surgical treatment acute dvt
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Surgical Treatment for Acute Deep Vein Thrombosis
Anthony J. Comerota, MD, FACS, FACCDirector, Jobst Vascular Institute
Adjunct Professor of Surgery, University of Michigan
Surgical Treatment for Acute Deep Vein Thrombosis
Venous Thrombectomy in Patients with Iliofemoral DVT
Long-term: Clinical Status and QOL
•95% Venous Insufficiency
•15% Venous Ulceration
•Venous claudication developed in almost 50%
•Limited ambulation in 15%
•Marked hemodynamic impairment
•Markedly reduced QOL
Delis KT et alAnn Surg 2004;239(1):118
Akesson HEur J Vasc Surg 1990
Observations at 5 Years
Iliofemoral DVT: Anticoagulation Alone
Intramuscular Pressures (mmHg)
Iliofemoral DVT
Days
IntramuscularPressure(mmHg)
Anterior & Deep Posterior Compartments (Mean)
Qvarfordt P et alAnn Surg 1983;197:450
• 12 Patients with iliofemoral DVT• Venous thrombectomy• Intramuscular pressures (wick)
(Surrogate for venous pressure)
Pre-Op(Mean)
Post-Op(Mean)
40
30
20
10
0Reduction of pressure to normalReduction of pressure to normalafter thrombus removalafter thrombus removal
Extensive DVT Rx’ed with anticoagulation alone…Extensive DVT Rx’ed with anticoagulation alone…
……obstructs venous returnobstructs venous return
… …causes valve reflux, leading to…causes valve reflux, leading to…
……venous hypertension, which...venous hypertension, which...
……activates the activates the cellular and metabolic pathwayscellular and metabolic pathways leading to chronic venous diseaseleading to chronic venous disease
……Producing avoidable and costly Producing avoidable and costly post-thrombotic morbiditypost-thrombotic morbidity
Basis for Argument
Venous Thrombectomy
Strategy of thrombus removal
– Eliminates obstruction
– Preserves valve function
Iliofemoral DVTIliofemoral DVT
Venous ThrombectomyVenous Thrombectomy
- History -- History -
• Early initial enthusiasm
• Disappointment with results(Lansing and Davis reports)
• Surgeons stopped performing procedure
• Recent enthusiasm– Better understanding principles– Randomized trials– Improved technique– Improved anticoagulation
Iliofemoral DVT
Strategy of thrombus removal– Venous thrombectomy– Catheter directed thrombolysis
…for iliofemoral DVT
ACCP 20082008
“Contemporary” Venous
Thrombectomy
Long-Term Results
Venous Thrombectomy
76%41 months6051984-9910
PatencyFollow-upNo.YearsReports
Iliac Vein Patency
(mean) (mean)
63%45 months1984-99
CompetenceFollow-upNo.YearsReports
Femoral-Popliteal Competence
(mean)(mean)
8
Venous ThrombectomyVenous Thrombectomy
- Randomized Trial -- Randomized Trial -
• Randomized trials: Scandinavian centers
• Iliofemoral DVT: N=63
• Randomized: Venous thrombectomy + AVF + Anticoagulationvs.
Anticoagulation alone
• Endpoints:– Patency– Post-thrombotic morbidity– Complications
• Follow-up: 6 months, 5 years, 10 years Plate G et alJ Vasc Surg 1984
Eur J Vasc Surg 1990Eur J Endovas Surg 1997
• Infrequent - both groups
• One recurrent, symptomatic PE (anticoag.)
• 3 wound complications
• No significant bleeding complication
• 13% early reocclusion (thrombect.)
Early Complications
Plate G et al, J Vasc Surg 1984
Venous ThrombectomyVenous Thrombectomy
- Randomized Trial -
Anticoag.Thrombectomy
6.7 mmHg3.2 mmHg*Exercise Pressure (iliac)
15%4%Venous Claudication
37%17%Varicose Veins
78%54%Swelling
7%42%Asymptomatic
26%52%N Valve fct. (fempop)
35%76%Normal Iliac (venogram)
*successful thrombectomy
Plate G et al, J Vasc Surg 1984
Venous ThrombectomyVenous Thrombectomy
- Randomized Trial - Results: 6 Months (N=51) -
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
*radionuclide phlebography
Venous ThrombectomyVenous Thrombectomy
- Randomized Trial - Results: 5 Years (N=41) -
14%
43%
33%
78%
Anticoag.Thrombectomy
63 mmHg55 mmHgAVP
18%8%Severe CVI24%54%N Clinical Score
N Valve fct. Femoral Popliteal
41%84%Patent iliac*
Plate G et al,Eur J Vasc Endovasc Surg 1990
*radionuclide phlebography
Venous ThrombectomyVenous Thrombectomy
- Randomized Trial - Results: 10 Years (N=30) -
Acute Post Op
Iliofemoral DVT
Venous ThrombectomyVenous Thrombectomy
- PreOp -- PreOp -
• Know full extent of thrombosis
• Image vena cava
• Therapeutic anticoagulation
• Arrange for complete imaging(leg through vena cava)
Venous ThrombectomyVenous Thrombectomy
- Operative -- Operative -
• Prep entire leg
• Expose CFV, SFJ, FV, profunda
• Infrainguinal thrombectomy first
• Catheter based infrainguinal thrombectomy if massage/compression not successful
• Iliocaval thrombectomy with fluoroscopic guidance
• Correct iliac vein stenosis
• Construct AVF
Femoral Vein Exposure
Venous Thrombectomy
Clot with Venous Hypertension
Venous Thrombectomy
Leg Compression
Venous Thrombectomy
Operative Technique
Venous Thrombectomy
Dual Catheter Technique
Venous Thrombectomy
Dual Catheter Technique
Venous Thrombectomy
Dual Catheter Technique
Venous Thrombectomy
Comerota AJ, Gale S
J Vasc Surg 2006;43:185-91.
Infrainguinal Balloon Catheter Passage
Venous Thrombectomy
Operative Technique
Venous Thrombectomy
Operative Technique
Venous Thrombectomy
Venous Balloon
Venous Thrombectomy
Venous Thrombectomy
Iliofemoral DVT
Completion Phlebogram
Venous Thrombectomy
Correct Iliac Vein Stenosis
Venous Thrombectomy
Comerota AJ, Gale S
J Vasc Surg 2006;43:185-91.
Caval Clot
Venous Thrombectomy
Specimen
Venous Thrombectomy
AV Fistula
Venous Thrombectomy
•Small anastomosis
•↑ venous velocity
•No ↑ pressure
•Permanent
Arteriovenous Fistula
Venous Thrombectomy
clampedclamp
removed
Femoral Vein Pressure
Iliofemoral DVT
AV Fistula and Distal Catheter
Venous Thrombectomy
Posterior Tibial Vein Infusion Catheter
Venous Thrombectomy
Anticoagulation Catheter
Venous Thrombectomy
Venous ThrombectomyVenous Thrombectomy
- PostOp -- PostOp -
• Leg infusion of heparin
• Long-leg compression
• Ambulation
• Pre-discharge venogram
• Long-term anticoagulation
Infrainguinal Phlebogram – Pre Discharge
Venous Thrombectomy
3 Years Post Op
Venous Thrombectomy
•Hairdresser
•No edema
•Minimal symptoms
•N valve function
January 2006
“Contemporary” Venous Thrombectomy
Acute DVT
What’s New in Venous Disease?
RecommendationsRecommendations
“In […patients] with extensive DVT…operative venous thrombectomy may be used to reduce acute symptoms and post-thrombotic morbidity…”
…GRADE 2B…
2008
“After venous thrombectomy, we recommend the same intensity and duration of anticoagulant therapy as those who do not undergo venous thrombectomy”
…GRADE 1C…
Acute DVT
What’s New in Venous Disease?
RecommendationsRecommendations
2008
• More comprehensive procedure than initially reported
• Follows principles of good vascular surgical technique
• Should be offered to all active patients with extensive, symptomatic DVT who cannot be Rx'ed with catheter-based methods
• Significantly reduces postthrombotic morbidity
Contemporary Venous Thrombectomy
SummarySummary
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