南口博紀教授-NEW-IR-for-DVT

IR

for

DVTinJapan2016.12.17@BeijingHirokiMinamiguchiM.D.Ph.D.Dept.ofRadiology,WakayamaMedicalUniv.Wakayama

Medical

Univ.Hospital800

Beds1500Outpatients/

dayAngiography2700/

yearinall

600/

yearinIRWakayama和歌山970,000inWakayamaPref.370,000inWakayamaCity高野山KoyasanA.D.816~

1,200yearsoldtemple白浜ShirahamaAdventureWorldBig

Panda

Family☆北京AcuteDVTLymphedemaAfterHysterectomyHematomaOverdoseofVKAChronicDVTPost-thromboticSynd.ChiefComplaints:LegSwelling↓IRRed,Fever,PainfulWhite,pittingedemaBlue,anemiaSkinUlcer,InfectionhistoryofDVTIntroductionVenousThromboembolism(VTE)=PulmonaryEmbolism(PE) +DeepVeinThrombosis(DVT)PEin70%ofDVTcasesDVTin30–70%ofPEcasesPHLEGMASIACERULEADOLENSPEincidence:JAPAN-62/million,USA-500/millionVTEincreasinginJAPAN:WesternizationofLifestyle,Aging

Population,GreaterrateofDiagnosisPE:Highmortality10-30% Over100,000deaths/yearinUSAEarlyDiagnosisandTreatment(includinginhibitionofDVT

progressionandpreventionofPErecurrence)arethereforevery

important

!!TreatmentofDVThasrecentlyadvancedsignificantlyDespitetheuseofstandardanticoagulanttherapy,DVTrecursfrequentlyandoftenleadstothedevelopmentofpost-thromboticsyndrome(PTS)Catheter-basedtechniqueshavebeenusedinthemanagementofDVTformanyyears,butareundergoingnowstrictevaluationinRCTstodeterminewhethertheyimprovepatientoutcomes70FAcuteDVT2001.1GreenfieldfilterMicrocath.viajugularExtravasation!FromJugularvein=RetrogradeapproachVascularInjurymayoccur?WasteofTimeG.O’Sullivan?2dayslater,Pop

V

approach(1stcase)Now86yearsold,alive,nosymptoms27limbs,CDTwithUK(1.4million~16.0millionIU)for30hr(15~74hr)Technical&clinicalsuccess85%,Nomajorcomplications.RationaleforThromboreductiveTherapiesConsequencesofDVTPTSdevelopsin25–50%withproximalDVTPTScauseschronicsymptoms(swelling,pain,heaviness,fatigue..)SeverePTSmayexperiencevenousclaudication,stasisdermatitis,skinchanges(hyperpigmentation,fibrosis,skinulcer)RecurrentipsilateralDVT:2to6-foldincreasedriskofPTSTherefore,adequateanticoagulationshouldbeakeyPTSpreventionmeasure,butitisclearthatdespiteanticoagulationmanyDVTpatientswillstilldevelopPTS.GuidelineEAST2002SIR2006BSH2006AHA2011ACCP2012ESC2014AcuteVTEandcontraindicationtoACYesYes(gradeB,levelIII)Yes(classI,levelB)Yes(grade1B)Yes(gradeIIa,levelC)FailureofACYesConsider(gradeC,levelIV)Yes(classIIa,levelC)Yes(gradeIIa,levelC)PreoperativelyifrecentVTEYes(gradeC,levelIV)AdjuncttotherapeuticACinacuteVTENo(gradeA,levelIb)No(classIII,levelC)No(grade1B)Free-floatingproximalDVTConsiderNo(gradeB,levelIII)NoMassivePEorproximalDVTundergoingthrombolysisConsiderNo(gradeC,levelIV)Consider(classIIb,levelC)Primaryprophylaxisinhigh-risksurgicalptYes,ifPPCI(levelIII)ConsiderifPPCINo(grade2C)RajasekharA:JThrombThrombolysis2015;39,315.IVCfilterindicationsNotreportedPREPIC

studyPermanentIVCfilter

&Anticoaglants(AC)vsAConly

forProximalDVTwith/withoutPE,f/uAcutephase:PEpreventableChronicphase(@8years):RecurrentDVTishigher!(p＝0.042) ?UseretrievableIVCfilter&retrieveASAP!DecoususH,NEJM,338,1998.PREPICStudyGroup.Circulation112,2005.PREPIC

2studyPEpatients:RetrievableIVCfilter&ACvsAConlyACfor6months,Filterretrieval@3months@3months,RecurrentPEin6casesvs3cases@6months,RecurrentPEin7casesvs4cases@6months,RecurrentDVTin1casevs2cases?NoneedforIVCfilterunderadequateACsStillControversial!!

MismettiP,JAMA313,2015.Retrievable(optional)filterinalmostallcasesbeforeThrombolysis1.IVCfilterGunthertulipOptEaseALNToPreventiatrogenicPEduetoThrombolysisand/orThrombectomy★Catheter-directedintrathrombusthrombolysis(CDT)forDVTImage-guided,Catheter-directed,intra-thrombusdruginfusionhasbeensafeandeffective

Advantages:(1)Achieveahighintra-thrombusdrugconcentrationand

Avoidbypassofthedrugviacollaterals(2)Reducedrugdose,treatmenttimeandcomplicationsRequiredEquipmentOurstandardIRprotocoltypicallyrequiresthefollowingdevices:6-Fvascularshortsheathkit(18-gaugeneedle,0.035

inguidewire);hydrophilic0.035

inguidewire;4-Fangled-tipmultipurposecatheterwithmultisideholetocrossDVT;5-Fpulse-spraycatheter6-FthrombectomycatheterwithVacLoksyringeGuidelinesfortheDiagnosis,treatmentandpreventionofDVT

(2009）JCS(TheJapaneseCirculationSociety)AcuteDVTHeparin&VKA(Warfarin) EvidencelevelⅠSystemicThrombolysis EvidencelevelⅡa CDTandThrombectomy

EvidencelevelⅡbStentingafterThrombolysis

EvidencelevelⅡbAHAScientificStatementCDTorPCDTshouldbegivenpatientswithproximalDVTwithlimb-threateningcirculatorycompromise(ie,phlegmasiaceruleadolens)

(EvidencelevelI;GradeC)CDTorPCDTisreasonableasfirst-linetreatmentwithAcuteproximalDVTtopreventPTSatlowriskofbleedingcomplication

(EvidencelevelIIa;GradeB)Chronic(>21days),highriskforbleeding

(EvidencelevelIII,GradeB)JaffMR,etal:Circulation2011.RecentmajortrialsofCDTforDVTCaVenTOpenRCT200IliofemoralDVT<21daysCDTAnticoagulationrt-PA6monthpatencyPTSat24monthsATTRACTOpenmulticenterRCT692Iliac,CF,SFDVT<14daysPMT+CDTAnticoagulationrt-PAPTSat24monthsDUTCH-CAVAAssessor-blindedmulticenterRCT180IliofemoralDVT<14daysUSacceleratedCDTAnticoagulation?PTSat12monthsStudyDesignNPathologyArmsTherapyPrimaryendNov2009-Jan2015May2010-Jan2015Jan

2006～Dec2009CaVenTstudyfromNorwayStandardTx(ACs&CompStokings)+CDTusingtPA:TopreventPTSornotStandardTxvsStandardTx&CDT（tPA,max

96hours)Majorbleedingin3casesPTS@24months:55.6vs41.1%(p=0.047)Patency@6months:47.4vs65.9％(p=0.012)?CDTrecommendforsevereproximalDVTwithoutbleedingrisksEndenT,Lancet379,2012.CDTprotocolAfterIVCfilterplacement(a)

Patientintoproneposition,andtheinvolvedextremityispreparedanddrapedinsterilefashion(b)Lowerextremityvein(usuallythepoplitealvein)isaccessedunderUSguidance;

”ipsilateralPopvein,Antegradeapproach”PopVPopA(c)subsequently0.035

inchguidewireisadvancedthroughthethrombusintotheIVCusingMPcatheterandguidewiretechnique.;(d)venographyisperformedtoassessextentofthethrombus;(e)MultisideholeMPcathetercrossthethrombosedsegmentExtravasationFromJugularvein=RetrogradeapproachVascularInjurymayoccur?WasteofTimeCurrently,themostcommonlyusedfibrinolyticdrugforDVTisurokinase(UK)inJAPANThedrugisinfusedcontinuouslyanddirectlyintothethrombusatalowdose(atypicalUKdoseis10,000I.U./hrinJAPAN.SeparatelyfromMPcatheter①andsheath②)Duringthistime,Heparininfusionatsubtherapeuticlevels③①②③Venography@24-48hrintervalsAfterthrombolysisiscompleted,venographyisrepeatedandanyvisualizedstenosesaretreatedwithballoonvenoplastyor

stenting

ifpossibleFull-doseAnticoagulanttherapyisre-startedandLong-termOralVitaminKantagonist(VKA)andwearCompressionStockingsLtAfterCDTIV-DSA

V&AoverlapimageNOTthrombusJustCompressbyRt-CIA&Lt-IIAWallstentVenographyStentingifpossible

Off-labeluseinJAPAN★"iliacveincompressionsynd.”PharmacomechanicalCDTCombinationofintrathrombusdrugdeliverywithPulse-spray

catheterand/orManual/MechanicalthrombectomydevicesImprovedrugdistributionandMacerateand/orAspiratethrombus

Fasterdistributionofthethrombolyticdrugwithinthethrombus,

Acceleratingsuccessfulthrombolysisand

Improvingsafetybyreducingthedrugandexposuretime

(mayreducebleedingrisk)Pulse-spraycatheterPharmaco-mechanicalCDTUK Powerinj.Manualaspirationdevice(Aspirarecath)withVacLoksyringePatientselectionforIRtherapyAcutephase:Age,ADL,underlyingdisease(malignancy...)"Trousseausynd."Ilio-femoro-poplitealIlio-femoralIliacFemoralCalfIVCinvolvementtypeThrombuslocation○◎◎◎×

CHECK!:ContraindicationforACsand/orThrombolysis(e.g.Intracranialhemorrhage,Activebleeding...)ASAP!!<2weeks<4weeksonset<2-3daysAcuteonchronicDVT:effectiveonacutethrombus★PeriproceduralComplicationsMajorbleeding:2–4%ofP-CDTSymptomaticPEhasbeenobservedinfrequentlyBUTincreasesriskwithmoremechanicallyaggressivemethods(e.g.AngioJet,Trellis)Hence,someIRistsuseRetrievableIVCfilterduringtheperi-procedureperiodImportanttoensurefilterretrievalassoonastheriskofPEisdiminishedClinicalFollow-UpAnticoagulationforatleast3-6monthsinuncomplicatedcaseswhohavenounderlyingriskfactorsforhypercoagulablestates

Patients

with

predisposingfactorsforthrombosis

may

require

longerAnticoagulation,basedontheunderlyingdiseaseClosefollow-upandstrictcompliancewithAnticoagulationandCompressionStockings

arenecessaryforfavorableoutcomes.43y

Female：idiopathiclt-DVT2daysafteronsetDay0Gunthertulip

filterPronepositionLt-Popveinpuncture6Fsheath4FMPcath.withmulti-sideholeCDTinthePt'sroomDay2partialthrombolysisIliacveincompression←LtDay4ThrombusonlyiniliacveinManualthrombectomyNothrombusWallstentIR3timesRestonbed5days.@10years,nosymptom,oralVKA60yFemale:Lt-DVT

Day0NO

IVCfilterPulse-spray&ThrombectomyCDTshrinkinglt-CIViliacveincompressionORchronicDVT?Dx:AcuteonChronicDVTNEEDfilter?Day3Day1CDTNothrombusIliacveinstent?NOstentGoodOutflowFlowofDVTpatientsinWakayamaDxIVCfilterPoppunctureP-CDTthrombectomyCDTStentingRetrieveIVCfilterVenographyCDTCCU,ICUSymptomaticPEEKOS（)USassistedFrancisCW,UltrasoundinMedicineandBiology21,1995DVTTREATMENTOPTIONS

(NOTAvailableinJAPAN)UltrasonicenergycausesfibrintothinDrugdeepintotheclotAngioJetUltraThrombectomySystem(BSCI)Pulse-sprayThrombolysis&

NegativeVortexAspirationKasirajan,JVIR

12,2001Trellis(Covidien)IsolatedPharmaco-mechanicalThrombolysis&ThrombectomyO'SullivanGJ,JVIR18(6)2007LargeboreaspirationEssentiallyperfusioncircuitPossibilitytoremoveLARGEvolumequickly?BUT2