Chuẩn mực mới trong điều trị thuyên tắc tĩnh mạch sâu và thuyên tắc động mạch phổi

Deep Vein Thrombosis • The blood clot or part of it can break free and causes PE 1... Endovascular DVT Rx Passive infusion of fibrinolytic drugs into the clot consist mostly of multiside

New Standard of Management of Deep vein thrombosis and Pulmonary

Vietnam Heart Association Meeting October 8th 2012 12:00-12:30 Hall C Thach Nguyen, M.D FACC FSCAI

St Mary Medical Center

Hobart IN USA

Deep Vein Thrombosis

• The blood clot or

part of it can break

free and causes PE

1 Bulger et al, Tech Vasc Interv Radiol 2004;7:50-4

Complications of extensive DVT

phlegmasia cerulea dolens

May-Thurner Syndrome

Post-thrombotic Syndrome:

Chronic pain, swelling, skin ulceration

• PE: most preventable

Unfractionated Heparin (UFH) and Systemic thrombolytic therapy

Endovascular DVT Rx

Passive infusion of fibrinolytic drugs into the clot (consist mostly of multisidehole infusion

catheters)

-Aka: catheter-directed thrombolysis (CDT)

• Limitation s: prolonged treatment times and the

potential risk for bleeding associated with the use

of current thrombolytic drugs

1) Prevention of clot propagation

2) Prevention of PE and recurrent thrombosis

3) Restoration of venous patency and flow

4) Preservation of valvular function

5) Elimination of clinical symptoms associated with PTS

Endovascular Rx for DVT:

A Contemporary Approach

-

Pharmaco-mechanical treatment (PMT): function to both

dissolve (lytic assisted) and mechanically remove clot

-3 main available techniques:

1) Angiojet

2) Trellis

3) EKOS

EKOS

TRELLIS

ANGIOJET

Ultrasound Accelerated

Thrombolysis

The Challenges why Thrombus Is So

Difficult To Dissolve

• Plasminogen receptor sites are embedded into thrombus

during formation

• Speed of lysis depends on ability of lytic to access

plasminogen receptor sites

• Tightly wound fibrin strands prevent lytic from penetrating

the thrombus, limiting access to plasminogen receptor sites

• Ultrasound energy causes

fibrin strands to thin and

loosen, exposing

plasminogen receptor sites

• Ultrasonic pressure waves

force drug deep into the

clot and keep it there

Ultrasound accelerated thrombolysis

WITH ULTRASOUND ENERGY

WITHOUT ULTRASOUND

ENERGY

• Drug acts faster, clearing

clot sooner with reduced

No valve or wall damage

Very low risk of embolization

Ultrasound: Mechanism of action

Standard Infusion Catheter

Spread of Stained t-PA

Spread of Stained t-PA

EkoSonic Endovascular

Device

Review of recent studies on

catheter-directed treatment for DVT

CDT improves patency and reduces PTS

compared to anticoagulation

CaVenT Trial :

Randomized, controlled clinical trial determining benefit of CDT

 209 patients in 20 Nowegian hospitals; first time, acute IFDVT

 Treatment: anticoagulation vs anticoagulation + CDT with tPA

 Patency evaluated at 6 months f/u

 Post-thrombotic syndrome (PTS) rates evaluated at 6 and 24

months f/u

Enden et al.; CaVenT Study Group Lancet 2012 Jan 7;379(9810):31-8

 CDT group achieved:

 Higher patency at 6 months f/u

 Lower rate of PTS at 24 months f/u

Enden et al.; CaVenT Study Group Lancet 2012 Jan 7;379(9810):31-8

CDT improves patency and reduces PTS

compared to anticoagulation

1) Patient should have documented iliac, femoral,

or popliteal DVT

2) Patient must have no absolute contraindications Recent surgery is a relative contraindication

Technique

1 Access POPLITEAL VEIN OF AFFECTED LIMB under ultrasound guidance (most common approach)

2 Perform pharmaco-mechanical thrombolysis of

choice (individualize per pt) and per local expertise

3 Can be done on full dose anticoagulation (no reason

to hold coumadin and therefore eliminate bridging

issues)

4 6 french sheath

THROMBUS- PRE and POST EKOS

IVC Filter for prevention of PE

EKOS thombolysis then Balloon Angioplasty of

left common iliac vein (8x60-evercross)

Self Expanding Stent to left common iliac vein residual stenosis (May Thurner) with Protégé 12x80 stent; post-dilated with 10x40 evercross

Echocardiographic findings of acute PE

• Right ventricular dilatation

• Right ventricular hypokinesis (McConnell’s sign)

• Septal deviation

Apical 4-chamber Parasternal short-axis Parasternal long-axis

Case Example

Pre-EKOS

Post-EKOS

STUDY TARGET STUDY LEVEL STATUS

retrospective, single arm)

Data collection complete; analysis underway

prospective, single arm)

Active

Ongoing clinical studies

phlegmasia cerulea dolens

May-Thurner Syndrome

Pre-EKOS Post-EKOS