Update on Management of Deep vein thrombosis Vietnam Heart Association Meeting October 10th 2016 8:17AM – 8:32 AM Dong Do Thach Nguyen, M.D FACC FSCAI Complications of extensive DVT May-Thurner Syndrome phlegmasia cerulea dolens Post-thrombotic Syndrome: Chronic pain, swelling, skin ulceration 1) Prevention of clot propagation 2) Prevention of PE and recurrent thrombosis 3) Restoration of venous patency and flow 4) Preservation of valvular function 5) Elimination of clinical symptoms associated with PTS Endovascular Rx for DVT: A Contemporary Approach Pharmaco-mechanical treatment (PMT): function to both dissolve (lytic assisted) and mechanically remove clot EKOS TRELLIS ANGIOJET Ultrasound Accelerated Thrombolysis Indications Acute limb threat Caval thrombus Iliac DVT Femoral-Popliteal DVT in symptomatic, low risk of bleeding, good life expectancy may be considered Patient must have no absolute contraindications Recent surgery is a relative contraindication Technique Access POPLITEAL VEIN OF AFFECTED LIMB under ultrasound guidance (most common approach) Perform pharmaco-mechanical thrombolysis of choice (individualize per pt) and per local expertise Can be done on full dose anticoagulation (no reason to hold coumadin and therefore eliminate bridging issues) french sheath THROMBUS- PRE and POST EKOS IVC Filter for prevention of PE EKOS thombolysis then Balloon Angioplasty of left common iliac vein (8x60-evercross) Self Expanding Stent to left common iliac vein residual stenosis (May Thurner) with Protégé 12x80 stent; post-dilated with 10x40 evercross DVT of upper extremities Thrombolysis is best accomplished with local administration of the thrombolytic agent directly at the thrombus After completion of a venographic study, a catheter is floated up to the site of the clot, and the thrombolytic agent is administered as a direct infusion Venographic assessment for clot lysis is repeated every 4-6 hours until venous patency is restored Heparin is usually given concurrently to prevent rethrombosis 1 Thrombolytic therapy is the treatment of choice for axillary/subclavian venous thrombosis Restoration of venous patency is more critical for the prevention of chronic venous insufficiency in the upper extremity