BackTable / VI / Podcast / Transcript #480

Podcast Transcript: Venous Treatments: How Low Do You Go?

with Dr. Adam Raskin

Get caught up on the current best practices and guidelines in venous interventions. Dr. Adam Raskin covers this and more, with host Dr. Sabeen Dhand in this discussion of DVT and PE treatments. Dr. Raskin is an interventional cardiologist, medical director of Cardiac ICU, and Co-Director of the PERT program at Mercy Health in Cincinnati, Ohio. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) The Evolving Landscape of Endovascular Interventions

(2) Building a Referral Base

(3) DVT Patient Management

(4) Lower Extremity Interventions After a Pulmonary Embolism

(5) How Does Technology Shape DVT Practice?

(6) Pulmonary Embolism Considerations & Expert Advice

(7) Device Decision Making

(8) The Symphony Catheter

(9) Common DVT Complications

This podcast is supported by:

Imperative Care

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Venous Treatments: How Low Do You Go? with Dr. Adam Raskin on the BackTable VI Podcast)

Ep 480 Venous Treatments: How Low Do You Go? with Dr. Adam Raskin

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[Dr. Sabeen Dhand]
Hello, everyone, and welcome to BackTable, your source for all things endovascular and more. You can find all of our episodes online on any platform you prefer, like Spotify, Apple Podcasts, or directly through our website, backtable.com. Now a quick word from our supporter.

This episode is supported by Imperative Care, a medical technology company elevating care for people suffering from stroke and other devastating vascular diseases. Achieve the ideal balance of power and control in your venous cases with the Symphony Thrombectomy System, the newest addition to the company's vascular portfolio.

By moving the clot capture into the palm of your hands, Symphony provides greater procedural control combined with on-demand, continuous aspiration for maximum clot removal. Equipped with two highly flexible catheters and a mechanical assist tool, Symphony delivers consistent, seamless clot removal in one fully integrated solution. To learn more, contact your local sales representative, visit imperativecare.com/vascular for important safety information, and follow Imperative Care Vascular on LinkedIn and Twitter.

Now back to the show. I'm Sabeen as your host today, and I'm here with Dr. Adam Raskin, an interventional cardiologist from Mercy Health in Cincinnati, Ohio. Welcome, Adam.

[Dr. Adam Raskin]
Thanks, Sabeen, for having me. This is a great opportunity, a great chance to talk. Like we just said, I've been a big fan of your show. I think this is great to hear what people have to say about all different topics across the country. Again, I just wanted to thank you for giving me the chance to talk.

[Dr. Sabeen Dhand]
Of course. Like I said, thanks for taking the time. I'm excited. We're going to be talking about really pushing the edge of DVT treatment thrombectomy today. Really interested in hearing your opinion and your approach to this disease. Before that though, let's hear more about your background. How did you end up in Mercy and everything else?

[Dr. Adam Raskin]
Sure. I'm an interventional cardiologist. I've been in practice now, which is pretty wild, 10 years starting this year. I trained on the East Coast. I was in private practice for five years on the East Coast. Then four and a half years ago, I moved to Cincinnati with my family and then joined a big medical center here, Mercy Heart and Vascular, which is five large hospitals. I got a great chance to get into the endovascular space a couple of years ago, but I really found a passion for endovascular medicine, critical limb, wounds, arterial ulcers, venous ulcers.

I was really fortunate to be involved in the OBL background on the East Coast. That got me an introduction into veins, and then ran with it here in Cincinnati. Run two vein offices, and we realize anyone who gets into the space is going to realize rather quickly that it's one, an under-treated disease. It's under-recognized for sure.

[Dr. Sabeen Dhand]
Yes.

[Dr. Adam Raskin]
Then it gives you a really great opportunity to really make a difference. Became a diplomate of the American Board of Vein and Lymphatic Medicine. That really gives you a nice background on the guidelines and the recommendations for people doing both deep and superficial vein work. Then once you get into that space, like I said, it's limitless in what you can do.

[Dr. Sabeen D

(1) The Evolving Landscape of Endovascular Interventions

[Dr. Adam Raskin]
Then as I'm sure we're going to get into, the technology has skyrocketed with it. Every six months, every year, there's another thing that you can do. It's really amazing what you can offer the disease of endovascular medicine, both arterial and venous.

[Dr. Sabeen Dhand]
Yes. That landscape has changed. You and I are both about 10 years out, and it's completely different from what we started with, and how we trained, and what we have now, and our tools.

[Dr. Adam Raskin]
Yes, absolutely.

[Dr. Sabeen Dhand]
It's crazy.

[Dr. Adam Raskin]
It's unbelievable.

[Dr. Sabeen Dhand]
Yes. It challenges some of the big data that's out there right now of how to treat stuff. We're definitely going to go into that. Now, in your practice, are you focused on veins or more anything endovascular peripheral? Do you do a lot of cardiac stuff too, or you're focused on the peripheral space?

[Dr. Adam Raskin]
Honestly, all of the above. I run a cardiac ICU as well, so I'm big into shock, which ties into VTE. When I give talks on pulmonary embolism, we started a PERC program here not too long ago. I teamed up with a vascular surgeon, so cardiology and vascular surgery got together, and we created a PERC program, which we love. We're super excited about it. We meet quarterly, we go over data, we go over cases. We're tracking our own data. Then when I talk about PE, and when you really get into PE, that is a big part of it too, is shock.

It is right heart failure, so that's got to be a big piece to it. That's my passion in terms of cardiology. Then a majority of what I do, and probably I would say 80% to 90% of my intervention is on the arterial and venous side. Critical limb, deep vein work, and then a good amount of superficial vein work. I love that side of it too because venous ulcers are awful. It's awful. What it does to people, being a cardiologist, how many referrals we get for heart failure and their hearts are fine. Then you start doing a whole workup, and they have brutal venous disease. It's just these patients' lives are forever altered, but then could be forever made better by superficial vein intervention. It's so rewarding for the people who do it.

[Dr. Sabeen Dhand]
Yes, you're totally right. It's undertreated. You have these patients who are going to a wound care clinic, and they just have this venous wound for years.

[Dr. Adam Raskin]
Years. Years. Imagine? People come to the office, "I've had this wound for three years."

[Dr. Sabeen Dhand]
It's insane. Yes. It's just their skin has changed and everything. Then you can treat the superficial veins, and they heal so quickly.

[Dr. Adam Raskin]
Correct.

[Dr. Sabeen Dhand]
Life changing.

[Dr. Adam Raskin]
It's interesting, listening to other speakers that encompass that whole package of comprehensive endovascular work, which is, again, very rewarding. I think when I tell people about wounds healing all the time, it could be a combination of multiple things. To be able to treat whether it's arterial, whether it's venous, whether it's deep or superficial, I think gives people the best chance of getting their wounds healed.

(2) Building a Referral Base

[Dr. Sabeen Dhand]
Sure. Absolutely. We're going to focus on deep venous disease today, and more so the acute DVT. Now, you say you started your program. Has most of your referrals? I mean this is relatively recent, so I'm guessing the answer is.. How did you build referrals to be getting acute and then chronic DVT patients that you're treating at the hospital?

[Dr. Adam Raskin]
A lot of it comes with our PE program. Obviously, without saying, the majority of PEs wind up having DVTs. That's one subset of the population. Then it was just being very proactive and making things easy for people. In order to get referrals, I think for anybody, if you make it easier for someone else, they're going to want to send it to you. I give a great example.

I met with the division of orthopedics. "Hey, what do you do when you get a DVT?" Nothing to say anything wrong with an orthopedist, but that's not what they want to do. They want to operate. They'd send a person to the ER. The patient would sit in the ER for eight hours, finally get their Doppler, if at all, the same day, get a prescription for Eliquis. Hopefully, they can get into their internist's office. It'd be a whole production.
That was not easy for the patient. It wasn't easy for the referring doctor. Who knows by the time they get it actually maybe treated or not and can start rehabbing.

Imagine if I told you, "You get a DVT, you call me, I'll get them their ultrasound immediately in my office. I'll get their prescriptions filled immediately. If they need an intervention, it will be handled expeditiously." The phone calls just start. The phone calls just start. We've started picking the divisions that need our help. The emergency rooms, obviously, anyone after any surgery. Orthopedics, OBGYN. We have a big oncology department. How often do you think an oncologist gets a phone call that their patient's leg is swollen? Now what do you do? I'll take care of it. It was the fact that we were passionate about it. We knew that there was a huge subset of patients that would benefit from our services. Once we told people that we would take care of it, the referrals exploded.

[Dr. Sabeen Dhand]
That's super key. Making it easy is the key. If they have to jump through hoops, or even work with old fax papers and things like that, just, you gotta make it easy, and then it'll just come to you.

[Dr. Adam Raskin]
It'll never happen.

We got to make three phone calls. It's never going to happen. It's the good with the bad. You're going to get a lot of phone calls for things that are not required procedures or super beneficial from something. Maybe you need nothing, but you gotta take it all. If you're willing to do that, you'll get a lot of amazing cases that will really benefit from your expertise.

[Dr. Sabeen Dhand]
Absolutely.

[Dr. Adam Raskin]
You have to be willing to take all the phone calls, but that's a way to build a program. For us, it's been very, very successful.

(3) DVT Patient Management

[Dr. Sabeen Dhand]
Amazing. 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, that 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.

(4) Lower Extremity Interventions After a Pulmonary Embolism

[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.

[Dr. Sabeen Dhand]
Yes. Right now the big data set that we have, but it's old is ATTRACT. Right?

[Dr. Adam Raskin]
Yes.

[Dr. Sabeen Dhand]
ATTRACT didn't really use the devices that we have available now, and so it's hard to use that as a reason to not treat below-groin DVT.

[Dr. Adam Raskin]
Correct. The one thing I could say is I think that at least showed, which we all know, making something that was occlusive, less occlusive, patients did get better. The post-thrombotic syndrome rates, despite it weren't different, were lower, especially in someone who got a catheter-directed therapy. Just, in my opinion, the wrong therapy, but we're heading in the right direction for sure. Even those patients who got anticoagulation, their post-thrombotic syndrome rates were really high. That's so devastating. When people do superficial vein work and they see these legs, if I had these deep veins that are occluded, now they have venous insufficiency, and I can't ablate anything because they're living on a saphenous, I'm like, "I would have done anything to have seen you three years ago and been able to use, the right catheter to open up your deep veins, and then we wouldn't be here." Sometimes it's, then when you're stuck, you really are stuck, and the morbidity is through the roof.

[Dr. Sabeen Dhand]
They're relatively young too.

[Dr. Adam Raskin]
Correct.

[Dr. Sabeen Dhand]
I have some patients that are 40, 50, and I'm like, "I have nothing else to offer you." Tried to recanalize their deep veins and tried to do this, but that still doesn't offer great benefit to them.

[Dr. Adam Raskin]
Correct.

(5) How Does Technology Shape DVT Practice?

[Dr. Sabeen Dhand]
We touched on this. The tech has improved over the last, five, six years. There's a lot on the market now from small bore devices to agitating devices, to large bore. How has the tech shaped your practice? What do you like to use? We can use specific case examples if you want, but what do you use or do you use everything?

[Dr. Adam Raskin]
I would say we probably use everything. It could be very patient-specific. It could be access-specific. It could be the location of the clot. You have an IVC thrombus, you're not going to use an 8 French catheter. You have something popliteal, distal fem, popliteal, you don't need a 24 French catheter. It's so variable. You can get phenomenal results based on the choice that you use. If you know what you're going after ahead of time, you have a good game plan. You can access the popliteal vein safely. I would say 90-plus percent of our patients, the access point is the popliteal vein. Typically prone, we feel pretty comfortable. Always in the back of our mind, that PE patient, a couple of days after their event, can they lie prone safely?

If God forbid you cause another one, are they going to be in a safe place in terms of their respiratory status? That's always a big thing in the back of our mind. Are we going to be able to reach? Where are we coming from? I think we have the opportunity now, which is new as I've been able to use it. There's a catheter with Imperative Care, the Symphony catheter, which I actually have been able to go up and over. I used to avoid it like the plague, going up and over in the venous system. What a disaster, but we've had this ability where we can access the tibial vein on the affected side, and then snare a wire up and over.

The patient is on their back, and we can access the femoral vein. We can snare a wire, and then run a sheath from the contralateral side up and over, pretty smoothly. We can run a 16 French GORE DrySeal sheath if someone is on their back, from the contralateral common femoral vein up and over, and run a catheter down. The catheter symphony is really flexible and travels really easily, especially those valves, which we're fighting. If you have the sheath pretty far down, we can get as far down into a tibial vein. I think that's always also the big question, how far do you treat?

If you can get down there and get a result, I think that the more you can get, the better. That's a nice option. Coming from the popliteal vein up, I think that popliteal vein can handle pretty large bore catheters. We can put in a 16, no problem, put in a 24 bareback, no problem. Depends on obviously the patient's size and stuff like that. The beauty of the vein work is you can be pretty aggressive. That's why I love it. The risk is not that high. You could be aggressive. You could be really aggressive. I think one of the things that we're always in the back of our mind sometimes is, bigger is better.

You can get a lot of thrombus removed. You have to be mindful of blood loss, obviously. I think as the bigger the catheter goes up, that's always an issue. I think we're still learning. We really are. Keep your options open. That's what I would tell anyone. Keep your options open. Try different things. Use all different techniques because you can get incredible results. You really can.

[Dr. Sabeen Dhand]
Yes. I think right now, with people who are treating VTE and NTVT, a lot of people are familiar with the two big players, Inari and Penumbra. Again, you mentioned Symphony and other products that are there. I was really interested in this approach you're talking about doing the up and over from the contralateral groin. Is that specifically in your PE patients that you bring them back? I'd just love to hear an example of a PE patient you treat, and then what you do after with them.

(6) Pulmonary Embolism Considerations & Expert Advice

[Dr. Adam Raskin]
Sure. Let's just say a large bore thrombectomy for PE, good result. You have gotten a good distal outflow of the pulmonary tree, certain things that we always look for. As a cardiologist, I'm neurotic about pulmonary pressures, the pulmonary systolic pressure, and keeping a good eye on the right heart. The right heart is a wimp, and it scares me to death. If you've gotten a really good result and that patient has improved in terms of their respiratory status, we feel really comfortable before they go home, typically anywhere between 48 hours, bringing them back, and then doing an iliofemoral intervention.

We'll put them on their belly and get popliteal vein access, and clear out as much as we can. That would be our standard practice for almost all of our PE patients. If you didn't get a good result, it would make me even more nervous sending them home with an iliofemoral DVT. That RV is still not what I would like it to see. Makes me even more nervous because again, the next one, you don't know what it's going to do. I would say we would be even more aggressive about the DVT if we did not get this amazing PE result. If you did get a great result, the reserve is probably okay, that if they had a small one, might be clinically insignificant.

We don't have great predictors of that, and there's all different ways, I think, to re-stratify people, but that would be pretty standard. Then I guess the question would come up is, if it's more than just iliofemoral, popliteal vein, tibial veins are all occluded, everything, right?

[Dr. Sabeen Dhand]
That type of patient, exactly.

[Dr. Adam Raskin]
Yes, right. You tell me that you're going to clear out their common fem, but their inflow is still terrible. Pops occluded, tibialis are occluded, gashes occluded. That patient is going to do okay? I don't know. They might. We don't know. We don't know because I think we were never at the technology where we could treat it. No one is going to give someone the systemic lytic for tibial vein DVT. Usually, let's just say majority of the time, clinically insignificant patients will do fine, but I don't know that. I think once anyone really sees vein ulcers, really sees chronic venous insufficiency, could you have done something?

Could those tibial veins, all the deep vein reflux that's brutal that you can't do anything for, the saphenouses are five seconds of reflux, eight seconds of reflux, could you have done something? That's always in the back of my mind. I love the question, what if we really did clear out the pop in the tibial veins a little bit more effectively and maybe kept those valves still somewhat competent? Maybe they wouldn't be so symptomatic for a devastating morbidity later in life. I think we're at the point where we'll give it a shot. We'll try. If someone is young, and again, always in the back of our mind is safety, but if you can, whether it's to access a tibial vein, which comes up a lot now, there's all different procedures that you're going to have to start accessing veins down the ankle.

Anyone who does DVA work, you're accessing down there. If you do a lot of superficial vein work, your skills with ultrasound and accessing those veins for a lot of people, I think, are growing every day. People are getting more experience with it, and they're having what would probably take and still can take a very long time, if you give it a little bit more efficient of accessing the tibial veins, you can come up, and you can clear out a posterior tibial vein and you could really open up the popliteal vein. Now imagine an occluded pop that's open on top of the iliofemoral.

I find it hard to believe that we won't hopefully one day show that that is truly beneficial now that we have the ability to, like I said, come up and over, and I could put a 16 French catheter retrograde into a tibial vein and clear out some clot or at least tell you that the pop is going to be wide open. I feel that that likely makes a difference. As technology grows and hopefully, research grows, and again, we'll get some publications down the line here, I'd find it hard to believe that increasing inflow isn't going to make a difference. Then imagine if you put a stent.

I love it, but I hate it. If I'm putting in an iliac stent, that inflow better be phenomenal. If the pop is occluded, how's that going to be? One, it better be tight, and there better be phenomenal inflow, and that's not always the case. Then, how often do you deal with occluded iliac stents? That is not fun.

[Dr. Sabeen Dhand]
Oh, yes. Once they're occluded, then it's just, yes, forever.

[Dr. Adam Raskin]
There are just so many questions, but what's amazing is that we have the ability to do something now, and we can do it safely. Who benefits from it? I'm not sure, but like I said, we try and re-stratify if it's early on. Someone who's had it, it's been weeks or months. I don't think there's much utility there, but truly the acute DVT from the ankle up, if you could do something, we have the ability to do something now. Safely and effectively.

(7) Device Decision Making

[Dr. Sabeen Dhand]
You described your technique. Basically, you get access into the posterior tibial vein on the ipsilateral leg with the DVT, and then the contralateral fem, and you bring your sheath up and over. Are you using multiple devices then to clear out iliac, common fem, femoral, pop, and then posterior tibial?

[Dr. Adam Raskin]
Correct. Usually, the times we've done it, the iliacs are probably okay. It's going to be mostly the femoral system. Then what we'll do is, going up and over, I would avoid. That is not easy to do, but if you can get a wire, if you can get an 035 Advantage wire, it's the most common, from the tibial system straight up, then snare it and pull it out the contralateral common femoral vein, you have a rail, and you have a really good rail. Once you've got that rail, you can run anything up and over, instead of trying to do it on your own without that rail is a headache, and it's just very difficult.

It's technically challenging, especially once you're trying to fight all those valves. Now I've taken that out of the equation. I have a good rail. You can then run a sheath. Typically, what we use 99% of the time is we'll take a 16 GORE DrySeal. We'll then put it up and over, over the rail, and then we'll run our catheter down. We'll start with a 16, so that'll clear out as much as we can. The 16 goes pretty far. You can then run a smaller catheter within the 16. You can either run an 8. Most of the time the 8s won't reach through the 16, but again, just use the rail.

You can run the 8 up the tibial vein from the ankle. I think it'll handle it no problem. Most of the tibials can handle an 8 French catheter, sort of above and below, a retrograde and antegrade approach, and meet in the middle. Run the 16 from retrograde and run the 8 antegrade, and that gives you your best shot. We can get some really, really phenomenal results. Trying to clear everything out really from the ankle to the iliac.

(8) The Symphony Catheter

[Dr. Sabeen Dhand]
You mentioned you're using the Symphony catheter. Does that come in all these sizes?

[Dr. Adam Raskin]
Really nice catheter, 16, soon to be 24. The 16 for us is just a really nice combination of everything from IVC to the ankle. If you can keep it simple, one catheter can do everything in one shot. We've had some really, really nice results, so we've been really happy with it so far. We look forward to even more experience and some research.

[Dr. Sabeen Dhand]
What are things that you like about it? Is it just as flexible? Is the suction any different, or anything like that?

[Dr. Adam Raskin]
When I say different, I would say it is just as powerful as anything else. The suction capability is really high. To me, sometimes what we've seen is a single aspiration. The more time you're there with any procedure, just the complication risk goes up. If I can tell you I can turn the catheter on and do a single pull, and then do a venogram and you're done, that's a pretty easy sell, and reduces fluoro time, contrast time, sedation time. Anything reducing procedure time is a benefit not only to the operator but also to the patient. We've had some really, really quick results.

Sometimes quick is not always what we're looking for, but if it works that fast, to me, that's a no-brainer. We like the speed of it, the deliverability of it, whether you need to run it. It comes with a dilator. You can run it up the leg with the dilator, you can run it up without the dilator. We can inject through it, so you can do your venograms with the catheter in place. You can also hook it up. It's a multi-port, but you can hook it up to pressures. You can check pressures if you'd want to. I like being able to take isolated pictures and identify specifically where you're going so you can see exactly where there's residual clot.

It's got nice torquability. It's a one-to-one torque, I would say. The tip has got an angle to it, so I can angle where I'm going. Directionality is really nice. All these little tips and tricks that increase the success of not only getting good flow, but as much to 100% thrombus resolution as you can. It's not always what we're looking for, but the closer you can get, the better. We've had, like I said, really nice, safe results thus far. We're really happy.

[Dr. Sabeen Dhand]
I think every iteration, and that's what we're seeing, all companies coming out with catheters, they make each other better. Right?

[Dr. Adam Raskin]
Oh, absolutely.

[Dr. Sabeen Dhand]
Good points. You mentioned multi-port. It's nice to have more ports to be able to do pressures or inject and just a bunch of other features that may seem small, but they all add on, making it something that you want to use. It's nice when it's there. Yes, it's nice when it's there. It's like you don't know what you have until you have it. Right?

[Dr. Adam Raskin]
Exactly.

(9) Common DVT Complications

[Dr. Sabeen Dhand]
How would you say, is it pretty easy? The clot comes out from the tibial? 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 spasm 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.

[Dr. Sabeen Dhand]
Yes. It's eye-opening for me. Like I said, when I treat PEs and what we do in our practice is we treat the PE. Obviously, if there's iliofemoral stuff, we'll do that, but below the groin, we just say, "Okay," but it totally makes sense. You're obviously at a big place and everything, well-organized, so I'm assuming you've got some data that we're going to be looking forward to seeing in the next couple years.

[Dr. Adam Raskin]
Absolutely. It's important to us. I feel one way about it. I'm very passionate about it. My partners are too. We love doing it just because we're really trying to be as comprehensive and the whole scope of what's going on, but I think the real answer is going to be when we can put it on paper and have hard data that shows that there's a benefit. I would encourage anyone who's involved in a PE program to collect data, have coordinators involved. It's very difficult to do it yourself. We have residents who are involved, a lot of prospective data collection, retrospective data review.

Things that we get together, like I said, quarterly, and see how we're doing and keeping everyone up to speed and making sure that we're on the same page as a group. Then we feel better about it too, that we're doing the right thing, that everyone is just on the same level of passion and support. Making sure these people follow up. Follow-up is so critical. That could be the smallest thing. Someone disappears, and the leg looks terrible years down the line. Making sure that they get phone calls, they get into the office, and that they're being seen by the right people makes a huge difference. It really does.

[Dr. Sabeen Dhand]
No, I totally agree. That's a big part of it, following these patients up, seeing how their leg improves, if it changes, and it starts getting worse again. Doing a follow-up venogram and improving things, you got to stay on top of it.

[Dr. Adam Raskin]
Correct. Yes, just because they went home doesn't mean you can't get something down the line. Like I said, we talked about, every day that goes by is going to make your procedure a little harder, but that's not a reason not to give someone a chance. Good close follow-up. That leg doesn't look right, they're symptomatic. There's all sorts of scoring systems, whether it's Villalta, or VCSS, or CEAP classification. There's all these things that you can follow and document well. What exactly, we put pictures in the chart. Every leg gets a picture, so we could see exactly how the leg is changing. I think that makes a big difference. You don't see someone for a couple months. Maybe, yes, no. Patient says, "Ah, I think it's a little less red," but is it, isn't it? Little things like that go really, really far and really help us whether or not someone would benefit.

[Dr. Sabeen Dhand]
Okay. What do you think the future holds for venous intervention? I know that's a big question. What makes you excited about the future? It's almost like we're breaking the tip of the iceberg. What other things are you seeing down the line?

[Dr. Adam Raskin]
I can't wait for the data. As a cardiologist, that is obviously my bread and butter, and every cardiologist is neurotic about the data. Show me a randomized trial, randomized trial, randomized trial. When they happen, they are game-changing. I'm more excited that more people, more operators feel the same way as us, as I do, as my partners do. As more and more people start doing it, more and more people are going to want to enroll in trials, get involved with these companies, and start getting real good data. I think that is really what changes guidelines, that's what changes practice.

As I go around and talk about whether it's PE or DVT and all the different things that we can do, and other people build PE programs or VTE centers, it's amazing to see other people be successful. Then hear other people's stories, and then see pictures online of great results, other than the standard of care. Getting more people believing in it, and then eventually, like I said, getting it really looked at, whether it's large randomized trials by excited and quality operators, I can't wait to see how that pans out, which just takes a while, but that'll really be the game changer. I know it's going to happen, and so that's what I'm really, really excited for.

[Dr. Sabeen Dhand]
That's awesome. Yes, there's a lot. Just as we saw a lot of differences in how we treat disease in the last five years, I think the next five years, we're going to see so much data like you're saying. I think people are going to change the way they treat. Then there's going to be more devices out and more ways. It's ever-changing, and that's what I like about endovascular therapy too. It's like you're learning and changing, and new data is coming out. That's just the fun of it.

[Dr. Adam Raskin]
Yes, absolutely. Just, it exploded, yes.

[Dr. Sabeen Dhand]
Yes, it's going to explode.

[Dr. Adam Raskin]
When I graduated fellowship, nothing of what I'm doing now was even a discussion then. Just, really, it's wild. We love it. Hopefully, more people will join the ride because it's a lot of fun.

[Dr. Sabeen Dhand]
Love it, love it. Adam, dude, thanks for coming on, taking the time, sharing your experience, and really showing how you can push more and more work that we can do with VTE. It's really amazing what you guys are doing at Mercy. Thank you for coming on the show and enlightening all of us.

[Dr. Adam Raskin]
Thank you for having me. It was a great time. Again, a topic I love talking about. You put on a great show, and I'll look forward to keeping listening as the years go on.

[Dr. Sabeen Dhand]
Yes, I will look forward to having you on again too. Thank you.

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.