Deep Vein Pathophysiology: Reflux & Obstruction
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Transcript of Deep Vein Pathophysiology: Reflux & Obstruction
Disclosure Peter J. Pappas, M.D.
I have no financial relationship(s) to disclose.
Deep Vein Pathophysiology:
Reflux and Obstruction
Peter J. Pappas M.D.
Chairman, Department of Surgery
The Brooklyn Hospital
2011 International Vein
Congress
16.8
2
81.2
29.6
22.8
92.4
0.8
7.6
27.6
64
7.2
5.2
25.2
23.2
86.8
3.6
16.8
0 10 20 30 40 50 60 70 80 90 100
Ref lux + obstruction
Obstruction
Ref lux
Deep
Perforating
Superf icial
Congenital
Primary + Secondary
Secondary
Primary
Active Ulcer
Healed Ulcer
Skin changes
Edema
Varicose veins
Prominent veins
Telangiectases
Percent
Clinical, etiologic, anatomic and pathophysiologic data (n= 250 limbs)Clinical
Etiologic
Anatomic
Pathophysiologic
Labropoulos N. Vasc Surg 1997;31:224-5
Chronic Venous Disease – Pathophysiology
Chronic Venous Disease – Pathophysiology
Pathophysiology
Isolated Obstruction – 2%
Incompetence + Obstruction – 16.8%
Incompetence plus obstruction
most severe morbidity!
Labropoulos N. Vasc Surg 1997;31:224-5
Etiology
- Non-thrombotic Venous Lesions
- Post-thrombotic Lesion
Leads to Venous Hypertension
Deep venous thrombosis is the most
common cause of venous obstructions
Chronic Venous Obstruction – Pathophysiology
Chronic Venous Obstruction – Clinical Presentation
Swelling/Pain
Venous claudication
Lipodermatosclerosis
Venous ulceration
Signs and symptoms of venous congestion
Chronic Venous Obstruction - Location
Chronic Venous Obstruction - Location
Chronic Venous Obstruction - Location
Algorithms for workup of CVI often emphasize
reflux and testing for outflow obstruction
above inguinal ligament is omitted
- Don’t look for it
- Don’t see it when we look at it
- Don’t know how to measure it
Chronic Venous Obstruction – Diagnostic Evaluation
Hemodynamic tests
Chronic Venous Obstruction – Diagnostic Evaluation
Lack of accurate objective noninvasive or
invasive tests for evaluation
of hemodynamically significant CVO
Morphologic diagnosis of venous obstruction
Chronic Venous Obstruction – Diagnostic Evaluation
Duplex US
RIA LIA
VB
Velocity ratio
Poststenotic/prestenotic >2.5
18cm/s
210cm/s
V2/V1= 12
Chronic Venous Obstruction – Diagnostic Evaluation
Duplex US
Labropoulos N, et al. J Vasc Surg 2007;46:101-7
Chronic Venous Obstruction – Complimentary test
CTV/MRV
Neglen P, Raju S. J Vasc Surg 2002;35:694-700
•IVUS is superior to phlebography for the
morphologic diagnosis of iliac venous outflow
obstruction.
•With IVUS, fine intraluminal and mural details
were detected (eg, trabeculation, frozen valves,
mural thickness, and outside compression) that
were not seen with venography.
The median stenosis on
phlebographic
results was 50%
on IVUS 80%.
Chronic Venous Obstruction – “The standard”
• Comparison of IVUS with venography in the
assessment of chronic iliac vein obstruction
• 304 consecutive limbs during balloon dilation
and stenting of an obstructed iliac venous
segment
IVUS - Venous obstruction
Neglen P, Raju S. J Vasc Surg 2002;35:694-700
Methods
• With IVUS, fine intraluminal and mural
details were detected (eg, trabeculation,
frozen valves, mural thickness, and outside
compression) that were not seen with
venography.
IVUS - Venous obstruction
Neglen P, Raju S. J Vasc Surg 2002;35:694-700
Methods
The median stenosis on phlebographic
results was 50% on IVUS 80%.
Neglen P, Raju S. J Vasc Surg 2002;35:694-700
IVUS is superior to phlebography
for the morphologic diagnosis
of iliac venous outflow obstruction.
IVUS - Venous obstruction
Conclusion
Pre-intervention Imaging
Post-intervention Result
• Think obstruction
• Clinical signs and symptoms
postthrombotic disease
Severe C3, C4-6
pain out of proportion to lesion
no detectable lesion explaining symptoms
• Positive indicators of obstruction
stenosis/occlusion on venogram, MR-V, CT-V
presence of collaterals
Chronic Venous Obstruction – How to find it?
Chronic Venous Obstruction –Treatment
Chronic Venous Obstruction –Treatment
Results of open bypass surgery
Chronic Venous Obstruction –Treatment
Stenting of the venous outflow is the
preferred initial treatment over bypass
Technically simple
Minimally invasive
Outpatient procedure
Low morbidity
Does not preclude later open surgery
• 982 Chronic, nonmalignant
obstructions
• Femoral-ilio-caval segments
• Mean age 54
• Primary/secondary 518:464
Neglen P et al
J Vasc Surg 2007;46:979
Chronic Venous Obstruction - Treatment
0 6 12 18 24 30 36 42 48 54 60 66 720
10
20
30
40
50
60
70
80
90
100
Primary
Assisted-primary/Secondary
302 192 143 120 96 80 65 55 43 34 24 16302 189 135 110 87 72 54 45 36 26 18 11
Months
Pa
ten
cy
Ra
tes
(%
)
100%
79%
[SEM <10%]
Chronic Venous Obstruction - Treatment
Neglen P et al
J Vasc Surg 2007;46:979
Chronic Venous Obstruction – Clinical Response
QoL-Scores (CIVIQ)
Total score (mean±SD)
Pre Post
Leg pain 3.5±1.1 2.6±1.2***
Work 3.5±1.1 2.7±1.3***
Sleep 3.2±1.3 2.5±1.3***
Social
Activity 25.1±8.4 21.4±9.0***
Morale 26.0±9.8 22.1±9.7***
VCSS 8.5 (range: 4-18)
2 (range: 2-3)
VDS 2 (range:0-9)
0 (range:0-2)
Hartung O, et al. J Vasc Surg 2005;42:1138-44
Neglén et al. J Vasc Surg 2007;46:979
Endovascular
Mid-thigh UG-access FV
Chronic Venous Obstruction - Treatment
Chronic Venous Obstruction - Treatment
Hybrid
Endophlebectomy + stenting
• 47yo male presented with LLE non-healing
venous ulcer.
• VDU – LLE GSV/SSV reflux, pelvic collaterals
and CIV occlusion
Chronic Venous Obstruction – Case: CIV occlusion
Chronic Venous Obstruction – Case: CIV occlusion
Chronic Venous Obstruction – Case: CIV occlusion
• 59 yo woman with
chronic LLE swelling.
Venous claudication.
Skin pigmentation
• Prior DVT 15 yr ago
• CS-4, ES, AS,D,P, PR,O
Chronic Venous Obstruction – Case: EIV occlusion
Chronic Venous Obstruction – Case: EIV occlusion
Chronic Venous Obstruction – Case: EIV occlusion
Chronic Venous Obstruction – Case: EIV occlusion
Chronic Venous Obstruction – Case: EIV occlusion
Massive Ilio-femoral VTE
During Pregnancy
• Lytic therapy contra-indicated due to risk of
placental, fetal and maternal bleeding
• Percutaneous Mechanical Thrombectomy
– Trellis
– Angiojet
– Ekos
• Open Thrombectomy
32 Week Pregnancy
Iliofemoral DVT of Pregnancy: RB
32 Week Pregnancy
Iliofemoral DVT of Pregnancy: RB
Trellis® Catheter
32 Week Pregnancy
Iliofemoral DVT of Pregnancy: RB
EKOS LysUS
System®
Post Trellis ®, LysUS ®, Angiojet®
Iliofemoral DVT of Pregnancy: RB
Decision to perform
operative venous
thrombectomy
Substantial residual
thrombus…hence…
Completion Phlebogram
Iliofemoral DVT of Pregnancy: RB
Completion Phlebogram
Iliofemoral DVT of Pregnancy: RB
• Patient
Asymptomatic
• Rx’ed with SQ
LMWH
24 Month Follow-Up
• Patient pregnant
• Normal venous function
• Asymptomatic
• On prophylaxis
2 Years Post Rx
Iliofemoral DVT of Pregnancy: RB
HPI
• 35 y/o male evaluated by an outside vascular surgeon for a one week history of mild left leg swelling and groin pain.
• Venous duplex and MRV performed at this outside institution demonstrated an isolated left iliac vein thrombosis and possible iliac vein stenosis.
• Patient was referred to University Hospital for lytic therapy.
• On arrival to the ED, the patient was short of breath and found to have a PE by chest CT.
• He was admitted and started on intravenous Heparin.
History
• PMHx- testicular ca 6 yrs ago – No radiation/chemotherapy, no lymph node
dissection
• PSHx-left orchiectomy
• Meds-none
• Allergy-NKDA
Physical Exam
• Lungs-CTA B/L
• Cardiac-RRR, no murmurs
• Abdomen-soft, non tender, no organomegaly,
not distended
• Vascular exam-palpable distal pedal pulses b/l
• Extremity- minimal LLE swelling
– No difference in leg circumferences
Hospital Course HD #1
• Admitted to vascular surgery service
• CT scan of chest -small PE
• IV heparin initiated
• Venous duplex performed
CT Angiogram: PE in Left Pulmonary Artery
CFV flow pattern on admission
Phasic Flow Loss of Phasicity
LCIV thrombosis on admission
Hospital Course-HD#2
• IVC filter placed.
• Mechanical thrombectomy with an Angioget
system.
• Chest pain, bradycardia, decreased oxygen
saturation to 90s.
• Procedure aborted.
Codes
• 37620 – IVC filter placement
• 75940-26 – SI code for IVC filter placement
• 36010-50 – Cannulation of IVC via bilateral
Common Femoral Vein approaches
• 75827-26,59 – SI code for Inferior
Venacavagram
• 37187 – Code for initial venous mechanical
thrombectomy.
Hospital Day 2-5
• Patient continued on IV heparin and started on Coumadin.
• Poor response to coumadin with minimal change in INR. PTT was always therapeutic.
• Hospital day 5, patient’s left leg increased in size.
• Venous duplex repeated. Demonstrated thrombus from filter to infra-popliteal tibial veins.
Left CFV, DFV, FV, POPV, GSV thrombosis
Captured thrombus in the IVC filter
Hospital Day 6:
Thrombectomy/Thrombolysis
• Patient taken to cardiac cath lab and placed in prone position. An ultrasound guided cannulation of PV.
• Pulse spray with tPA
• Mechanical thrombectomy
• Left lower extremity venogram
• Catheter left in femoral and popliteal vein overnight with continuous infusion of TPA
Percutaneous mechanical
thrombectomy • Angiojet (Possis)
• Xpedior cath
• 4-12 mm vessels
• OTW 0.035 system
• 6Fr catheter
• 120 cm working length
• 6 saline jets
• Venturi effect
Percutaneous mechanical
thrombectomy
Codes for Hospital Day 6
• 36005-58 – Cannulation of Femoro-popliteal
vein
• 76937-26,58 – US Guidance SI code
• 75820-26,58 – SI code for LE venogram
• 37188-58 – Secondary mechanical
thrombectomy
• 37201-58 – Overnight instillation of TPA
• 75896-26,58 – SI code for infusion of
thrombolytics overnight
Hosptial Day 7
• Venogram through existing catheter demonstrated
liquified thrombus in Femoral and popliteal
veins.
• Mechanical thrombectomy performed and
catheter repostioned into left external iliac vein.
• TPA infusion continued.
Codes For Hospital Day 7
• 75898-26,58 – Venogram through existing
catheter
• 37188-58 – Repeat venous mechanical
thrombectomy
• 75896-26,58 – SI code for continued instillation
of lytic therapy
• 36012-58 – Repositioning catheter into external
iliac veins.
Hospital Day 8
• Venogram through existing catheter demonstrated
no resolution of IVC thrombus.
• Mechanical thrombectomy attempted without
success.
• Lysis continued for another 24 hours.
Codes for Hospital Day 8
• 75898-26,58 – Venogram through existing
catheter
• 37188-58 – Mechanical thrombectomy
• 75896-26,58 – SI code continued instillation of
thrombolytics
Hospital Day 9
• Venogram through existing catheter demonstrated
no resolution of IVC thrombus.
• TPA infusion terminated. Catheters removed.
Sheath removed three hours later.
• Patient anticoagulated with coumadin again.
Codes for Hospital Day 9
• 75898-26,58 – Venogram through
existing catheter.
Chronic Venous Obstruction:
Pharmacomechanical and Open
Venous Thrombectomy
Peter J. Pappas M.D.
Professor and Director
Chairman, Department of Surgery
The Brooklyn Hospital
BSN Jobst Seminars
[SEM <10%]
0 6 12 18 24 30 36 42 48 54 60 66 720
10
20
30
40
50
60
70
80
90
100
Primary
Assisted-primary
Secondary
603 383 290 243 195 165 139 114 88 69 53 34603 381 287 242 195 165 139 114 88 69 53 34603 373 267 218 176 143 113 90 68 52 39 24
Months
Pa
ten
cy
Ra
tes
(%
)
93%89%
67%
Chronic Venous Obstruction - Treatment
Neglen P et al
J Vasc Surg 2007;46:979
0 6 12 18 24 30 36 42 48 54 60 66 720
10
20
30
40
50
60
70
80
90
100
Primary
Assisted-primary
Secondary
303 191 147 123 99 87 74 59 45 35 29 18303 189 144 122 99 87 74 59 45 35 29 18303 184 132 107 89 74 59 45 32 26 21 13
Months
Pa
ten
cy
Ra
tes
(%
)
86%
80%
57%
[SEM <10%]
Chronic Venous Obstruction - Treatment
Neglen P et al
J Vasc Surg 2007;46:979