1 Chronic Iliofemoral DVT Anthony J. Comerota, MD, FACS, FACC Director, Jobst Vascular Institute Adjunct Professor of Surgery, University of Michigan UCSF Vascular Symposium UCSF Vascular Symposium San Francisco, California April 26-28, 2012 April 26-28, 2012 Is there a Role for Clot Removal? What does chronic venous thrombus (≥1 year) look like? A. B. C. D. 8% 52% 25% 15% A. Pale red – gummy (fibrous thrombus) B. Redish – white (fibrous thrombus) C. Maroon – grey (fibrous thrombus) D. White – grey (fibrosis) Chronic Iliofemoral DVT Chronic Iliofemoral DVT What is clear… …there is no clot (thrombus)! Post-thrombotic obstruction is the accurate term! Fibrosis…not thrombus Chronic Post-Thrombotic Iliofemoral Venous Obstruction Chronic Post-Thrombotic Iliofemoral Venous Obstruction • Severe morbidity • High recurrence • Severe morbidity • High recurrence – Better Term –
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Chronic Iliofemoral DVT A. Pale red – gummy (fibrous ... · Endovenectomy and Endoluminal Recanalization Endovenectomy and Endoluminal Recanalization In patients with chronic, post-thrombotic
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Chronic Iliofemoral DVT
Anthony J. Comerota, MD, FACS, FACCDirector, Jobst Vascular Institute
Adjunct Professor of Surgery, University of Michigan
• Duration of obstruction:7 mos – 25 yrs (Mean 6.8 years)
Patients
PreOp Preparation
1. Phlebography of target leg and IVC
2. Successful guidewire passage through occlusion into patent IVC
3. Chlorhexidine showers BID X 3 days
4. Preoperative platelet inhibition
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
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Common Femoral Vein ObstructionPost-Thrombotic Iliofemoral ObstructionPost-Thrombotic Iliofemoral Obstruction
Operative Intervention
Venous PressureCava - 8mmHgCFV - 16mmHg
Operative Intervention
Post-Thrombotic CFV Lumen- 4 Years -
Common Femoral Vein ObstructionPost-Thrombotic Iliofemoral ObstructionPost-Thrombotic Iliofemoral Obstruction
Operative Intervention
CFV - Patch VenoplastyCFV - Post Endovenectomy
Common Femoral Vein ObstructionPost-Thrombotic Iliofemoral ObstructionPost-Thrombotic Iliofemoral Obstruction
Operative Intervention
Venous PressureCava - 8mmHgCFV - 8mmHg
Common Femoral Vein ObstructionPost-Thrombotic Iliofemoral ObstructionPost-Thrombotic Iliofemoral Obstruction
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Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
• 67 year old woman – active: walked 6 milesa day
• IFDVT 7 months earlier
• Rx’ed with anticoagulation alone
• Unable to ambulate any distance
• Missing work: painful lower limb
• US, APG, venogram → extensive
• 67 year old woman – active: walked 6 milesa day
• IFDVT 7 months earlier
• Rx’ed with anticoagulation alone
• Unable to ambulate any distance
• Missing work: painful lower limb
• US, APG, venogram → extensive
Case
chronic obstructionchronic obstruction
Patient
Symptoms• Heaviness left leg
• Constant pain left leg
• Venous claudication restricting ambulation
Signs• Bluish discoloration of left lower leg
• Tense left leg
• Calf painful to compression
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
Patient
Assessment Score
Villalta Score 18
Venous Clinical Severity Score 12
– PreOp –
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
LEft CFV With Compression
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
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Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization– 7 Months –
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
CFVCFV
PFVPFV
FVFV
GSVGSV
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
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Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
PFV OrificePFV OrificeFV
(Occluded)FV
(Occluded)
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
Endovenectomy SpecimenEndovenectomy Specimen
CFVCFVFVFV
– 7 Months –
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
PFVPFV
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Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
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Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
Vena Cava
CommonIliac Vein
InternalIliac Vein
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
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Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization– Patch Closure –
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization– AV Fistula –
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
CFVCFV
PFVPFV
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Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
Follow-up: At 3 months postopwalking 2 miles… and increasing
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization– Duplex PostOp –
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization– Duplex PostOp –
Patient
Assessment PreOp2 Months Post Op
Villalta Score 18 3
Venous Clinical Severity Score
12 4
– 2 Month Follow-Up –
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
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Strategy of Thrombus RemovalStrategy of Thrombus Removal
Bilateral iliofemoraland vena caval occlusion
Strategy of Thrombus RemovalStrategy of Thrombus Removal
Strategy of Thrombus RemovalStrategy of Thrombus RemovalEndovenectomy
Strategy of Thrombus RemovalStrategy of Thrombus Removal
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Strategy of Thrombus RemovalStrategy of Thrombus Removal
Endovenectomy Specimen
- Iliocaval Thrombosis X 9 Years -
Iliocaval Recanalization
Strategy of Thrombus RemovalStrategy of Thrombus Removal
Iliocaval Recanalization
Strategy of Thrombus RemovalStrategy of Thrombus Removal Strategy of Thrombus RemovalStrategy of Thrombus Removal
• Healed ulcer in 3 mos.
• Swelling controlled
• Pain free
• Significantly increase agility and ambulation
• Lost 30 lbs in 3 mos.
• Healed ulcer in 3 mos.
• Swelling controlled
• Pain free
• Significantly increase agility and ambulation
• Lost 30 lbs in 3 mos.
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After 3 months
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Strategy of Thrombus RemovalStrategy of Thrombus Removal Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
• 1 operative mortality– 52 year old woman, multiple CV risk
factors, AMI at home 9 days post op
• 3 evacuation hematoma
• 3 early postop thrombosis1 – hematoma under pressure1 – residual stenosis, ext iliac vein
…both lysed and remained patent…all had patency restored
• 1 operative mortality– 52 year old woman, multiple CV risk
factors, AMI at home 9 days post op
• 3 evacuation hematoma
• 3 early postop thrombosis1 – hematoma under pressure1 – residual stenosis, ext iliac vein
…both lysed and remained patent…all had patency restored
Results
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
Results
Pre Op Post Op p-value
Villalta 14 6 .002
VCSS 17 10 .02
CEAP 4.8 3.8 <.05
QOL - - .01
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Issues Requiring Further Study
1. Risk/benefit of combined platelet inhibition
2. Intensity of postop anticoagulation
3. Risk/benefit of target leg heparin infusion
4. Optimal location of AV fistulaA. Saphenous – SFA
B. Caudal CFV – SFA
5. Size of wound drain
Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization Endovenectomy and Endoluminal RecanalizationEndovenectomy and Endoluminal Recanalization
In patients with chronic, post-thrombotic iliofemoral venous obstruction…
CFV endovenectomy with endoluminal recanalization of the iliac veins: