Subtitle of other. information. Management of Chronic DVT. Presenter name Title. Date. Sid Bhende, MD. Sentara Vascular Specialists April 26 th 2014
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1 Sid Bhende, MD Sentara Vascular Specialists April 26 th 2014 Management of Chronic DVT
2 Outline Chronic DVT Definition Diagnosis Complication of Chronic DVT Post Thrombotic Syndrome (PTS) Management of Chronic DVT Medical Surgical
3 Chronic DVT Definition DVT that has been present for > 4 weeks Diagnosis Ultrasound is the gold standard
4 Criteria for Ultrasound CHARACTERISTICS ACUTE DVT CHRONIC DVT Thrombus Echogenicity Hypoechoic Hyperechoic Vein Lumen Size Distended Narrow, Irregular Compressibility Spongy Rigid Collateral Veins Absent Present
5 Subtitle Normal Vein of other Acute Presenter DVT name
6 Chronic DVT
7 Complication of Chronic DVT Post Thrombotic Syndrome (PTS)
8 What is PTS? A complication from having a chronic DVT National Alliance for Thrombosis and Thrombophilia (NATT) 60% of patients in whom DVT develops will recover without further symptoms 40% will have some degree of post thrombotic syndrome (PTS)
9 What is PTS? The American Venous Forum (AVF) suggests that PTS will develop in up to two thirds of patients with DVT PTS is the most common complication after chronic DVT PTS can still occur even if the patient receives appropriate anticoagulant treatment
10 Why is PTS a problem? It is a chronic lifelong condition Symptoms of PTS can wax and wane over time - but there is no cure Severe PTS can cause painful venous ulcers or sores that are difficult to treat and tend to recur 5-10% of PTS patients develop venous ulcerations
11 Why does PTS occur? Clot (thrombus) in the vein Damage to valves inside the vein The damaged valves as well as residual clot create an obstruction Capillary leak, Fibrin Deposition, RBC & WBC sequestration Reduce skin and tissue oxygenation Venous Hypertension Post Thrombotic Syndrome Increased venous pressures
12
13 What are risk factors for PTS? Difficult to predict which patients with DVT will go on to develop PTS Extent of DVT Proximal DVT above knee Obesity Ipsilateral DVT recurrence Another DVT in a leg with a Presenter previous name DVT Inadequate anticoagulation - Subtherapeutic INR (mainly in first 3 months)
14 What are risk factors for PTS? Rate of recanalization Recent studies show that persistence of DVT symptoms and signs at one month after the blood clot are associated with a higher risk of developing PTS
15 What are symptoms of PTS? Worse after standing or walking and tend to improve with rest and leg elevation Leg pain (dull, aching, throbbing) Heaviness or Tiredness Swelling or Cramping New varicose Presenter veins popping name up
16 What are clinical signs of PTS? Leg edema Brownish skin pigmentation Bluish discoloration of the leg/foot/toes Formation of new varicose veins Hardening of the skin (lipodermatosclerosis) Leg ulceration
17
18 When does PTS occur? PTS usually develops within the first six months after DVT, but can occur up to two years after the clot
19 What are treatment options for Medical Management Surgical Management PTS?
20 Medical Management of PTS Prevention is the Goal Compression stockings (30 40 mm Hg) worn daily for 2 years from onset of DVT Shown in studies to reduce the risk of developing PTS American College of Chest Physicians (ACCP) Highly recommend compression Presenter stockings name
21 What can you do for the patient diagnosed with Subtitle PTS? of other Steps that may help patients who already have PTS include Leg elevation Use of compression stockings Analgesics (pain medication) for pain management Treatment of varicose veins If patient develops severe PTS (Leg ulcers) Require specific care (Unna Boot)
22 Surgical Management of PTS Endovascular interventions For Acute DVT venous thrombolysis Awaiting results from ATTRACT (Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter-Directed Thrombolysis) Trial
23 Surgical Management of PTS What about CHRONIC DVT? Old Mentality has been that if clot hasn t resolved and is now old, then there is nothing to do aside from compression New Mentality is perhaps we can attempt endovascular recanalization of a chronic DVT to offer patients symptomatic Presenter relief name
24 Surgical Management of PTS First Chronic DVT intervention trial ACCESS PTS (Accelerated Thrombolysis Post Thrombotic Syndrome) Industry sponsored trial Prospective, Multicenter 30 centers Purpose: To evaluate efficacy of thrombolysis for PTS and chronic venous occlusion
25 Surgical Management of PTS ACCESS PTS Population: Pt with documented chronic DVT (confirmed by ultrasound for a minimum of 6 months) Failed 3 months of conservative therapy (anticoagulation & compression stockings) CEAP classification 3 Patients with Proximal DVT only
26 While we wait for the ACCESS PTS trial, what can we offer? Endovascular venous recanalization for Chronic DVT Iliocaval DVT Iliofemoral DVT Indications CEAP classification (C3-C6) Venous claudication Pain in the leg due to increase in venous pressure with exercise and outflow obstruction
27 CEAP Classification
28 CASE 52 yr man with h/o LLE DVT after spine surgery 4 years ago Treated with Coumadin, No stockings Complaining of Chronic LLE edema and stasis ulcer Exam LLE chronic edema, stasis Presenter changes, name medial malleolar ulcer, groin and suprapubic varices US No evidence of DVT in leg, Varicose veins
29 CT scan
30 Left Leg Venogram Volcano IVUS
31
32
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34 Take Home Points PTS is the most common complication of chronic DVT Prevention of PTS is the goal Appropriate anticoagulation & Compression stockings (acute DVT) Medical management of PTS Leg elevation and compression stockings Endovascular intervention is possible for chronic DVT (Iliocaval & Iliofemoral) Follow results of the ACCESS PTS trial
35 THANK YOU
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