Slide 1

PERIFERAL ARTERY DISEASESLower extremity artery disease

Aterial diameter

Intima Media Thickness (IMT)

Measurement of plaques

Measurement of blood flow patern

Percent stenosis

Doppler method

HistoryDVT is common but elusiveIn 1644, SchenkillnessThe Burden of Health The worldwide incidence 100 cases per 100,000annuallyperson, The incidencein Asians is 2.2 - 62.5 % Pulmonary Embolism is the cause of death in 0.9 % Post Thrombotic Syndrome from 60 - 85 %TheSurgical risk of Deep Vein Thrombosis16 - 30 %inininingeneral surgicalorthopedic surgerygynecologic surgeryurologic surgery457 -25- 70 %45 %%PROXIMALDISTALNomenclature ofDVTLowerExtremity of DVT1. Proximal DVT (thigh)Popliteal, femoral and iliac vein.Incidence is higher than distal.:Large thrombus , SymptomaticUncomplete spontaneus lysisPropagates proximally 60 %2. Distal DVT (calf )Tibial and Peroneal VeinIncidence is lower than prox.:Small thrombus , AsymptomaticComplete Spontaneous lysisPropagates proximally 20 %- 30 %Small IncidenceProximal DVT :Thoracic Outlet SyndromeCatheterizationVenous punctureDistal DVT:UPPER EXTREMITY OF DVTClinicalDVTUnspecificSource Modified from LeClereJR 1954,Condit.ions Sensitivity SpecificityCalf pain 66 91 % 3 19 % Calf tenderness 56 82 % 26 74 % Ankle edema 40 76 % 23 52 % Leg swelling 35 97 % 8 88 % Redness 15 26 % 90 91 % Superficial venous distention 27 33 % 30 91 % Homans sign 13 43 % 39 84 %Wells Score ( increase sensitivityand Specificity )- Active cancer11111-----Paralysis, recent plaster castRecent immobilisation or surgeryTenderness along entire deep veinsystemSwelling of entire> 3 cm difference with other leg Pitting oedemalegincalfcircumferencecompared111-2---Collateral superficialveinsAlternative diagnosis likelyThe prevalence of disease in each pre-test category was 85,33 and 5 % for thehigh, moderate,and low probability groups, respectively.Wells PS et al.Lancet 1997 ; 350 : 1795-8High probability > 3Moderate probability 1-2Low Probability < 0 Interobserver reliability kappa 0.85Clincal Features ScoreImagingmodalityofDVTSensitivitySpecificityPROXIMALDISTALSensitivitySpecificitySensitivityVenographyMRI / CTAVascular Ultrasound97 %> 95 %91 %100 %100 %95 %97 %87 %-94 %97 %-VenographyInvasive .Painful, allergic .Complicated by phlebitis.30 % technically inadequate( Un expert ) .Contraindicated 20 25 % .Relatively expensiveVENOGRAPHYNORMALDVTMagnetic Resonance Imaging----No available in the most HospitalForbidden to Pace Maker and Severe CasesExpensiveOnly useful in the pelvic vein thrombosis, especially pregnant women .forULTRASOUND( CompressionUltraSound)Available in all hospitalEasy to performedHigh Sensitive and specificfor ProximalDVTLow sensitiveand specific for Distal DVT( operator dependence )DVTCUSNORMALCOMPRESSIONULTRASOUND(CUS) VEIN DVTVEINUn CompressibleARTERYCUSARTERYCUSScoreClinic- Active cancer11111-----Paralysis, recent plaster castRecent immobilisation or surgeryTenderness along entire deep veinsystemSwelling of entire> 3 cm difference with other leg Pitting oedemalegincalfcircumferencecompared111-2---Collateral superficialveinsAlternative diagnosis likelyThe prevalence of disease in each pre-test category was 85,33 and 5 % for thehigh, moderate,and low probability groups, respectively.Wells PS et al.Lancet 1997 ; 350 : 1795-8High probability > 3Moderate probability 1-2Low Probability < 0 Interobserver reliability kappa 0.85Clincal Features ScoreCUSSQUEEZEDEEP VEIN THROMBOSISNORMALFIBRINOGENTROMBINTHROMBUS FIBRIN POLIMERSOLUBLE(UNSTABLE)XIII aD DIMERTHROMBUS FIBRIN POLIMERINSOLUBLE( STABLE )ObjectiveDiagnosis of suspectedDVTD-Dimer AssaysELISAsensitivity90 100 %specificity30 40 %Latex agglutination70 -90 %70 90 %Whole blood (the simpli RED)85 -95 %65 68 % RED ) 500Abnormal Value: Quantitative ( ELISA, SIMPLID-Dimerare often positive in varietyof common conditions(Specific fibrin degradation product)CancerDisseminated intravascularSerious infectionRecent trauma or surgeryVasculitisCardiovascular diseasescoagulationDiagnosis Modalities?VENOGRAPHY / MRA/CTAClinicalDVTD-DIMERWell ScoreVascular UltrasoundClinical DVT (Un-Specific )WellsScoreScore 100 kg bw 10 mg.dailyNo monitoringAs effective andsafeas UFH7 14 days duration of treatmentanticoagulantcontinueby oralOral Anticoagulant Warvarin Following discharge for monitoring INR : 1 week,2 weeks thenmonthly is advised.Duration of Time3 to 6 months(Target2.0 3.0)ConditionFirst event with reversible or time limitedrisk ( surgery, trauma, immobility,use )First event idiopathicoestrogen6 months12 monthsto lifetimeAnticardiolipin antibodyAntithrombin deficiencyRecurrent event , thrombophiliaCancerFibrinolytic( direct catheter fibrinolytictherapy)Percutaneus intervention is Performed in Cath labTechnique:Popliteal vein is accessed by ultrasound guidance5 Fr multisidehole catheter and wire is placed into occlusion urokinase 80,000 IU / hr ( side arm ) + 80,000 /hr ( multisidehole) Infusion heparin following bolus 5,000 IU.Evaluation after overnight with Standford algoritm..Fibrinolytic TreatmentIndicationILLIOFEMORALDVT < days 141.----Complete trombolysisNo underlying stenosis Complete thrombolysis Underlying iliac vein stenosisComplete thrombolysis Underlying femoral vein stenosisPartial thrombolysisNo further intervention2.PTA + stenting3.--PTA4.-Continue thrombolysisfor one additional nighNo further interventionThe Stanford algorithm 19985.-No thrombolysisVena Cava FilterIndication:- DVT + Recurrent Pulmonary Embolism despite adequateanticoagulation- Contraindication for anticoagulant in Proximal DVTprogress to illiac vein- After pulmonary embolectomy- Floating Thrombus in inferior vena cavaPercutaneusintervention is Performed in Cath lab