Vascular Conference

10/4/2018
Imad Mokalled PGY-3
 Case Presentation
• 0011839
• 62 year old male patient presented to Bassile
Outpatient for chemotherapy
• Dyspnea of 1 week duration and decreased PO
intake
• Initial labs: Hb 7.9 Cr:1.7 INR: 2.7
 Case Presentation
• PMHx: - epitheloid hemangioedothelioma
cancer involving the iliac crest and inguinal
lymph nodes
- HTN ?CHF CAD s/p stenting CKD (2)
* History of DVT in Nov 2017 in right common
femoral vein for which he is maintained on
sintrom
 Case Presentation
• PSHx: appendectomy cholecystectomy left
inguinal hernia repair
• Meds: aspicot plavix sintrom 1mg vastarel
concor vessel duo
• Allergies: NKDA
 Case Presentation
• PE: VS: WNL
• lungs: bibasilar mild crackles
• Vascular: RLE> LLE swelling ~ 2 cm from the
thigh down to the ankle
• Tender tense calf on the right and warmer than
the left
• Pulses: b/l femoral 2+
• b/l PT and DP: not palpable biphasic on doppler
 Case Presentation
• Patient was kept on aspirin plavix and sintrom
was switched to inohep
• 3 days later: developed hematochezia (2
episodes) painless
• DRE: stools with minimal amount of old blood
• Hb: 7.92 units pRBCs 9.98.2 INR 1.1
• GI consulted: Nexium BID stop plavix switch
inohep to heparin drip and colono/endoscopy 5
days after stopping plavix
 Case Presentation
• Patient developed the following day tonic- clonic
seizure with fecal and urinary incontinence and
fresh blood per rectum
• Transferred to ICU
• Heparin stopped and aspirin skipped
• Started on antiepileptic drug
• Hb: 7.9
• EEG, CT brain and MRI: negative for IC bleed or
brain mets
 Case Presentation
• Decision was made: insertion of IVC filter
• On March 29: insertion of Trapease IVC filter
• Patient was transferred back to ICU in stable
condition
Treatment of DVT
 Introduction
Anticoagulation is the mainstay of therapy for patients with acute lower
extremity DVT. Indications include:
• Acute symptomatic proximal DVT
• Asymptomatic proximal DVT
• Symptomatic isolated distal DVT
– However, for selected patients with isolated distal DVT eg,
• those at high risk of bleeding
• negative D-dimer level
• asymptomatic or minor symptoms, without risk factors for
extension, and/or minor thrombosis of the muscular veins,
surveillance with serial ultrasound over a two-week period
rather than anticoagulation is suggested.
• Those who exhibit signs of thrombus extension should be
anticoagulated.
• In most patients, anticoagulation should be started
immediately as a delay in therapy increases the risk of
potentially life-threatening embolization.

Options include :
• (LMW) heparin
• Fondaparinux
• Oral factor Xa inhibitors rivaroxaban or apixaban
• Unfractionated heparin (UFH)
Outpatient anticoagulation :
• hemodynamically stable
• low risk of bleeding
• do not have renal insufficiency
• practical system at home for the administration and
surveillance of anticoagulant therapy

It is not appropriate in patients with :

• massive DVT (eg, iliofemoral DVT, phlegmasia cerulea
dolens)
• concurrent pulmonary embolism
• a high risk of bleeding on anticoagulant therapy
• comorbid conditions
• Therapeutic anticoagulation should be ensured during the transition from
initial to long-term (maintenance) therapy.

• Options for long-term agents are:

– oral anticoagulants (direct factor Xa inhibitors, [rivaroxaban, apixaban,
edoxaban],
– thrombin inhibitors [dabigatran]
– vitamin K antagonists [warfarin]
– subcutaneous agents (LMW heparin and fondaparinux)

• factor Xa and thrombin inhibitors are preferred, a decision between these

agents is usually made based upon:
– clinician experience
– risks of bleeding
– patient comorbidities
– preferences
– cost
– convenience
For patients with acute DVT, the duration of anticoagulation
should be individualized according to the:
• presence or absence of provoking events
• risk factors for recurrence and bleeding
• the individual patient's preferences and values

For most patients with a first episode of DVT (provoked and

unprovoked, proximal and distal), anticoagulants should be
administered for three months rather than for shorter periods
• Extending anticoagulation beyond 3 months is
NOT routinely considered in patients who
have provoked episode of VTE with the
following:
- Transient risk factors, assuming the risk factor
is no longer present (surgery, cessation of
hormonal therapy), isolated distal DVT,
subsegmental or incidental PE, or those in
whom the risk of bleeding is high
• In select populations, anticoagulation is
extended to 6 or 12 months (e.g, phlegasma
cerulea dolens, a persisting but reversible risk
factor), although the benefits of this are
unproven.
HIT
• For patients with a DVT and a diagnosis of heparin-induced
thrombocytopenia (HIT), all forms of heparin should be
discontinued and immediate anticoagulation with a non-
heparin anticoagulant started.
 Patient Education and Monitoring
• For patients with acute DVT who are fully anticoagulated,
hemodynamically stable, and whose symptoms (eg, pain, swelling)
are under control, early ambulation in preferred to bed rest

• Patients should be monitored for the complications of DVT as well

as those of anticoagulation which include:
– further clot extension
– recurrence
– embolization
– post-thrombotic syndrome
– chronic thromboembolic pulmonary hypertension,
– bleeding
– thrombocytopenia
 Thrombolysis 
• For most patients with DVT, anticoagulant therapy alone is
preferred over thrombolytic therapy, and thrombolysis is
typically reserved for cases of extensive DVT

• Evidence from observational retrospective studies in patients

with acute DVT indicates that thrombolytic therapy (systemic
and catheter-directed) results in:
– more rapid and complete lysis of clot
– reduces the rate of post-thrombotic syndrome (PTS)
compared to anticoagulant therapy alone
 
 Post-Thrombotic Syndrome
• Post-thrombotic syndrome is the development of symptoms
and signs of chronic venous insufficiency following deep vein
thrombosis .

• A combination of reflux due to valvular incompetence, and

venous hypertension due to thrombotic obstruction, is thought
to contribute to post-thrombotic syndrome

• Symptoms and signs of chronic venous insufficiency may

include pain, vein dilation, edema, skin pigmentation, and
venous ulcers
• The addition of thrombolytic therapy to anticoagulation has
not been proven to lead to a reduction in recurrent
thromboembolism or mortality, and is associated with a
higher rate of adverse events including major bleeding

• Thrombolytic agents activate plasminogen to form plasmin,

resulting in the accelerated lysis of thrombi.
 Indications for Thrombolysis
Indications of thrombolysis:

provided that they’re:

• massive iliofemoral DVT • symptomatic for less
• proximal femoral DVT with a than 14 days
high risk of limb gangrene • and are at low risk of
• phlegmasia cerulea dolens bleeding
 Phlegmasia Cerulea Dolens
PCD results from acute massive venous thrombosis that causes an
obstruction of the venous drainage of an extremity and is
associated with a high degree of morbidity.

Patients usually present with :

• Sudden severe pain
• Swelling
• Cyanosis
• Edema
• Venous gangrene
• Compartment syndrome
• Systemic and catheter-directed thrombolytic agents have been
studied.

• Although lower doses of lytic agent can be administered using

catheter-directed techniques to potentially lower the risk of
bleeding, outcomes appear similar whether thrombolytic
therapy is catheter-directed or administered systemically.