically requires the following devices:6-F vascular short sheath kit(18-gauge needle,0.035 in guidewire);hydrophilic 0.035 in guidewire;4-F angled-tip multipurpose catheter with multisidehole to cross DVT;5-F pulse-spray catheter6-F th

13、rombectomy catheter with VacLok syringeGuidelines for the Diagnosis,treatment and prevention of DVT(2009）JCS(The Japanese Circulation Society)Acute DVT1.Heparin&VKA(Warfarin)Evidence level2.Systemic ThrombolysisEvidence levela3.CDT and ThrombectomyEvidence levelb4.Stenting after ThrombolysisEvidence

14、 levelbAHA Scientific StatementCDT or PCDT should be given patients with proximal DVT with limb-threatening circulatory compromise(ie,phlegmasia cerulea dolens)(Evidence level I;Grade C)CDT or PCDT is reasonable as first-line treatment with Acute proximal DVT to prevent PTS at low risk of bleeding c

15、omplication(Evidence level IIa;Grade B)Chronic(21days),high risk for bleeding(Evidence level III,Grade B)Jaff MR,et al:Circulation 2011.Recent major trials of CDT for DVTCaVenTOpen RCT200Iliofemoral DVT 21 daysCDTAnticoagulationrt-PA6 month patencyPTS at 24 monthsATTRACTOpen multicenter RCT692Iliac,

16、CF,SF DVT 14daysPMT+CDTAnticoagulationrt-PAPTS at 24 monthsDUTCH-CAVAAssessor-blindedmulticenter RCT 180Iliofemoral DVT 14daysUS accelerated CDTAnticoagulation?PTS at 12 monthsStudyDesignNPathologyArmsTherapyPrimary endNov 2009-Jan 2015May 2010-Jan 2015Jan2006Dec 2009CaVenT study from NorwayStandard

17、 Tx(ACs&CompStokings)+CDT using tPA:To prevent PTS or notStandard Tx vs Standard Tx&CDT（tPA,max 96 hours)Major bleeding in 3 casesPTS 24 months:55.6 vs 41.1%(p=0.047)Patency 6 months:47.4 vs 65.9(p=0.012)CDT recommend for severe proximal DVT without bleeding risksEnden T,Lancet 379,2012.CDT protocol

18、After IVC filter placement(a)Patient into prone position,and the involved extremity is prepared and draped in sterile fashion(b)Lower extremity vein(usually the popliteal vein)is accessed under US guidance;”ipsilateral Pop vein,Antegrade approach”(c)subsequently 0.035 inch guidewire is advanced thro

19、ugh the thrombus into the IVC using MP catheter and guidewire technique.;(d)venography is performed to assess extent of the thrombus;(e)Multisidehole MP catheter cross the thrombosed segmentExtravasationFrom Jugular vein=Retrograde approachVascular Injury may occurWaste of TimeCurrently,the most com

20、monly used fibrinolytic drug for DVT is urokinase(UK)in JAPANThe drug is infused continuously and directly into the thrombus at a low dose(a typical UK dose is 10,000I.U./hr in JAPAN.Separately from MP catheter and sheath)During this time,Heparin infusion at subtherapeutic levelsVenography 24-48 hr

21、intervalsAfter thrombolysis is completed,venography is repeated and any visualized stenoses are treated with balloon venoplasty or stenting if possibleFull-dose Anticoagulant therapy is re-started and Long-term Oral Vitamin K antagonist(VKA)and wear Compression StockingsLtAfter CDTIV-DSAV&A overlap

22、imageNOT thrombusJust Compress byRt-CIA&Lt-IIAWallstentVenographyStenting if possibleOff-label use in JAPANiliac vein compression synd.”Pharmacomechanical CDTCombination of intrathrombus drug delivery with Pulse-spray catheter and/or Manual/Mechanical thrombectomy devicesImprove drug distribution an

23、d Macerate and/or Aspirate thrombus Faster distribution of the thrombolytic drug within the thrombus,Accelerating successful thrombolysis and Improving safety by reducing the drug and exposure time(may reduce bleeding risk)Pulse-spray catheterPharmaco-mechanical CDT UK Power inj.Manual aspiration de

24、vice(Aspirare cath)with VacLok syringePatient selection for IR therapyAcute phase:Age,ADL,underlying disease(malignancy.)Trousseau synd.Ilio-femoro-poplitealIlio-femoral IliacFemoralCalf IVC involvement typeThrombus locationCHECK!:Contraindication for ACs and/or Thrombolysis(e.g.Intracranial hemorrh

25、age,Active bleeding.)ASAP!2weeks 4weeksonset 2-3daysAcute on chronic DVT:effective on acute thrombusPeriprocedural ComplicationsMajor bleeding:24%of P-CDTSymptomatic PE has been observed infrequently BUT increases risk with more mechanically aggressive methods(e.g.AngioJet,Trellis)Hence,some IRists

26、use Retrievable IVC filter during the peri-procedure periodImportant to ensure filter retrieval as soon as the risk of PE is diminishedClinical Follow-UpAnticoagulation for at least 3-6 months in uncomplicated cases who have no underlying risk factors for hypercoagulable states Patients with predisp

27、osing factors for thrombosis may require longer Anticoagulation,based on the underlying diseaseClose follow-up and strict compliance with Anticoagulation and Compression Stockings are necessary for favorable outcomes.43y Female：idiopathic lt-DVT2 days after onsetDay 0Gunther tulip filterProne positi

28、onLt-Pop vein puncture6F sheath4F MP cath.with multi-sideholeCDT in the Pts roomDay 2partial thrombolysisIliac vein compressionLtDay 4Thrombus only in iliac veinManual thrombectomyNo thrombusWallstentIR 3 timesRest on bed 5 days.10 years,no symptom,oral VKA60y Female:Lt-DVTDay 0NO IVC filterPulse-sp

29、ray&ThrombectomyCDTshrinking lt-CIViliac vein compressionOR chronic DVT?Dx:Acute on Chronic DVTNEED filter?Day 3Day 1CDTNo thrombusIliac vein stent?NO stentGood OutflowFlow of DVT patients in WakayamaDxIVC filterPop punctureP-CDTthrombectomyCDTStentingRetrieve IVC filterVenographyCDTCCU,ICUSymptomat

30、ic PEEKOS（)Francis CW,Ultrasound in Medicine and Biology 21,1995DVT TREATMENT OPTIONS(NOT Available in JAPAN)Ultrasonic energy causes fibrin to thinDrug deep into the clotAngioJet Ultra Thrombectomy System(BSCI)Pulse-spray Thrombolysis&Negative Vortex AspirationKasirajan,JVIR 12,2001Trellis(Covidien

31、)Isolated Pharmaco-mechanical Thrombolysis&ThrombectomyOSullivan GJ,JVIR 18(6)2007Large bore aspirationEssentially perfusion circuitPossibility to remove LARGE volume quicklyBUT 24F(Asians may forget it!)Sinus-Venous stent(OptiMed)Radial forceFor Iliac vein compressionZilver Vena（COOK)Device lag&Ins

32、urance coverage in JapanMany restrictions in JapanHave to devise these combined procedures.(complex,time-consuming)ConclusionIR for DVT provides rapid symptom relief and prevention of PTS-related disability.The quality of evidence in support of these treatments continues to improve.In particular,pha

33、rmacomechanical thrombolysis treatments show strong potential.Take Home MessagesGET IN THE LOOP!-there is no use in being the best venous expert in the world if you are not being referred DVT patients.（Emergency room,Cardiology.)DVT is an orphan disease-INTERVENTIONAL venous specialists should become the parent.by Dr.OSullivan And become patient!（NOT to be a patient.Many restrictions,Time-consuming.)Thank you for your attention!谢谢See you tomorrow.再明天的早上见吧