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Episode 59

Endovascular Treatment of DVT

with Dr. David Dexter and Dr. Steven Abramowitz

BackTable, LLC (Producer). (2020, March 25). Ep. 59 – Endovascular Treatment of DVT [Audio podcast]. Retrieved from https://www.backtable.com/podcasts

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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Podcast Participants

Dr. David Dexter

Dr. David Dexter is a practicing vascular surgeon with Sentar Vascular Specialists in Virginia.

Dr. Steven Abramowitz

Dr. Steven Abramowitz is a practicing vascular surgeon at MedStar Georgetown University Hospital in Washington, D.C.

Dr. Christopher Beck

Host Dr. Christopher Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans, LA.

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Show Notes

REFERRAL PATTERNS
• 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 EVALUATION
• Clinical presentation can vary widely
• Pick a method to help you and colleagues standardize your own practice
• Dr. Abramowitz uses Villalta score: https://www.mdcalc.com/villalta-score-post-thrombotic-syndrome-pts
• 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)

IMAGING
• 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!

ACCESS
• 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

IVUS
• 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

ENDPOINTS
• 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

AFTERCARE
• 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

ATTRACT TRIAL: https://www.nejm.org/doi/full/10.1056/NEJMoa1615066

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Disclaimer: The Materials available on BackTable.com 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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