What is new in deep venous disease

1European Venous Centre; Aachen-MaastrichtEuropean Venous Centre; Aachen-Maastricht
Prof. Cees H.A. Wittens, MD PhD
Head of Venous Surgery
Maastricht University Medical Center
Uniklinik AachenUniklinik Aachen
What is new in
Deep Venous Disease
VE C

2
VE C
European Venous Centre; Aachen-MaastrichtEuropean Venous Centre; Aachen-Maastricht
IntroductionIntroduction
 New in Deep Venous Thrombosis (DVT)New in Deep Venous Thrombosis (DVT)
 Standard care DVTStandard care DVT
 Etiology PTSEtiology PTS
 Diagnostics DVTDiagnostics DVT
 Scoring system DVTScoring system DVT
 Treatment OptionsTreatment Options
○ ConservativeConservative
○ InvasiveInvasive
○ New in Deep Venous Obstruction (DVO = > 80% PTS)New in Deep Venous Obstruction (DVO = > 80% PTS)
○ DiagnosticsDiagnostics
○ Indications for treatmentIndications for treatment
○ Treatment optionsTreatment options
○ StentingStenting
○ EndophlebectomyEndophlebectomy
○ MiscellaneousMiscellaneous
○ ConclusionConclusion

 Complications of standard (level1Complications of standard (level1
evidence) DVT treatment:evidence) DVT treatment:
 Pulmonary embolism (5% lethality)Pulmonary embolism (5% lethality)
 Recurrent thrombosis (30%)Recurrent thrombosis (30%)
 Overall 25% PTS within 1 year.Overall 25% PTS within 1 year.
 Iliofemoral thrombosis is associatedIliofemoral thrombosis is associated
with a twofold increased risk ofwith a twofold increased risk of
developing PTS >> 50%.developing PTS >> 50%.11
 Early thrombolysis may decreaseEarly thrombolysis may decrease
incidence PTS.incidence PTS.
1: Kahn, Ginsberg. Arch Intern Med 2004
3 33European Venous Centre; Aachen-MaastrichtEuropean Venous Centre; Aachen-Maastricht
VE C
3
Standard care in DVTStandard care in DVT

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VE C
Etiology of PTSEtiology of PTS
 20-82% of pt’s develop PTS after DVT20-82% of pt’s develop PTS after DVT
 PTS due to deep venousPTS due to deep venous obstructionobstruction::
Calf:Calf: PTS is rarePTS is rare
Popliteal:Popliteal: PTS is rarePTS is rare
Femoral:Femoral: commoncommon
Iliac/caval:Iliac/caval: commoncommon
○ Only 20-30% of thrombosed iliac veinsOnly 20-30% of thrombosed iliac veins
completely recanalize with anticoagulantcompletely recanalize with anticoagulant
therapytherapy
44% claudication 5 years post iliac DVT44% claudication 5 years post iliac DVT
15% ulcers 5 years post iliac DVT15% ulcers 5 years post iliac DVT

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VE C
Diagnostics in DVTDiagnostics in DVT
 Due to changed therapeuticDue to changed therapeutic
options there is a need tooptions there is a need to
change diagnostics in DVTchange diagnostics in DVT
2 point compression ultrasound2 point compression ultrasound
(not enough!!)(not enough!!)
 Complete venous roadmap !!Complete venous roadmap !!
Full duplex examinationFull duplex examination
MRVMRV
CTVCTV

A StandardizedA Standardized
classificationclassification
6European Venous Centre; Aachen-MaastrichtEuropean Venous Centre; Aachen-Maastricht
VE
C
LETLET (Lower extremity thrombosis)(Lower extremity thrombosis) classification:classification:
› Class I: calf vein thrombosis: calf vein thrombosis
 Limited to the calf veinsLimited to the calf veins
 Good recanalisationGood recanalisation
 Good outflow / collateralsGood outflow / collaterals
 Low PTSLow PTS
› Class II: femoro-popliteal thrombosis: femoro-popliteal thrombosis
 Popliteal vein, Femoral vein, Deep femoral veinPopliteal vein, Femoral vein, Deep femoral vein
 Good recanalisationGood recanalisation
 Good outflow / collateralsGood outflow / collaterals
 Medium PTSMedium PTS
› Class III: femoro-iliac thrombosis: femoro-iliac thrombosis
 Common femoral vein, iliac veinsCommon femoral vein, iliac veins
 Bad recanalisationBad recanalisation
 Impaired outflow / bad collateralsImpaired outflow / bad collaterals
 High PTSHigh PTS
› Class IV: inferior vena cava thrombosis: inferior vena cava thrombosis
 Inferior vena cavaInferior vena cava
 Bad recanalisationBad recanalisation
 Impaired outflow / bad collaterals / bilateralImpaired outflow / bad collaterals / bilateral
 High PTSHigh PTS

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VE C
Scoring system in DVTScoring system in DVT
 This system will help to document theThis system will help to document the
pathology in a standardized fashionpathology in a standardized fashion
 Make individual clinical decisionsMake individual clinical decisions
possible depending on the classificationpossible depending on the classification
 Makes future research comparableMakes future research comparable
(Meta-analyses)(Meta-analyses)

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VE C
•Why intervention:Why intervention:
•Reduction symptoms (acute stage)Reduction symptoms (acute stage)
•Reduction recurrent DVTReduction recurrent DVT
•Reduction PTS (by recanalisation and valveReduction PTS (by recanalisation and valve
preservation)preservation)
•In whom:In whom:
•Iliofemoral (cava) thrombosisIliofemoral (cava) thrombosis
•Poor recanalisation causing:Poor recanalisation causing:
 Venous hypertension (95%)Venous hypertension (95%)
 DVI (90%)DVI (90%)
 Calve muscle pump dysfunction (50%)Calve muscle pump dysfunction (50%)
 Venous claudication (15%)Venous claudication (15%)
 Ulcers (15%)Ulcers (15%)
 >50 %PTS>50 %PTS
DVT:DVT: interventionintervention

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VE C
Invasive treatment options:Invasive treatment options: DVTDVT
 ConservativeConservative
 thrombolysisthrombolysis
SystemicSystemic (obsoleet)(obsoleet)
CDTCDT
○ PTS 14,4%PTS 14,4% ARRARR
CavenT studyCavenT study
EKOSEKOS
TrellisTrellis
AngiojetAngiojet
All 80-95%All 80-95%
succesfull recanalisationsuccesfull recanalisation

asculaire Specialisatie
EV
Maastricht-Ake

EVC results for iliofemoral thrombolysisEVC results for iliofemoral thrombolysisEVC results for iliofemoral thrombolysisEVC results for iliofemoral thrombolysis
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VE C
Treatment options:Treatment options:
iliofemoral DVTiliofemoral DVT

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Treatment options:Treatment options: DVTDVT
 If it has been shown that a successful thrombusIf it has been shown that a successful thrombus
removal significantly improves outcome (removal significantly improves outcome (PTS,PTS,
recurrent DVT and QoL)recurrent DVT and QoL)
 CavenTCavenT
 AttractAttract
 CAVACAVA
 We need better dedicated devicesWe need better dedicated devices
○ Ideally as a 1 hour out patient procedureIdeally as a 1 hour out patient procedure
○ Without thrombolyticsWithout thrombolytics
 ComplicationsComplications
 Medium care admissionMedium care admission
 CostsCosts
 Malignancies can be treated !Malignancies can be treated !
 Postoperative patients can be treated !Postoperative patients can be treated !

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VE C
 New dedicated venous thrombus removalNew dedicated venous thrombus removal
devices will be developed:devices will be developed:
 Removal of thrombi with local lytic therapyRemoval of thrombi with local lytic therapy
○ Covidien (Trellis II)Covidien (Trellis II)
 Remove thrombi without lytic agentsRemove thrombi without lytic agents
○ LazarusLazarus
 Thrombectomy device (4F)Thrombectomy device (4F)
○ AngiodynamicsAngiodynamics
 Angiovac (22F)Angiovac (22F)

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 Removal of thrombi withRemoval of thrombi with locallocal lytic therapylytic therapy
○ LazarusLazarus

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VE C

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 Removal of thrombi with local lytic therapyRemoval of thrombi with local lytic therapy
○ LazarusLazarus

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VE C
 50%50% is stented and dedicatedis stented and dedicated
stent are coming to the market.stent are coming to the market.
CookCook
VenitiVeniti
OptiMedOptiMed

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VE C
Conclusion:Conclusion:
 What is new in DVT treatment:What is new in DVT treatment:
Etiology PTSEtiology PTS Obstruction!!!Obstruction!!!
DiagnosticsDiagnostics full venous roadmap!full venous roadmap!
Scoring systemsScoring systems LET scoreLET score
Treatment OptionsTreatment Options
○ DVTDVT (iliofemoral-caval)(iliofemoral-caval)
○ New dedicated equipmentNew dedicated equipment
○ Thrombectomy devicesThrombectomy devices
○ StentsStents
○ NOAC’sNOAC’s

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Conclusion:Conclusion:
 What is new DVT treatment:What is new DVT treatment:
Potential impact on practice to treatPotential impact on practice to treat
DVT and prevent PTS:DVT and prevent PTS:
○ DVT 1/1000/yearDVT 1/1000/year
25 % ilio-femoral25 % ilio-femoral 25/100.000/year25/100.000/year
Turkey: >>20.000 / yearTurkey: >>20.000 / year
Major impact if this treatment become routineMajor impact if this treatment become routine

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VE C
 Venous hypertension:Venous hypertension:
Deep venous insufficiencyDeep venous insufficiency ( < 90 mmHg)( < 90 mmHg)
Deep venousDeep venous obstruction !!obstruction !! (> 200 mmHg)(> 200 mmHg)
DVO
Internal causes
External causes
DVT
May-Thurner
Ext. compression
Cancer
Lymphocele
Fibrosis
Aneurysm
ICV atresia
Immobility
Thrombofilia
Pregnancy
Treatment of DVOTreatment of DVO

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VE C
EtiologyEtiology
 29-82% of pt’s develop PTS after DVT29-82% of pt’s develop PTS after DVT
 PTS due to deep venousPTS due to deep venous obstructionobstruction::
Calf:Calf: PTS is rarePTS is rare
Popliteal:Popliteal: PTS is rarePTS is rare
Femoral:Femoral: commoncommon
Iliac/caval:Iliac/caval: commoncommon
○ 20-30% of thrombosed iliac veins completely20-30% of thrombosed iliac veins completely
recanalize with anticoagulant therapyrecanalize with anticoagulant therapy
44% claudication 5 years post iliac DVT44% claudication 5 years post iliac DVT
15% ulcers 5 years post iliac DVT15% ulcers 5 years post iliac DVT

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VE C
DiagnosticsDiagnostics
 Clinical examination has to be performedClinical examination has to be performed
groin and abdominal wall: especially ingroin and abdominal wall: especially in
patients with:patients with:
 Venous ulcersVenous ulcers
 also in:also in:
 C 4,5C 4,5
 Venous claudicationVenous claudication
 Fast recurrent VaricositiesFast recurrent Varicosities
 10-15 % will show signs10-15 % will show signs
of central venous obstruction!!of central venous obstruction!!

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V
E C

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 Due to changed therapeuticDue to changed therapeutic
options there is a need tooptions there is a need to
change diagnostics in venouschange diagnostics in venous
ulcer diseaseulcer disease
 Complete venous roadmap !!Complete venous roadmap !!
Full duplex examinationFull duplex examination
MRVMRV
CTVCTV

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 Literature search showed noLiterature search showed no
comparable results becausecomparable results because
there arethere are no reporting standardsno reporting standards
for deep venous pathologyfor deep venous pathology
registrationregistration
LOVE scoreLOVE score

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VE C
Scoring systemsScoring systems
 LOLOwer extremitywer extremity VEVEnous pathologynous pathology
scoring systemscoring system
 Each segment:Each segment:
 Post thrombotic leasionsPost thrombotic leasions
 Residual lumenResidual lumen
 0 % (occlusion)0 % (occlusion)
 10-50 %10-50 %
 50-90 %50-90 %
 90-100%90-100%
 CollateralsCollaterals
 External compressionExternal compression

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VE C
Treatment optionsTreatment options
 Conservative:Conservative:
 CompressionCompression
 AnticoagulationAnticoagulation
 Invasive:Invasive:
 PTA alone (obsoleet)PTA alone (obsoleet)
 PTA + stentingPTA + stenting
 BypassBypass
 + or -+ or -
○ EndophlebectomyEndophlebectomy
○ AV fistulaeAV fistulae

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VE C
Indications for treatment:Indications for treatment:
 Improve QoL!!Improve QoL!!
Skin problemsSkin problems
Venous claudication !Venous claudication !
Swollen legsSwollen legs
PainPain

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VE
CEuropean Venous Centre; Aachen-MaastrichtEuropean Venous Centre; Aachen-Maastricht
 Inferior vena cava:Inferior vena cava:
 High radial force, minimal flexibility, large diameterHigh radial force, minimal flexibility, large diameter..
 Common iliac vein:Common iliac vein:
 High radial force, high flexibility, large length of stent.High radial force, high flexibility, large length of stent.
 External iliac vein:External iliac vein:
 High radial force, high flexibility, large length of stent.High radial force, high flexibility, large length of stent.
 Common femoral vein:Common femoral vein:
 fracture resistant?!fracture resistant?!
Requirements for stents per segmentRequirements for stents per segment

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E
C
V
 Compression of stentCompression of stent
(radial force to low)(radial force to low)
 Kinking of stent (highKinking of stent (high
rigidity)rigidity)
 Tapering of stentTapering of stent
(especially Wallstent)(especially Wallstent)
 Stent rigidityStent rigidity
fracturefracture
Bamboo stick effectBamboo stick effect
Shortcomings of stents todayShortcomings of stents today

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E
C
V
rigidity)rigidity)
fracturefracture

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E
C
V
rigidity)rigidity)
fracturefracture

35
E
C
V
rigidity)rigidity)
fracturefracture

36
E
C
V
rigidity)rigidity)
fracturefracture

37
VE
CEuropean Venous Centre; Aachen-MaastrichtEuropean Venous Centre; Aachen-Maastricht
 CookCook
 VenitiVeniti
 OptiMedOptiMed
New Venous stentsNew Venous stents

New Sinus-Venous stentNew Sinus-Venous stent
Max. Flexibility and radial forceMax. Flexibility and radial force

39
23

40
23

41
“Old” 2013 “New 2013”
Stents used Sinus XL, Wall, Silver
Vena and Andra stents
Sinus Venous
No 63 35
Average follow-up time
(y)
8.8 (±8.0, 1 – 31) 3.0 (±2.6, 1 - 10.2)
Patent at last follow up 87.3% 97.1%
Primary patent 74.3% 88.6% (P<0,05)
Patent after “primary
assisted” intervention
81.4% -
Patent after
“secondary”
intervention
96.1% 97.1%
Number of
reinterventions
23 in 13 (20.6%)
patients
4 in 3 (8.6%) patients
(P<0,05)

42
V
 New dedicated venous stent available!New dedicated venous stent available!
Silver Vena ?Silver Vena ?
Veniti ?Veniti ?
Sinus-Venous (OptiMed):Sinus-Venous (OptiMed):
better primary and secondary patencybetter primary and secondary patency
Easy deployment and positioningEasy deployment and positioning
High flexibility with good alignmentHigh flexibility with good alignment
High radial forceHigh radial force
E
C
ConclusionConclusion

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V
 Improved inflow measuresImproved inflow measures
○ Endophlebectomy (CFV involvement)Endophlebectomy (CFV involvement)
○ AV fistulaAV fistula
E C
Indications for EndophlebectomyIndications for Endophlebectomy

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VE C
ExperienceExperience
35 Patients35 Patients
Patients withPatients with
○CEAP C4-6CEAP C4-6
○Severe venous claudicationSevere venous claudication
Diagnosis of occlusion/obstructionDiagnosis of occlusion/obstruction
○Duplex ultrasoundDuplex ultrasound
○Magnetic resonance venographyMagnetic resonance venography
○Per-procedural venographyPer-procedural venography
Patency controlPatency control
○Duplex ultrasoundDuplex ultrasound

V
Improved inflow measuresImproved inflow measures
 when CFV involvement on MRVwhen CFV involvement on MRV
E C

46
Desobstructie VFC with iliac stent
V
E C

47
VE C
DemographicsDemographics
Number of patientsNumber of patients 3535
Number of legsNumber of legs 3737
SexSex 20 female / 15 male20 female / 15 male
Average ageAverage age 40 (18 – 63)40 (18 – 63)
DVT episodeDVT episode First 24 / recurrent 11First 24 / recurrent 11
DVT sideDVT side L 23 / R 7 / Bilat 5L 23 / R 7 / Bilat 5
Time betw. DVT andTime betw. DVT and
treatmenttreatment
7.6 (1 – 40)7.6 (1 – 40)
May-Thurner syndromeMay-Thurner syndrome 13 (37%)13 (37%)
Confirmed trombophiliaConfirmed trombophilia 6 (55%)6 (55%) (of 11 tested)(of 11 tested)
Primary operationPrimary operation Stent 29 / bypass 6Stent 29 / bypass 6

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PrimaryPrimary
operationoperation
PTA & stentingPTA & stenting 2929 83%83%
Venous bypassVenous bypass 66 17%17%
Side of bypassSide of bypass
CFV LCFV L  CIV RCIV R 55 14%14%
CFV RCFV R  CIV LCIV L 11 3%3%
Side of PTA &Side of PTA &
stentingstenting
Left tractLeft tract 1212 34%34%
Right tractRight tract 77 20%20%
Left and centralLeft and central 44 11%11%
Bilateral andBilateral and
centralcentral
66 17%17%
Concurrent AV-Concurrent AV-
fistulafistula
2929 83%83%

49
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Results - interventionResults - intervention
ReocclusionReocclusion 1111 31%31%
Wound infectionWound infection 33 9%9%
Lymph leakageLymph leakage 33 9%9%
SeromaSeroma 22 6%6%
Bleeding majorBleeding major 11 3%3%
Bleeding minorBleeding minor 11 3%3%
Pulmonary embolismPulmonary embolism 00 0%0%
MortalityMortality 00 0%0%

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VE C
Results – follow-upResults – follow-up
Average follow-upAverage follow-up 7,8 mo7,8 mo (1 – 23 mo)(1 – 23 mo)
Patent at last follow-upPatent at last follow-up 2828 81%81%

51
V
Treatment options:Treatment options: miscellaneousmiscellaneous
 Improved inflow measures / timingImproved inflow measures / timing
○ AV fistulaeAV fistulae
SurgicalSurgical
Percutaneous (future)Percutaneous (future)
○ Postoperative pneumatic compression !!Postoperative pneumatic compression !!
 Improved anticoagulationImproved anticoagulation
○ Oral “Heparines”Oral “Heparines”
E C

52
VE C
Conclusion onConclusion on
endophlebectomyendophlebectomy
Endophlebectomy is relatively safeEndophlebectomy is relatively safe
○ Associated with low complications ratesAssociated with low complications rates
○ Except reocclusionExcept reocclusion
 However good secondary patency rateHowever good secondary patency rate
○ Indications AV fistulae ?Indications AV fistulae ?
Future:Future:
○Stenting into CFV or endophlebectomy tract?Stenting into CFV or endophlebectomy tract?
○Better AV fistulae?Better AV fistulae?
○Need for patches?Need for patches?

53
VE C
Conclusion in DVO:Conclusion in DVO:
 What is new DVO treatment:What is new DVO treatment:
Potential impact on practice to treatPotential impact on practice to treat
DVO and PTS:DVO and PTS:
○ In TurkeyIn Turkey > 500.000 people> 500.000 people
have a significant deep venous outflowhave a significant deep venous outflow
obstrucion:obstrucion:
Major impact if this treatment become routineMajor impact if this treatment become routine

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VE C
Overall ConclusionOverall Conclusion
New DVT treatment optionsNew DVT treatment options
In patients with a LET III or IV DVTIn patients with a LET III or IV DVT
 Better thrombectomie devicesBetter thrombectomie devices
 Better stentsBetter stents
 Improve QoLImprove QoL
 Acute symptome relieveAcute symptome relieve
 Reduce PTSReduce PTS
 Reduce recurrent DVTReduce recurrent DVT
New DVO treatment optionsNew DVO treatment options
In patients with iliofemoral/caval occlusive diseaseIn patients with iliofemoral/caval occlusive disease
 Better stentsBetter stents
 EndophlebectomyEndophlebectomy
 AV fistulaeAV fistulae
 NOAC’sNOAC’s
 Improve QoL !!Improve QoL !! Thank youThank you

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