南口博紀(jì)教授-NEW-IR-for-DVT

1、南口博紀(jì)教授-NEW-IR-for-DVT南口博紀(jì)教授-NEW-IR-for-DVTWakayama Medical Univ. Hospital800 Beds1500 Outpatients/ dayAngiography 2700/ year in all 600/ year in IRWakayama 和歌山970,000 in Wakayama Pref.370,000 in Wakayama CityWakayama Medical Univ. Hospita高野山KoyasanA.D.816 1,200years old temple高野山Koyasan白浜Shirahama A

2、dventure WorldBig Panda Family北京白浜北京Acute DVTLymphedemaAfter HysterectomyHematomaOverdose of VKAChronic DVTPost-thrombotic Synd.Chief Complaints: Leg SwellingIRRed, Fever, PainfulWhite, pitting edemaBlue, anemiaSkin Ulcer, Infectionhistory of DVTAcute DVTLymphedemaHematomaChrIntroductionVenous Throm

3、boembolism (VTE) = Pulmonary Embolism (PE) +Deep Vein Thrombosis (DVT)PE in 70% of DVT casesDVT in 3070% of PE cases PHLEGMASIA CERULEA DOLENSIntroductionPHLEGMASIA CERULEAPE incidence: JAPAN- 62/ million, USA- 500/millionVTE increasing in JAPAN : Westernization of Lifestyle, Aging Population, Great

4、er rate of DiagnosisPE: High mortality 10-30%Over 100,000 deaths/ year in USAEarly Diagnosis and Treatment (including inhibition of DVT progression and prevention of PE recurrence) are therefore very important !PE incidence: JAPAN- 62/ milliTreatment of DVT has recently advanced significantlyDespite

5、 the use of standard anticoagulant therapy, DVT recurs frequently and often leads to the development of post-thrombotic syndrome (PTS)Catheter-based techniques have been used in the management of DVT for many years, but are undergoing now strict evaluation in RCTs to determine whether they improve p

6、atient outcomesTreatment of DVT has recently 70 FAcute DVT2001.1Greenfield filterMicrocath. via jugularExtravasation!From Jugular vein=Retrograde approachVascular Injury may occurWaste of Time70 FExtravasation!From JugularG. OSullivan2 days later, Pop V approach (1st case) Now 86 years old, alive, n

7、o symptoms27 limbs, CDT with UK(1.4 million16.0 million IU) for 30 hr (1574 hr)Technical & clinical success 85%, No major complications. G. OSullivan2 days later, PRationale for Thromboreductive Therapies Consequences of DVTPTS develops in 2550% with proximal DVTPTS causes chronic symptoms (swelling

8、,pain,heaviness,fatigue.)Severe PTS may experience venous claudication, stasis dermatitis, skin changes (hyperpigmentation, fibrosis, skin ulcer)Recurrent ipsilateral DVT: 2 to 6-fold increased risk of PTSTherefore, adequate anticoagulation should be a key PTS prevention measure, but it is clear tha

9、t despite anticoagulation many DVT patients will still develop PTS.Rationale for ThromboreductiveRajasekhar A: J Thromb Thrombolysis 2015; 39, 315.IVC filter indicationsNot reportedRajasekhar A: J Thromb ThromboPREPIC studyPermanent IVC filter & Anticoaglants(AC) vs AC only for Proximal DVT with/wit

10、hout PE, f/uAcute phase: PE preventableChronic phase(8 years): Recurrent DVT is higher ! (p0.042)Use retrievable IVC filter & retrieve ASAP !Decousus H, NEJM, 338,1998. PREPIC Study Group. Circulation 112, 2005.PREPIC studyPREPIC 2 studyPE patients: Retrievable IVC filter & AC vs AC onlyAC for 6 mon

11、ths, Filter retrieval 3 months3 months, Recurrent PE in 6 cases vs 3 cases6 months, Recurrent PE in 7 cases vs 4 cases6 months, Recurrent DVT in 1 case vs 2 casesNo need for IVC filter under adequate ACsStill Controversial !Mismetti P, JAMA 313, 2015.PREPIC 2 studyRetrievable(optional) filter in alm

12、ost all cases before Thrombolysis1. IVC filterGunther tulipOptEaseALNTo Prevent iatrogenic PE due to Thrombolysis and/or ThrombectomyRetrievable(optional) filter iCatheter-directed intrathrombus thrombolysis (CDT) for DVTImage-guided, Catheter-directed, intra-thrombus drug infusion has been safe and

13、 effective Advantages: (1)Achieve a high intra-thrombus drug concentration and Avoid bypass of the drug via collaterals(2)Reduce drug dose, treatment time and complicationsCatheter-directed intrathrombuRequired EquipmentOur standard IR protocol typically requires the following devices:6-F vascular s

14、hort sheath kit (18-gauge needle, 0.035in guidewire);hydrophilic 0.035in guidewire;4-F angled-tip multipurpose catheter with multisidehole to cross DVT;5-F pulse-spray catheter6-F thrombectomy catheter with VacLok syringeRequired EquipmentGuidelines for the Diagnosis, treatment and prevention of DVT

15、 (2009）JCS (The Japanese Circulation Society)Acute DVTHeparin & VKA (Warfarin)Evidence levelSystemic ThrombolysisEvidence levelaCDT and ThrombectomyEvidence levelbStenting after ThrombolysisEvidence levelbGuidelines for the Diagnosis, AHA Scientific StatementCDT or PCDT should be given patients with

16、 proximal DVT with limb-threatening circulatory compromise (ie, phlegmasia cerulea dolens) (Evidence level I; Grade C)CDT or PCDT is reasonable as 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

17、for bleeding (Evidence level III, Grade B)Jaff MR, et al: Circulation 2011.AHA Scientific StatementCDT orRecent major trials of CDT for DVTCaVenTOpen RCT200Iliofemoral DVT 21 daysCDTAnticoagulationrt-PA6 month patencyPTS at 24 monthsATTRACTOpen multicenter RCT692Iliac, CF, SF DVT 14daysPMT+CDTAntico

18、agulationrt-PAPTS at 24 monthsDUTCH-CAVAAssessor-blindedmulticenter RCT 180Iliofemoral DVT 14daysUS accelerated CDTAnticoagulation?PTS at 12 monthsStudyDesignNPathologyArmsTherapyPrimary endNov 2009-Jan 2015May 2010-Jan 2015Jan2006Dec 2009Recent major trials of CDT forCaVenT study from NorwayStandar

19、d Tx(ACs & CompStokings) +CDT using tPA: To prevent PTS or notStandard Tx vs Standard Tx & CDT（tPA, max 96 hours)Major bleeding in 3 casesPTS 24 months: 55.6 vs 41.1% (p=0.047)Patency 6 months: 47.4 vs 65.9 (p=0.012)CDT recommend for severe proximal DVT without bleeding risksEnden T, Lancet 379, 201

20、2.CaVenT study from NorwayCDT protocolAfter IVC filter placement(a) Patient into prone position, and the involved extremity is prepared and draped in sterile fashion (b) Lower extremity vein (usually the popliteal vein) is accessed under US guidance; ”ipsilateral Pop vein, Antegrade approach”Pop VPo

21、p ACDT protocolPop VPop A(c) subsequently 0.035inch guidewire is advanced through the thrombus into the IVC using MP catheter and guidewire technique.; (d) venography is performed to assess extent of the thrombus;(e) Multisidehole MP catheter cross the thrombosed segmentExtravasationFrom Jugular vei

22、n=Retrograde approachVascular Injury may occurWaste of Time(c) subsequently 0.035inch guCurrently, the most commonly used fibrinolytic drug for DVT is urokinase (UK) in JAPANThe drug is infused continuously and directly into the thrombus at a low dose (a typical UK dose is 10,000I.U./hr in JAPAN. Se

23、parately from MP catheter and sheath)During this time, Heparin infusion at subtherapeutic levelsCurrently, the most commonly uVenography 24-48 hr intervalsAfter thrombolysis is completed, venography is repeated and any visualized stenoses are treated with balloon venoplasty or stenting if possibleFu

24、ll-dose Anticoagulant therapy is re-started and Long-term Oral Vitamin K antagonist (VKA) and wear Compression StockingsVenography 24-48 hr intervalsLtAfter CDTIV-DSAV&A overlap imageNOT thrombusJust Compress byRt-CIA & Lt-IIAWallstentVenographyStenting if possibleOff-label use in JAPANiliac vein co

25、mpression synd.”LtAfter CDTIV-DSANOT thrombusPharmacomechanical CDTCombination of intrathrombus drug delivery with Pulse-spray catheter and/or Manual/Mechanical thrombectomy devicesImprove drug distribution and Macerate and/or Aspirate thrombus Faster distribution of the thrombolytic drug within the

26、 thrombus, Accelerating successful thrombolysis and Improving safety by reducing the drug and exposure time (may reduce bleeding risk)Pharmacomechanical CDTPulse-spray catheterPharmaco-mechanical CDT UK Power inj.Pulse-spray catheterManual aspiration device (Aspirare cath) with VacLok syringeManual

27、aspiration device (AspiPatient selection for IR therapyAcute phase:Age, ADL, underlying disease(malignancy.) Trousseau synd.Ilio-femoro-poplitealIlio-femoral IliacFemoralCalf IVC involvement typeThrombus locationCHECK!: Contraindication for ACs and/or Thrombolysis (e.g. Intracranial hemorrhage, Acti

28、ve bleeding.)ASAP!2weeks 4weeksonset 2-3daysAcute on chronic DVT: effective on acute thrombusPatient selection for IR theraPeriprocedural ComplicationsMajor bleeding: 24% of P-CDTSymptomatic PE has been observed infrequently BUT increases risk with more mechanically aggressive methods (e.g. AngioJet

29、, Trellis) Hence, some IRists use Retrievable IVC filter during the peri-procedure periodImportant to ensure filter retrieval as soon as the risk of PE is diminishedPeriprocedural ComplicationsClinical Follow-UpAnticoagulation for at least 3-6 months in uncomplicated cases who have no underlying ris

30、k factors for hypercoagulable states Patients with predisposing factors for thrombosis may require longer Anticoagulation, based on the underlying diseaseClose follow-up and strict compliance with Anticoagulation and Compression Stockings are necessary for favorable outcomes.Clinical Follow-Up43y Fe

31、male：idiopathic lt-DVT2 days after onsetDay 0Gunther tulip filter43y Female：idiopathic lt-DVTDaProne positionLt-Pop vein puncture6F sheath4F MP cath. with multi-sideholeCDT in the Pts roomDay 2partial thrombolysisIliac vein compressionLtProne positionDay 2LtDay 4Thrombus only in iliac veinManual thr

32、ombectomyNo thrombusDay 4Manual thrombectomyWallstentIR 3 timesRest on bed 5 days.10 years, no symptom, oral VKAWallstentIR 3 times60y Female: Lt-DVTDay 0NO IVC filterPulse-spray &ThrombectomyCDTshrinking lt-CIViliac vein compressionOR chronic DVT ?Dx: Acute on Chronic DVTNEED filter?60y Female: Lt-

33、DVTDay 0shrinDay 3Day 1CDTNo thrombusIliac vein stent?NO stentGood OutflowDay 3Day 1No thrombusNO stentFlow of DVT patients in WakayamaDxIVC filterPop punctureP-CDTthrombectomyCDTStentingRetrieve IVC filterVenographyCDTCCU,ICUSymptomatic PEFlow of DVT patients in WakayaEKOS（)US assistedFrancis CW, U

34、ltrasound in Medicine and Biology 21, 1995DVT TREATMENT OPTIONS (NOT Available in JAPAN)Ultrasonic energy causes fibrin to thinDrug deep into the clotEKOS（)Francis AngioJet Ultra Thrombectomy System(BSCI)Pulse-spray Thrombolysis & Negative Vortex AspirationKasirajan, JVIR 12,2001AngioJet Ultra Thrombectomy SyTrellis(Covidien)Isolated Pharmaco-mechanical Thrombolysis & ThrombectomyOSullivan GJ, JVIR 18(6) 2007Trellis(Covidien)OSullivan GJLarge bore a