A New Systematic Approach to Diagnosis and Treatment of Deep Vein Thrombosis (DVT) MD, FACS April 1, 2011 Richard J DeMasi Acute Vascular Insufficiency • Arterial • Venous – Hx PAD – Hx DVT risk factors – Severe pain in foot and toes – Moderate pain in upper or lower leg – No edema – Significant edema – Pale – Cyanotic – No pulses – Palpable pulses Virchow’s Triad Hypercoagulability BCP, Cancer, Hereditary Endothelial Injury Stasis Limb Trauma, Major Surgery Travel, Obesity, Immobility Demography Why are We Going There… Post thrombotic Syndrome (PTS) • Occurs following DVT • Residual occlusion • Damage to the veins and valves causes high pressures in the venous system • Post Thrombotic Syndrome • Chronic signs and symptoms of DVT • Often 1st reason for medical consultation • These signs and symptoms include: • Pain Swelling(edema) Itching • Heaviness Cramps Burning • Varicose veins • • Symptoms aggravated by standing or exercise. High pressures and occlusion, can prevent blood flow to the tissues in the limb. • Tissue break down Skin discoloration • Atrophy Ulcers DVT: Goals of Therapy • Eliminate thrombus • Minimize risk of PE • Preserve Valvular function • Prevent Postphlebitic syndrome In the beginning, there was heparin…. In spite of 8 editions : Devil of a time standardizing care Executive Summary (42 pages !!) ACUTE DVT TREATMENT PROGRAM Purpose: To standardize the management of DVT in accordance with evidence-based practice guidelines. To stratify treatment in accordance with severity of DVT Utilize EMR to Efficiently Triage Patients For : 1. Diagnostic Testing 2. Specialist Referral (If Positive) The Wells DVT Score Active Cancer (Treatment ongoing, within the previous 6 months, or palliative). 1 Paralysis, paresis, or recent cluster immobilization of the lower extremities. 1 Recently bedridden greater than three days or major surgery within 12 weeks requiring general or 1 regional anesthesia Localized tenderness along the distribution of the deep system 1 Entire leg swollen 1 Calf swelling 3.0 cm larger than asymptomatic side measured 10.0 cm below the tibial tuberosity. 1 Pitting edema combined to the symptomatic leg. 1 Collateral, superficial veins, nonvaricose. 1 Alternative diagnosis at least as likely as deep venous thrombosis -2 High risk = 3 or greater Moderate risk = 1-2 Low risk = less than or equal to 0. Who / when / where : To refer for testing • Clinical Parameters • Wells Score • Utilize EMR (Central scheduling ) which triages to a hospital or outpatient PVL based on : – Pt Location, convenience – Availability – Pt or PCP preference Specialist Referral • Confirm Diagnosis • Initiate Treatment • Define goals and duration of Treatment • Determine Follow up – Clinical – Imaging Treatment • For patients with objectively confirmed DVT, we recommend shortterm treatment with SC LMWH (Grade 1A), IV UFH (Grade 1A), monitored SC UFH (Grade 1A), fixed-dose SC UFH (Grade 1A), or SC fondaparinux (Grade 1A) rather than no such short-term treatment. • For patients with a high clinical suspicion of DVT, we recommend treatment with anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C). 1.1.3. In patients with acute DVT, we recommend initial treatment with LMWH, UFH, or fondaparinux for at least 5 days and until the INR is > 2.0 for 24 h (Grade 1C). • In patients with acute DVT, we recommend initiation of VKA together with LMWH, UFH, or fondaparinux on the first treatment day rather than delayed initiation of VKA (Grade 1A). Calf Vein DVT • All managed outpatient • 5 days LMWH or Arixstra • Simultaneous initiation of VKA for 3 months • Follow up 3 months with PVL and clinical evaluation for VKA endpoint or continued therapy Femoropopliteal DVT • Standard anticoagulation with LMWH, UFH, Arixstra, for 5 days • Simultaneous initiation of VKA for 3 months • Support Stockings • Inpatient or outpatient depending on sx or clinical circumstances • Follow up 3 months with PVL and clinical evaluation for VKA endpoint or continued therapy Proximal DVT • Ileofemoral DVT • Occlusive fempop DVT • Non-occlusive fempop DVT with recalcitrant sx despite usual therapy. – Inpatient management with LMWH, UFH, Arixstra – Vascular consultation for consideration of Lytic Therapy Proximal DVT Initiate VKA simultaneously or after intervention Follow up 3 months with PVL and clinical evaluation Strong consideration for extending therapy to 6 months or indefinite DVT • Nuances – Poor candidate for anticoagulation • (active bleeding, major surgery within 24 hrs or anticipated within 14 days, noncompliance, fall risk, CNS Lesion, etc.) - referral to VTS practitioner for consideration for IVC Filter. – Cancer patients • LMWH 3 months • Convert to VKA until Ca risk eliminated – Upper extremity Quiz • T/F • Patients with UE DVT in association with a functioning catheter should have the catheter removed and 3 months of anticoagulation False • 8.4.2. For most patients with UEDVT in association with an indwelling central venous catheter, we suggest that the catheter not be removed if it is functional and there is an ongoing need for the catheter (Grade 2C). First Patient • 64 yo with leg swelling and pain 3/8/11 • Long plane flight • PVL 3/8/11 – extensive occlusive left f-p DVT • 3/9/11 – Venogram with thrombolysis SUMMARY • Suspected DVT should be diagnosed with Duplex Ultrasound (PVL) • DVT categorized according to severity • Treatment with anticoagulation is standard • Catheter Directed Thrombolysis (CDT) now considered standard of care for severe forms of DVT Quiz • T/F ? • The current recommended dose of Lovenox for therapeutic management of VTE is 1.5 mg/kg once a day. True  1.4 LMWH for the Initial Treatment of DVT      1.4.1. In patients with acute DVT, we recommend initial treatment with LMWH SC once or twice daily, as an outpatient if possible (Grade 1C), or as an inpatient if necessary (Grade 1A), rather than treatment with IV UFH.  LMWHs can be administered once or twice daily by  subcutaneous injection, without anticoagulant monitoring. Based on their greater convenience,  LMWHs have replaced UFH for many clinical indications. Quiz • T/F • Arixstra (Fondaparinux) is an acceptable alternative to heparin for treatment of acute PE TRUE Fondaparinux, a synthetic pentasaccharide, catalyzes the inhibition of factor Xa, but not thrombin, in an antithrombin-dependent fashion. Fondaparinux binds only to antithrombin; therefore, HIT and osteoporosis are unlikely to occur. Fondaparinux has excellent bioavailability when administered subcutaneously, has a longer half-life than LMWHs, and is given once daily by subcutaneous injection in fixed doses, without anticoagulant monitoring. Quiz • T/F • Although CDT has been available for > 20 years, it is still not included in the ACCP Guidelines False 1.9 Catheter-Directed Thrombolysis for Acute DVT 1.9.1. In selected patients with extensive acute proximal DVT (eg, iliofemoral DVT, symptoms for <14 days, good functional status, life expectancy of >1 year) who have a low risk of bleeding, we suggest that catheter-directed thrombolysis (CDT) may be used to reduce acute symptoms and postthrombotic morbidity if appropriate expertise and resources are available (Grade 2B). 1.9.2. After successful CDT in patients with acute DVT, we suggest correction of underlying venous lesions using balloon angioplasty and stents (Grade 2C). 1.9.3. We suggest pharmacomechanical thrombolysis (eg, with inclusion of thrombus fragmentation and/or aspiration) in preference to CDT alone to shorten treatment time if appropriate expertise and resources are available (Grade 2C). 1.9.4. After successful CDT in patients with acute DVT, we recommend the same intensity and duration of anticoagulant therapy as for comparable patients who do not undergo CDT (Grade