Venous Disease: The Who, How, When and Why. Jacoby Stieler ARNP-C Iowa Heart Vein Center

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1 Venous Disease: The Who, How, When and Why Jacoby Stieler ARNP-C Iowa Heart Vein Center

2 Objectives Patients to refer to the vein center Office procedures commonly performed in the vein center at Iowa Heart Current Recommendation for anticoagulation management in DVT patients

3 Vein Center Appropriate symptoms for referral o Aching, throbbing, itching, skin discoloration, bulging varicose veins, spider veins, non healing wounds, lower extremity swelling. Venous insufficiency risk factors o Hx DVT, varicose veins, obesity, pregnancy, smoking, occupation, family history

4 Clinical Presentation

5 Referral to Vein Center Testing o Venous Reflux Ultrasound o Lower Extremity Venous DVT Consultation o Review medical history, current symptoms, conservative therapy, review testing Conservative therapy o Compression stockings, leg elevation, exercise

6 Reflux Anatomy Copyright 2015 Tepas Healthcare

7 Ablation of the vessel After some period of conservative therapy, outlined by the individuals insurance company, often the initial procedure is an ablation of the incompetent vessel.

8 Ablation Procedure o Less then an hour, driver required, not NPO, in office o One week restrictions No lifting greater then 25 lbs No vigorous activities Most can return to work the following day

9 Ablation Follow up o 3-6 day follow up and ultrasound If near a junction o One month follow up and ultrasound Risks o Discoloration, numbness, DVT, cellulitis, burn

10 Ambulatory Phlebectomy Procedure o minutes typically, driver needed, not NPO, in office o Two weeks restrictions No lifting greater then 25 lbs No vigorous activities All require 3 full days off work, some can return post procedure day 4 No soaking in water two full weeks minimum

11 Ambulatory Phlebectomy Follow up o Two week to check puncture sites o Continue to encourage avoiding sun exposure and soaking Risks o Discoloration, numbness, DVT, cellulitis

12 Sclerotherapy Hypertonic saline or polidocanal solutions injected into spider vein and reticular veins In office, two separate visits, 6 weeks apart Reasonable expectations 50%-90% improvement o Takes 4 weeks to respond, no guarantee on length or new veins

13 Lymphedema Copyright Central Coast Lymphedema Therapy,

14 Lymphedema Referral to lymphedema center o Often check with local PT to see if service is offered, complete decongestive therapy o Compression o Lymph node massage o Elevation o Pneumatic pump

15 Lymphedema Therapy is often 1-2 weekly for several weeks Risk factors o Cancer, obesity, recurrent infections Often not curative, constant management

16 Deep Vein Thrombosis & Pulmonary Embolism The precise number of people affected by DVT/PE is unknown, although as many as 900,000 people could be affected (1 to 2 per 1,000) each year in the United States. Estimates suggest that 60, ,000 Americans die of DVT/PE (also called venous thromboembolism). 10 to 30% of people will die within one month of diagnosis. Sudden death is the first symptom in about one-quarter (25%) of people who have a PE. Among people who have had a DVT, one-half will have long-term complications (post-thrombotic syndrome) such as swelling, pain, discoloration, and scaling in the affected limb. One-third (about 33%) of people with DVT/PE will have a recurrence within 10 years. Approximately 5 to 8% of the U.S. population has one of several genetic risk factors, also known as inherited thrombophilias in which a genetic defect can be identified that increases the risk for thrombosis. (Venous thromboembolism: a public health concern, 2010)

17 DVT Treatment First time provoked DVT 3 months anticoagulation duration o Bed rest, surgery, malignancies, immobilization, trauma, pregnancy, OCP, travel, childbirth Additional risk factors 3-6 months o Shorter courses of 4-6 weeks is associated with recurrent thrombosis Lifetime anticoagulation recommendations o Unprovoked proximal DVT o Recurrent DVT

18 Distal DVT associated with lower rate of reoccurrence then Proximal DVT o Distal DVT still recommended 3 months anticoagulation Recurrent DVT o Hypercoagulable study Factor V, protein C, protein S, antiphospholipid antibodies, anti-thrombin III, homocysteine, MTHFR, prothrombin o Clinical risk factors greater predictor for recurrent DVT, inherited thrombophilia increase initial event risk. o Men have a 2.7 greater recurrence rate then women, idiopathic have greater recurrence rate then provoked (JAMA, 2006)

19 Cleveland Clinic Journal of Medicine clinical prediction rule o Men and HERDOO2 Male sex Signs of post thrombotic syndrome o Hyperpigmentation o Edema o Redness o Positive D-dimer o Obesity o Old age (>65 years) o Lifelong anticoagulation consideration for two or more risk factors

20 Follow-up o Initial ultrasound, 1 month recheck and ultrasound, 6 month recheck and ultrasound, D-dimer when considering anticoagulation discontinuation o 6-8 weeks can retest Protein C/S after ceasing anticoagulation o Compression stocking recommended for minimum 2 years post DVT (ACCP recommendation) 30-40mmHg ideally

21 CloHing Cascade 2014 Macmillan Publishers Limited

22 Anticoagulation Agents

23 Factor Xa inhibitors

24 Eliquis / apixaban Dose for DVT/PE 10mg BID 7 days 5mg BID (74 pills first 30days) - For 6 months, then o 2.5mg BID remainder Dose for Afib 5 mg BID If renal 2.5 mg BID

25 Renal o Eliquis / apixaban Renal no adjustment - Unless NVAF and 2/3 >80yrs, <60kg, > 1.5crt Surgery o o d/c 48 hrs before mod/high risk d/c 24 hrs before low risk Diet o o No diet restrictions With or without food Missed dose o Take asap and still take second dose of day, do not double missed dose

26 Xarelto / rivaroxaban Dose for DVT/PE o 15mg twice daily for 21 days(acute); then 20mg once daily o Dose for AFib o 20mg QD o If renal 15mg QD

27 Xarelto / rivaroxaban Renal o CrCl<30 ml/min avoid Surgery o d/c 24 hours o Diet o No diet restrictions TAKE WITH FOOD, frequent GI upset with long term Missed dose o Take asap, do not double dose

28 Savaysa / edoxaban Dose for DVT/PE 5-10 days parenteral antiocoag therapy 60mg QD CrCl>50ml 30mg QD CrCl 15 to 50mL ***CrCl on ALL pts*** Black box warning for ischemic stroke with impaired renal fxn Dose for Afib 60mg QD CrCl 50> to <95mL 30mg QD CrCl 15 to 50mL

29 Savaysa / edoxaban Renal o CrCl based dosing for all pts Surgery o d/c 24 hours before Diet o No diet restriction. Take with or without food Missed dose o Take asap, do not double dose

30 Direct thrombin inhibitor

31 Pradaxa / dabigatran Dose for DVT/PE o 150mg BID For acute clots, lovenox for 5-10 days Dose for Afib o 150mg BID o 75mg BID if renal

32 Pradaxa / dabigatran Renal o CrCl 30-50mL/min decrease to 75mg Surgery o 1-2 days for CrCl > 50mL o 3-5 days for CrCl < 50mL Diet o Take with a full glass of water Missed dose o Take at least 6 hours before next scheduled dose, do not double dose

33 Dose for DVT/PE o Initially started with heparin o 2-5mg QD Coumadin o 10mg QD for 2 days (acute, healthy) Adjust based on INR (takes 2 days for effect) Dose for Afib o Per INR protocol

34 Renal o No adjustment Surgery o Bridge pt Coumadin Diet o Avoid alcohol o Consistent diet of vitamin K Missed dose o Take asap, do not double dose

35 Switching from Warfarin Eliquis / apixaban Xarelto / rivaroxaban Savaysa / edoxaban Pradaxa / dabigatran INR < 2.0 INR<3.0 INR < 2.5 INR < 2.0 Stop warfarin then begin Stop warfarin and begin. Stop warfarin and begin. Stop warfarin and begin.

36 Switching to Warfarin Eliquis / apixaban Xarelto / rivaroxaban Savaysa / edoxaban Pradaxa / dabigatran Lovenox and Coumadin No INR initially, will be skewed Next scheduled dose stop Xarelto and begin Lovenox and Coumadin Reduce dose by half and take Coumadin concomitantly until INR > 2.0 Overlap Coumadin to discontinue 1-3 days based on CrCl

37 Beckman, M.G., Hooper, W.C., Critchley, S.E., Ortel, T.L. (2010). Venous thromboembolism: a public health concern. American Journal of Preventative Medicine 38(4). Kaatz, S. (2011). Venous thromboembolism: What to do after anticoagulation is started. Cleveland Clinic Journal of Medicine 78(9). Christiansen, S.C., Cannegieter, S.C., Koster, T., Vandenbroucke, J.P., Rosendaal, F.R. (2005). Thrombophilia, Clinical Factors, and Recurrent Venous Thrombotic Events. Journal of American Medical Association 293(19).

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