南口博纪教授-NEW-IR-for-DVT

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,11/7/2009,#,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,南口博纪教授-NEW-IR-for-DVT,南口博纪教授-NEW-IR-for-DVT,Wakayama Medical Univ.Hospital,800 Beds,1500 Outpatients/,day,Angiography 2700/,year,in all,600/,year in IR,Wakayama 和歌山,970,000 in Wakayama Pref.,370,000 in Wakayama City,Wakayama Medical Univ.Hospita,高野山Koyasan,A.D.816,1,200years old temple,高野山Koyasan,白浜,Shirahama Adventure World,Big Panda Family,北京,白浜北京,Acute DVT,Lymphedema,After Hysterectomy,Hematoma,Overdose of VKA,Chronic DVT,Post-thrombotic Synd.,Chief Complaints:Leg Swelling,IR,Red,Fever,Painful,White,pitting edema,Blue,anemia,Skin Ulcer,Infection,history of DVT,Acute DVTLymphedemaHematomaChr,Introduction,Venous Thromboembolism(,VTE,)=Pulmonary Embolism(,PE,)+Deep Vein Thrombosis(,DVT,),PE in 70%of DVT cases,DVT in 3070%of PE cases,PHLEGMASIA CERULEA DOLENS,IntroductionPHLEGMASIA CERULEA,PE incidence:JAPAN-62/million,USA-500/million,VTE increasing in JAPAN,:Westernization of Lifestyle,Aging Population,Greater rate of Diagnosis,PE:,High mortality,10-30%,Over 100,000 deaths/year in USA,Early Diagnosis and Treatment,(including inhibition of DVT progression and prevention of PE recurrence)are therefore very important,!,PE incidence:JAPAN-62/milli,Treatment of DVT has,recently advanced significantly,Despite the use of standard anticoagulant therapy,DVT recurs frequently,and often leads to the development of,post-thrombotic syndrome(PTS),Catheter-based techniques have been used in the management of DVT for many years,but are undergoing now strict evaluation in RCTs to determine whether they improve patient outcomes,Treatment of DVT has recently,70 F,Acute DVT,2001.1,Greenfield filter,Microcath.via jugular,Extravasation!,From Jugular vein,=Retrograde approach,Vascular Injury may occur,Waste of Time,70 FExtravasation!From Jugular,G.OSullivan,2 days later,Pop V approach(,1,st,case,),Now 86 years old,alive,no symptoms,27 limbs,CDT with UK(1.4 million16.0 million IU)for 30 hr(1574 hr),Technical&clinical success 85%,No major complications.,G.OSullivan2 days later,P,Rationale for Thromboreductive Therapies Consequences of DVT,PTS,develops in 2550%,with proximal DVT,PTS causes,chronic symptoms,(swelling,pain,heaviness,fatigue.),Severe PTS may experience venous claudication,stasis dermatitis,skin changes(hyperpigmentation,fibrosis,skin ulcer),Recurrent ipsilateral DVT:2 to 6-fold increased risk of PTS,Therefore,adequate anticoagulation should be a key PTS prevention measure,but it is clear that despite anticoagulation many DVT patients will still develop PTS.,Rationale for Thromboreductive,Rajasekhar A:J Thromb Thrombolysis 2015;39,315.,IVC filter indications,Not reported,Rajasekhar A:J Thromb Thrombo,PREPIC study,Permanent IVC filter,&Anticoaglants(AC),vs AC only,for Proximal DVT with/without PE,f/u,Acute phase:PE preventable,Chronic phase(8 years):Recurrent DVT is higher!,(,p0.042,),Use,retrievable IVC filter&retrieve ASAP!,Decousus H,NEJM,338,1998.,PREPIC Study Group.Circulation 112,2005.,PREPIC study,PREPIC 2 study,PE patients:Retrievable IVC filter&AC vs AC only,AC for 6 months,Filter retrieval 3 months,3 months,Recurrent PE in 6 cases vs 3 cases,6 months,Recurrent PE in 7 cases vs 4 cases,6 months,Recurrent DVT in 1 case vs 2 cases,No need for IVC filter under adequate ACs,Still Controversial,!,Mismetti P,JAMA 313,2015.,PREPIC 2 study,Retrievable(optional)filter,in almost all cases,before Thrombolysis,1.IVC filter,Gunther tulip,OptEase,ALN,To Prevent iatrogenic PE due to Thrombolysis and/or Thrombectomy,Retrievable(optional)filter i,Catheter-directed intrathrombus thrombolysis(CDT)for DVT,Image-guided,Catheter-directed,intra-thrombus drug infusion has been,safe and effective,Advantages:,(1)Achieve a high intra-thrombus drug concentration and,Avoid bypass of the drug via collaterals,(2)Reduce drug dose,treatment time and complications,Catheter-directed intrathrombu,Required Equipment,Our standard IR protocol typically requires the following devices:,6-F vascular short sheath kit(18-gauge needle,0.035in guidewire);,hydrophilic 0.035in guidewire;,4-F angled-tip multipurpose catheter with multisidehole to cross DVT;,5-F pulse-spray catheter,6-F thrombectomy catheter with VacLok syringe,Required Equipment,Guidelines for the Diagnosis,treatment and prevention of DVT(2009）,JCS(The Japanese Circulation Society),Acute DVT,Heparin&VKA(Warfarin),Evidence level,Systemic Thrombolysis,Evidence level,a,CDT and Thrombectomy,Evidence level,b,Stenting,after Thrombolysis,Evidence level,b,Guidelines for the Diagnosis,AHA Scientific Statement,CDT or PCDT should be given patients with proximal DVT,with limb-threatening circulatory compromise,(ie,phlegmasia cerulea dolens),(Evidence level I;Grade C),CDT or PCDT is,reasonable as first-line treatment with Acute proximal DVT to prevent PTS,at low risk of bleeding complication,(E