Pulmonary embolus KILLS more people in Western Europe than AIDS/Breast cancer/prostate cancer combined

1. Veinous thrombectomy
new interventional
technique
M.Cuinet
THE BRICK HOTEL
Buenos Aires - October 27th

2. Introduction
• Deep vein thrombosis DVT
incidence : 1/1000/year
Treatment :anticoagulation>6 months ,elastic stockings >2
years
• DVT: 3rd most common cardiovascular disease
• DVT :15-20% in cancer
• DVT: 2nd cause of mortality (patients with Kc) after cancer
itself
- Pulmonary embolus KILLS more people in Western
Europe than AIDS/Breast cancer/prostate cancer combined
Spencer FA et al ,2016

3. TVP complications
• Acute
• Extension
• Pulmonary embolism 30%
• Recurrence
• Post thrombotic++ Syndrome
• Veinous obstruction
• Reflux
• Oedema,pain
• 23-63 % in the 2 years
• Increase with level of TVP (FI x1,5-3 )
• Ulcer: 2M days off sick/year
Spencer FA et al, 2016
Centres pour le contrôle et la prévention des maladies. Thromboembolie
veineuse (caillots sanguins). Données et statistiques.
http://www.cdc.gov/ncbddd/dvt/data.html. Visité le 5 octobre 2015.

4. Why treat
• About 1/3 patients mess up anticoagulation regimes
• High incidence of post thrombotic syndrome (PTS) with
conventional treatment
• No specific treatment for PTS
• In cancer ,therapeutic problems (reduced venous access
,venous compression,antiangiogenic associated )

5. Review
• Lin 2006
• CAVENT 2011/2016
• COCHRANE 2014
• ATTRACT trial 2016

6. Cavent (Lancet 2011)
• 209 p
• 24 months : anticoagulant alone / TL in situ
• SPT 66% 41%
• Permeabilitý : 47% 55%
• Bleeding : 20% (3 major and 5 significant
• But thrombolytic infusion time too long (average 2,4
days)

7. Attract trial
• No significant overall difference between control and PCDT arms
but- infra inguinal DVT included
• PTS at 2 years less in PCDT arm for IFDVT(18% vs 28%)
• Intervention probably not warranted for infrainguinal DVT alone
• Await full publication –
• DUTCH CAVA trial (IFDVT) results awaited

8. Guidelines for thrombolysis and endovascular
approaches to acute DVT for the prevention of PTS
(Circulation 2014)
• CDT et PCDT : experimented centers, ilio femoral
TVP< 15D, patients selectionned with expectancy
life >1year and good condition and low risk of
bleeding (IIb, B)
• no intravenous TL(III, A)
• with anticoagulation (I,C)
• CI : Chirugical thrombectomy (IIb, B)
• Obstructives Lésions => stent (IIb, B)

9. Pharmacomechanical Thrombectomy
• peripheral device to treat thrombosed vessels, to removal
clots ,rapidly restoring blood flow
• Catheter introduced by veinous puncture

10. Mechanism
• Bernoulli effect
• Powerful saline jet in vessels
• High velocity 550 km/H
• Jet creates a low pressure zone around the catheter tip that
causes a vacuum effect
• Thrombus is drawn into the catheter, where it is fragmented
by the jets and then removed from the body

12. Materials et methods
• 7 patients ,with cancer
• Mean age: 56 years
• Lower or upper limbTVP, life expectancy > 15 days
• Etiology of cancers :colorectal (3),sarcoma (2),lung (2)
• anticoagulant treatment ineffective

13. Methods
• Score assessment symptoms before and after PMD:
• pain scored : 0 to 10
• Heaviness paraesthesia ,disability of moving : 0 to 3
• œdema,induration ,hyperpigmentation :0 to 3
total score of 16
ultrasonographic +/- CT scan before and after PMD

14. Drug
lower dose of lytic agents
AngioJet™ + Thrombolytic =PharmacomecanicThrombolysis
+
Device to reduce thrombus
• Power Pulse Delivery (PPD) 1
• +/- Lytic agent directly in thrombus 20-25 mg tPA
in 50-100 mL NSS2
Wait
• Permits to remove clots (20 to 30mn)
• then thrombectomy
Procedure
Thrombectomy

15. 13
12
11
14
15
14
77
2
5
7
1
3
2
0
2
4
6
8
10
12
14
16
Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7
Score assessment before/after thrombectomy
Avant Après

16. Results
• Mean score : 12,2 before procedure
: 4,4 after procedure
• recanalization 50 to 100% + stentings 6/7 cases to
avoid recurrence on stenosis
• Use of cava veinous removal filter (ALN) in iliac TVP (3 )

17. • H 53 years , recurrent embolism pulmonary
• Rectal adenocarcinoma with liver metastasis
• CT : thrombosis right humeral vein and
subclavian vein around PICCLINE.
• Heparin 42 000 U
• US : thrombosis right subclavian vein
• Thrombectomy March 3rd 2017

18. 27/03 : V axillaire droite

19. 43 years extrinsic compression of left iliofemoral vessels by retroperitoneal sarcoma
with thrombosis left lower limb
Patient symptomatic with incapacitating oedema
Indication : thrombectomy - stenting.

20. Endovascular procedure
• Under local anaesthesia
• Transjugular or transfemoral or humeral approach
• Usually long 6/8 french
• Angiojet Zelante jet 4 x more powerfull
• In Pulse spray mode from cephalad to distal
• 20 mg tPa + 180 cc N saline
• Let this sit for 20 mn
• DVX in thrombectomy for 10 mn
• Aspirate then veinogram
• Nitinol stents and cava vein filter +/-

21. DVT plan
• Information patient ++ consultation before procedure
• Under local anaesthesia
• Previous strong hydratation recommended : D-1 ,D0, D1
• Premedication : Hydroxyzine and analgesic
• Attention: renal insufficiency.

22. Post operative care essential
• Mobilise from Day 1
• Full Anticoagulation after
• Doppler ultrasound before and after
procedure
• Follow up +++ , follow the patient < 2 weeks

23. Risks
• hemolysis : red cells destruction which cross through
catheter Jets
hydratation before and after procedure
reduces this risk.
short timing (4 or 8 min) protects from this risk
• arythmy due to release K+ ( cellular destruction)
for prevent arythmy necessary to activate KT on
and off
( 10sec on/ 10 sec off)

24. Conclusion
• Effective and promising technique under local
anesthesia with few thrombolytic and short
hospitalization
• Impact on quality-of-life
• May reduce the incidence of PTS
• to manage intravenous access for patients under
chemotherapy
• Waiting randomized controlled trials