Ambulatory Venous HypertensionComponents

•Obstruction

•Valve incompetence

•Obstruction and valve incompetence…Highest venous pressure…Most severe morbidity

Iliofemoral DVT

Contraindication to Lysis

Yes No

Surgical Thrombectomy + AVF

Anticoagulation

Catheter-directedThrombolysis

Success

Yes

No

• 63 patients: iliofemoral DVT• Thrombectomy + AVF vs. Anticoagulation• Follow-up: 6 mos, 5 yrs, 10 yrs

• Patency– Valve function– Venous hemodynamics– Clinical evaluation

Plate G et al, J Vasc Surg 1984

Venous Thrombectomy vs. Anticoagulation

Randomized TrialRandomized Trial

Anticoag.Thrombectomy

60 mmHg43 mmHgAVP

27%11%Severe CVI

18%37%Asymptomatic

37%7%Reflux + obstruction

6%40%N Valve fct. (fempop)

50%78%Patent iliac*

Plate G et al, Eur J Vasc Endovasc Surg 1990

Venous Thrombectomy vs. Anticoagulation

Results: 5 years (n=41)

*radionuclide phlebography

Acute DVT

“…There is no evidence that supports the use of thrombolytic agents for the initial treatment of DVT….”

Thrombolytic Therapy: ACCP 2004Thrombolytic Therapy: ACCP 2004

Buller H, et alChest 2004;126:401S

Recommend against the routine use of catheter-directed thrombolysis (Grade 1C)

…Treatment..[with lytic Rx] .. Be confined to patients requiring limb salvage. (Grade 2C)

Catheter-Directed Lysis Iliofemoral DVT

• Significantly better QOL with lysisPhysical function StigmaHealth distress Post thromb Sx

• Successful lysis correlated w/QOL

• Lytic failures and heparin Rx similar

Improvement in Quality of LifeImprovement in Quality of Life

Comerota AJ et alComerota AJ et alJ Vasc SurgJ Vasc Surg 2000 2000

• 35 consecutive patients• Iliofemoral DVT• Randomized

• Follow-up 1week/6mos–Clot lysis–Venous reflux

Cath-dir SK (pulse spray)vs.

Anticoagulation alone

Elsharawy M, et alEur J Vas Surg. 2002; 24:209

Catheter-Directed Lysis Iliofemoral DVT

Improvement in Quality of LifeImprovement in Quality of Life

Elsharawy M, et alEur J Vas Surg. 2002; 24:209

0.4 7d 6dLOS

0.04 11%41%*Reflux

<0.001 72%12%Patency

P-valve Lysis (n=18)

Anticoag(n=17)

*Underestimate 20 occlusion

Catheter-Directed Lysis Iliofemoral DVT

Randomized Trial: Outcome at 6 monthsRandomized Trial: Outcome at 6 months

Postthrombotic SyndromeElastic Stockings (30-40 mmHg)

Lancet 1997;349:759

<.0151%24%49%

<.0155%21%47%

P-valueRRRStockingControl

Postthrombotic Syndrome

Brandjes DP

Prandoni P

(n=194)

(n=170)Patho Hemst Thromb 2002;32(suppl 2):72

A Strategy of Thrombus Removal for Venous Thromboembolism:

We Owe it to Our Patients