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DVT Treatment in 2024: The Critical Role of Interventional Care
Melissa Malena • Updated Oct 9, 2024 • 35 hits
Even with the advent of purpose-built medical devices, the inherent complexities of deep vein thrombosis (DVT) treatment continue to challenge interventionalists. How do you approach the DVT patient with concomitant PE? How do you best determine if the thrombus is acute or chronic? And how do you safely treat challenging deep vein anatomies? Interventional cardiologist Dr. Adam Raskin and interventional radiologist Dr. Sabeen Dhand share their experiences in treating deep vein thrombosis, offering practical answers to these questions and more.
This article features transcripts for the BackTable Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.
The BackTable Brief
• Interventional DVT removal can provide patients with a greater sense of safety and relief while also lowering the thrombus burden far greater than medical management alone.
• According to Dr. Raskin, there are now multiple specialty catheters on the market that are suitable to treat DVT, inclusive of new and improved mechanical and aspiration thrombectomy technologies.
• In DVT patients, a history of pulmonary embolism increases the risk of right ventricular failure. Dr. Raskin recommends operating on these patients.
• A common DVT treatment challenge is misunderstanding the chronicity of symptoms, often resulting in different clot morphology than originally expected.
• IVUS can be used to better visualize vein anatomy, understand collateralization, and determine clot morphology.
Table of Contents
(1) The Impact of Recent Advances in Interventional DVT Treatment
(2) Who to Treat? Navigating the Many Presentations of DVT
(3) Overcoming Common DVT Treatment Challenges
The Impact of Recent Advances in Interventional DVT Treatment
Recent technological advancements have changed the lower extremity DVT treatment landscape. Previously, DVT treatment consisted of anticoagulants and lytics, with lytics offering debatable effectiveness. Given the dearth of treatment options, operators often questioned the benefits of intervening on DVT altogether. According to Dr. Raskin, patient thrombus burden can now be lowered to nearly zero percent utilizing contemporary mechanical and aspiration thrombectomy devices. These results are far greater than can be achieved using anticoagulants, such as Eliquis, alone.
[Dr. Sabeen Dhand]
So I’m really interested in this PE population. In our practice, I'll say, when we have a patient with a PE that we're intervening on, usually, we focus on getting the PE out. Maybe they have some residual DVT in the femoral vein and popliteal vein, but we don't leave a filter. We give anticoagulation, and we're assuming that that's going to work. You're right, we've had these instances where patients have had a recurrent pulmonary embolism. Granted, usually it's smaller. I wonder, where did you guys come up with this approach, or is it very common that people are doing additional intervention on the lower extremity after a PE?
[Dr. Adam Raskin]
I'm sure it's going to vary everywhere. It's going to vary on the operator. It's going to vary on the system. It's going to vary on your comfortability. It's going to vary on your experience. We got aggressive fairly early on, I think for multiple different reasons. When I came out of training, it was lytics. That was the option. It was either anticoagulation or it was lytics. How effective were lytics? Maybe not. The randomized data is up in the air. There were trials that shown lytics years out really didn't show that much of an effect. Okay, fine.
When that's all you've had, I could see people, very good argument, "If it's not really effective, then what's the point anyway?" Okay. I hear that, but in the last, let's say three to four years, our ability to treat this with multiple different catheters, whether it's mechanical thrombectomy, aspiration thrombectomy, safely, effectively, thrombus burden from 90% or occlusive to almost zero, when you see it and you experience it, when you see the clot on the back of your table, you look at this thing, there's no way Eliquis, and I prescribe Eliquis all the time, there is no way Eliquis is getting rid of that when it's already starting to turn white.
[Dr. Sabeen Dhand]
No.
[Dr. Adam Raskin]
We've seen it. Do you think, "What's TPA going to do for that?" I understand why those trials didn't work. It makes sense. Our ability to extract a clot at such large quantities safely, patients, one, when you tell them that they're going to go home, when you can look them in the eye, and say safer, for the most part, thrombus free, the look on someone's eye, they want it done. Patient is like, "Get this thing out of my leg." We don't just do it just to do it, but we do it when we think it could be safe, effective, and make a difference. Technology has allowed us to do it. That's why once we started, the ball kept rolling. It makes sense to us if we can do something safely and effectively. The trials will show it soon. That's what it's going to take eventually when we get there.
[Dr. Sabeen Dhand]
That's what we're waiting for, yes.
[Dr. Adam Raskin]
We're just way too ahead of the game, but once all the randomized trials show it's going to be effective, which we know it's going to, it's going to eventually be the standard of care.
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Who to Treat? Navigating the Many Presentations of DVT
When approaching patients with suspected DVT, Dr. Raskin begins by considering the patient’s pulmonary embolism status. Symptomatic pulmonary embolism patients typically have right-sided heart symptoms and often present as quite ill, complicating deep vein thrombosis treatment. Pulmonary embolism patients with a concomitant iliofemoral or femoral DVT are considered particularly high risk for a second event. To combat this risk, Dr. Raskin aggressively treats all DVT patients with a history of pulmonary embolism. For patients without a history of pulmonary embolism presenting with an isolated DVT, patients should be thoroughly evaluated with a workup that considers symptom onset, ultrasound results and sedation risk. In cases of occlusive iliofemoral DVT, Dr. Raskin universally opts for surgical intervention.
[Dr. Sabeen Dhand]
DVT comes in all shapes and forms. You can have an isolated below-the-knee DVT, the tiny one, you can have a larger DVT above the knee, or you can have this extensive DVT, from say May-Thurner or something. You're going from iliac all the way down to where your ultrasound can reach, and then you see a clot. What's your way of approaching a patient with a DVT for, you gave that example of an ortho calling you and they have a popliteal DVT? What is your way and approach to managing these patients?
[Dr. Adam Raskin]
Sure. It's a good question. The first thing that usually we think about is one, do they have a pulmonary embolism. There's two, I think, very different subsets of patients. Someone who has a PE, if they're getting treated or not, and also has a DVT, to me, is a very different patient that just has a DVT. Then that could be a whole separate set of patients as well. If you have a pulmonary embolism and you're intervening, you're obviously intervening because there's a right heart issue. That patient is sick. Keep it really simple. That patient is sick.
If they have a concomitant DVT, really, let's just say iliofemoral or femoral, to me, that's a very high-risk patient because if they go home and have another event, and it's happened to us, what is their pulmonary reserve? What is their RV reserve? That's hard to identify. Unless you're telling me they're going home with perfectly normal right hearts, which a lot of people don't, that is a high-risk patient. Anyone who comes in with an iliofemoral DVT that we've treated for their pulmonary embolism, that DVT gets treated. No matter how it looks, how extensive it is, that patient is going home on the same admission with an intervention because we want to give them every chance of not having another event.
We've had cases where patients will go home, they seem fine, and they did well with their intervention, but then their next thromboembolic event put them in RV failure, putting them in shock. That is one set of patients. That, we're very aggressive about. Then let's just say it's an isolated DVT. I think that takes the patient in its entirety. What are their risk factors? What was the event that you think happened that caused it in the first place? Is it reversible? It's idiopathic. Is it something where their symptom onset was within the last 48 hours, or was it three months ago?
How does it look on ultrasound? Is it mobile? Is it adherent to the wall? If it gets into the caval system, is there any possible suggestion of compression? All these things come into our head. I think we're, for sure, on the aggressive side. I think any iliofemoral DVT is likely going to get an intervention from us. I think that the data, the little that we have, really shows these patients do benefit in the iliofemoral system for sure. I think the question also comes up, is it occlusive or not? That's super simple, but if it's occlusive, I think there's almost no question.
We are rather aggressive, I would say, but so many things at least go into our mind. There's so many different options. What is their access site ability, our access site ability? What is their risk for conscious sedation? You have a 450-pound patient, which happens. That's the state of the world that we're in, how safe is that patient putting on the table for something that could take a little bit of time? There are so many different factors, but an iliofemoral DVT that's symptomatic, and let's just say a low-risk procedure patient who is relatively young, active, and is symptomatic. Again, whatever that is, that varies for everyone. It could be very different from, I'm not saying phlegmasia, I think that's easy.
[Dr. Sabeen Dhand]
Yes, obviously.
[Dr. Adam Raskin]
Yes, right. It's the patient who's got maybe a little bit of swelling. They can't mobilize like they want to, just, it's bothering them. They're going to benefit. That patient gets a procedure from us.
Overcoming Common DVT Treatment Challenges
A challenge of DVT management arises when patients unintentionally misrepresent the chronicity of their symptoms, resulting in differences between expected presentation and reality. Dr. Raskin combats this by thoroughly discussing a full history of symptoms with the patient and their family to accrue an accurate chronological description of illness. Another challenge of DVT treatment is visualization and knowledge of anatomy, especially below the knee as it can be difficult to differentiate between deep and superficial veins. Dr. Raskin recommends consistent utilization of IVUS as a safety precaution to define the collateral system of the target vein.
[Dr. Sabeen Dhand]
What should you watch out for? I feel like now the veins are getting a little bit smaller, you're going up and over, it's a little bit new territory. Have you noticed any severe spasms or extrav or anything like that, or is it pretty straightforward?
[Dr. Adam Raskin]
I think the areas that we get into a little bit of trouble is when we don't understand the chronicity. I can't tell you how many times, oh, this symptom started three days ago, but if you really spend the time and talk to a patient or a family, they've had symptoms a lot longer. I can't tell you how many times we take a picture and the collateral system is so extensive. That's really where you got to be careful. I think the danger is not knowing the anatomy, not feeling really comfortable where you are, thinking you're in a true deep vein when you're collateral, thinking you're at a true deep vein when you're in a superficial vein.
Knowing the anatomy is so important, especially when you get below the knee because it could be tricky. It could be really tricky. Feeling really confident on ultrasound that the artery is right there. Knowing that you truly are at a deep vein because it's a relationship to the artery, so being careful, obviously, but knowing that that's what you want to see. I think IVUS is your friend. I can't tell you how many times that's bailed us out, or sure, we're not sure before you start putting 16 French or 8 French, whatever French it is, not where you want to be.
Running an IVUS catheter, I think, is so critical because it's super easy and safe, and it'll give you the answer. The learning curve is a little steep, but once you start doing it, it's automatic. That's really helpful. I would recommend always being on the side of caution of using an IVUS catheter. Knowing the anatomy really well, and then, commonly, once you get in there and you realize that it's not as much clot as you thought, but it's fibrotic tissue, the vein is stenosed, and then the patient doesn't need an aspiration, per se, but just even balloon angioplasty.
Just increasing their flow in any way. Gentle balloons, and you can be aggressive, 4, 6, 8, 10 will get you somewhere. I think that's such a key piece to it, too, if you don't need to get all this clot out. It's chronic. It's adherent to the wall. It's not going anywhere. I'm not worried about it, but if the vein is occluded and you can just re-establish flow with angioplasty, a benefit to me. Like I said, going from occlusive to non-occlusive, that, to me, is such a big piece of it. Knowing it's okay to be aggressive with balloon angioplasty is also, I think, more than okay, and you'll still really make a big difference.
If you do a couple of pulls and you're not getting anything out, that's fine. Like I said, you're establishing the diagnosis. You're realizing that this is really chronic, and then, instead, you have other options of what you could do, and then you take a picture, and half the collateral is gone. That's the best feeling in the world. You take a picture, and they have no collateral. The collateral system in the veins is wild. The same thing with the arteries, but just how extensive and massive they could be, and they can disappear right in front of your eyes, that patient is going to get better.
[Dr. Sabeen Dhand]
How often do you go in with this up-and-over approach, and your wire flies up the PT, pop, and you're doing your whole thing, and you realize the pop and PT are chronically occluded, how often does that happen?
[Dr. Adam Raskin]
I think more than we realize. Usually, we're going to know ahead of time. Doppler is pretty much a standard. We do a good amount of CT venograms also. That, you're not going to see anything low enough, but we really try and get a good idea of what's going on. We get a good idea of the anatomy, especially if it's an outpatient or you have some time. This isn't, again, that PE patient. You have a good time to see exactly what's going on. I think it is more common than what we think, and it is by far the most common not treated, but I don't know if it's right or wrong. I don't. If someone said, "You're crazy, and it doesn't need to be done," I'd have a hard time arguing. I also know that it can be done. It can be done safer, and it'd be a very different conversation a couple years from now, that that would be automatic and almost, it'd be uncommon not to treat it.
Podcast Contributors
Dr. Adam Raskin
Dr. Adam Raskin is an interventional cardiologist in Cincinatti, Ohio.
Dr. Sabeen Dhand
Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.
Cite This Podcast
BackTable, LLC (Producer). (2024, September 17). Ep. 480 – Venous Treatments: How Low Do You Go? [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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