醫(yī)學(xué)交流課件：NEW IR for DVT

1、Wakayama Medical Univ. Hospital 800 Beds 1500 Outpatients/ day Angiography 2700/ year in all 600/ year in IR,970,000 in Wakayama Pref. 370,000 in Wakayama City,高野山Koyasan A.D.816 1,200years old temple,白浜 Shirahama Adventure World Big Panda Family,北京,Acute DVT,Lymphedema After Hysterectomy,Hematoma O

2、verdose of VKA,Chronic DVT Post-thrombotic Synd,Chief Complaints: Leg Swelling,IR,Red, Fever, Painful,White, pitting edema,Blue, anemia,Skin Ulcer, Infection history of DVT,Introduction Venous Thromboembolism (VTE) = Pulmonary Embolism (PE) +Deep Vein Thrombosis (DVT) PE in 70% of DVT cases DVT in 3

3、070% of PE cases,PHLEGMASIA CERULEA DOLENS,PE incidence: JAPAN- 62/ million, USA- 500/million VTE increasing in JAPAN : Westernization of Lifestyle, Aging Population, Greater rate of Diagnosis PE: High mortality 10-30% Over 100,000 deaths/ year in USA Early Diagnosis and Treatment (including inhibit

4、ion of DVT progression and prevention of PE recurrence) are therefore very important,Treatment of DVT has recently advanced significantly Despite the use of standard anticoagulant therapy, DVT recurs frequently and often leads to the development of post-thrombotic syndrome (PTS) Catheter-based techn

5、iques have been used in the management of DVT for many years, but are undergoing now strict evaluation in RCTs to determine whether they improve patient outcomes,70 F Acute DVT 2001.1 Greenfield filter Microcath. via jugular,Extravasation,From Jugular vein =Retrograde approach Vascular Injury may oc

6、cur Waste of Time,G. OSullivan,2 days later, Pop V approach (1st case) Now 86 years old, alive, no symptoms,27 limbs, CDT with UK(1.4 million16.0 million IU) for 30 hr (1574 hr) Technical 39, 315,IVC filter indications,Not reported,PREPIC study Permanent IVC filter hydrophilic 0.035in guidewire; 4-F

7、 angled-tip multipurpose catheter with multisidehole to cross DVT; 5-F pulse-spray catheter 6-F thrombectomy catheter with VacLok syringe,Guidelines for the Diagnosis, treatment and prevention of DVT (2009） JCS (The Japanese Circulation Society) Acute DVT Heparin Grade C) CDT or PCDT is reasonable a

8、s first-line treatment with Acute proximal DVT to prevent PTS at low risk of bleeding complication(Evidence level IIa; Grade B) Chronic (21days), high risk for bleeding (Evidence level III, Grade B,Jaff MR, et al: Circulation 2011,Recent major trials of CDT for DVT,CaVenT Open RCT 200 Iliofemoral DV

9、T 21 days CDT Anticoagulation rt-PA 6 month patency PTS at 24 months,ATTRACT Open multicenter RCT 692 Iliac, CF, SF DVT 14days PMT+CDT Anticoagulation rt-PA PTS at 24 months,DUTCH-CAVA Assessor-blinded multicenter RCT 180 Iliofemoral DVT 14days US accelerated CDT Anticoagulation ? PTS at 12 months,S

10、tudy Design N Pathology Arms Therapy Primary end,Nov 2009-Jan 2015,May 2010-Jan 2015,Jan2006Dec 2009,CaVenT study from Norway Standard Tx(ACs ”ipsilateral Pop vein, Antegrade approach,c) subsequently 0.035inch guidewire is advanced through the thrombus into the IVC using MP catheter and guidewire te

11、chnique.; (d) venography is performed to assess extent of the thrombus; (e) Multisidehole MP catheter cross the thrombosed segment,Extravasation,From Jugular vein =Retrograde approach Vascular Injury may occur Waste of Time,Currently, the most commonly used fibrinolytic drug for DVT is urokinase (UK

12、) in JAPAN The drug is infused continuously and directly into the thrombus at a low dose (a typical UK dose is 10,000I.U./hr in JAPAN. Separately from MP catheter and sheath) During this time, Heparin infusion at subtherapeutic levels,Venography 24-48 hr intervals After thrombolysis is completed, ve

13、nography is repeated and any visualized stenoses are treated with balloon venoplasty or stenting if possible Full-dose Anticoagulant therapy is re-started and Long-term Oral Vitamin K antagonist (VKA) and wear Compression Stockings,Lt,After CDT,IV-DSA V&A overlap image,NOT thrombus Just Compress by

14、Rt-CIA & Lt-IIA,Wallstent,Venography,Stenting if possible Off-label use in JAPAN,iliac vein compression synd.,Pharmacomechanical CDT Combination of intrathrombus drug delivery with Pulse-spray catheter and/or Manual/Mechanical thrombectomy devices Improve drug distribution and Macerate and/or Aspira

15、te thrombus Faster distribution of the thrombolytic drug within the thrombus, Accelerating successful thrombolysis and Improving safety by reducing the drug and exposure time (may reduce bleeding risk,Pulse-spray catheter Pharmaco-mechanical CDT UK Power inj,Manual aspiration device (Aspirare cath)

16、with VacLok syringe,Patient selection for IR therapy Acute phase,Age, ADL, underlying disease(malignancy.) Trousseau synd,CHECK!: Contraindication for ACs and/or Thrombolysis (e.g. Intracranial hemorrhage, Active bleeding.,Acute on chronic DVT: effective on acute thrombus,Periprocedural Complication

17、s Major bleeding: 24% of P-CDT Symptomatic PE has been observed infrequently BUT increases risk with more mechanically aggressive methods (e.g. AngioJet, Trellis) Hence, some IRists use Retrievable IVC filter during the peri-procedure period Important to ensure filter retrieval as soon as the risk o

18、f PE is diminished,Clinical Follow-Up Anticoagulation for at least 3-6 months in uncomplicated cases who have no underlying risk factors for hypercoagulable states Patients with predisposing factors for thrombosis may require longer Anticoagulation, based on the underlying disease Close follow-up an

19、d strict compliance with Anticoagulation and Compression Stockings are necessary for favorable outcomes,43y Female：idiopathic lt-DVT 2 days after onset,Day 0 Gunther tulip filter,Prone position Lt-Pop vein puncture 6F sheath 4F MP cath. with multi-sidehole CDT in the Pts room,Day 2 partial thromboly

20、sis Iliac vein compression,Lt,Day 4 Thrombus only in iliac vein,Manual thrombectomy No thrombus,Wallstent,IR 3 times Rest on bed 5 days. 10 years, no symptom, oral VKA,60y Female: Lt-DVT,Day 0 NO IVC filter Pulse-spray & Thrombectomy CDT,shrinking lt-CIV,iliac vein compression OR chronic DVT ,Dx: Ac

21、ute on Chronic DVT,NEED filter,Day 3,Day 1 CDT,No thrombus Iliac vein stent,NO stent Good Outflow,Flow of DVT patients in Wakayama,Dx,IVC filter Pop puncture P-CDT thrombectomy,CDT,Stenting,Retrieve IVC filter,Venography,CDT,CCU,ICU,Symptomatic PE,EKOS（) US assisted,Francis CW, Ultrasound in Medicin

22、e and Biology 21, 1995,DVT TREATMENT OPTIONS (NOT Available in JAPAN,Ultrasonic energy causes fibrin to thin Drug deep into the clot,AngioJet Ultra Thrombectomy System(BSCI,Pulse-spray Thrombolysis & Negative Vortex Aspiration,Kasirajan, JVIR 12,2001,Trellis(Covidien) Isolated Pharmaco-mechanical Thrombolysis & Thrombectomy,OSullivan GJ, JVIR 18(6) 2007,Large bore aspiration Essentially perfusion circuit Possibility to remove LARGE volume quickly,BUT 24F (Asians may forget it,Sinus-Venous stent (OptiMed) Radial force For Iliac vein compression,Zilver Vena（COOK,Device lag & Insurance coverage