Endovascular Treatment of DVT
with Dr. David Dexter and Dr. Steven Abramowitz
Vascular Surgeons David Dexter and Steven Abramowitz discuss endovascular treatment of lower extremity DVT, including patient selection and risks and benefits of catheter-directed therapy (CDT), mechanical thrombectomy, and pharmaco-mechanical thrombolysis.
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In this Episode
Dr. David Dexter is a practicing vascular surgeon with Sentar Vascular Specialists in Virginia.
Dr. Steven Abramowitz is a practicing vascular surgeon at MedStar Georgetown University Hospital in Washington, D.C.
Host Dr. Christopher Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans, LA.
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• Difficulty is getting the right patient to the right physician at the right time
• ER, urgent care, inpatient – all potential referral sources
• Helpful to have algorithm integrated into EMR – important to triage appropriately and risk stratify patients appropriate for discharge, patients appropriate for admission, patients appropriate for early intervention
• Clinical presentation can vary widely
• Pick a method to help you and colleagues standardize your own practice
• Dr. Abramowitz uses Villalta score:
• Also mentions Venous Clinical Severity Score (VCSS)
• Dr. Dexter comments on ER patients specifically
• True bleeding assessment – will patient tolerate anticoagulation
• Mobility is critical – how mobile will they be after procedure
• Why did DVT develop?: prior DVT, family history of clot, surgical interventions which may interrupt venous system (anterior exposure for lumbar spinal surgery, pelvic lymph node dissection)
• Extent of thrombus is important
• Duplex ultrasound good starting point
• Patients at higher risk for proximal DVT: cross-sectional imaging
IDEAL PATIENT THAT BENEFITS FROM DVT TREATMENT
• Young, healthy, hypercoagulable, first episode of DVT, mobile, compliant!
• Concept: expose as much of clot to therapy as possible
• Popliteal or small saphenous vein
• Posterior tibial (PT): internal jugular and popliteal good for mechanical thrombectomy devices; PT can be good for catheter directed thrombolysis
• Both Dr. Dexter and Dr. Abramowitz use IVUS 100% of time
• Clot morphology
• External compression
• Venous wall scarring
DEVICES FOR DIFFERENT PATIENTS AND SCENARIOS
• Time frame of clot is important
• Size device to vessel being treated
• Patient consideration and possible contraindication to certain devices or treatments
• Remove as much clot as possible
• Dr. Abramowitz: ideally <5% of clot
• Dr. Dexter: ideally completely clean
• What to do after maximal effort and clot remains
• Consider catheter lysis and return next day
• Anticoagulation, anticoagulation, anticoagulation
• Sequential compression devices (SCDs) - SCDs are critical peri-op and post-op
• Will typically continue the anticoagulant patient was on preop
• Lovenox for anticoagulation failures
Disclaimer: The Materials available on the BackTable Podcast are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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