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

New Standard of Management of
Deep vein thrombosis and Pulmonary
Embolism

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

• DVT is a blood clot
in a deep vein

• Annual US incidence
250,000. 50 percent
are “silent.”

• 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
cause of in-hospital
death
1

• 70%-80% of fatal
PEs occur in
nonsurgical patients
2

The first manifestation of DVT/PE may be fatal PE
3
Pulmonary Embolism

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)
• Limitations: 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
bleeding complications,
Ultrasound accelerated thrombolysis
(Máu trở nên xốp)
ULTRASONIC ENERGY
& THROMBOLYTIC
No hemolysis

No valve or wall damage
Very low risk of embolization
Ultrasound: Mechanism of action
Standard Infusion Catheter
Spread of Stained t-PA
Plasma Clot
Plasma Clot
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)