Interventional RADIOLOGY Update Volume 12, Issue IR01, June 2012

Your Imaging Experts INTERVENTional RADIOLOGY Update Volume 12, Issue IR01, June 2012

Additional Therapies for DVT The risk factors for deep venous thrombosis include hereditary and acquired conditions. These are Venous thromboembolic (VTE) disease is a major beyond the scope of this newsletter and can be found cause of morbidity and mortality in the United in many sources. The basic teaching for the cause States. It is the third most common cardiovascular is Virchow’s triad of stasis, hypercoagulability illness after acute coronary syndrome and stroke. and injury to the veins of the upper as well as the The exact incidence of lower extremities. VTE disease is unknown but predicted to be Deep Venous Thrombosis 1,000,000 cases per year Typical symptoms of DVT in the upper and lower in the US. Many cases are extremities include pain or tenderness and swelling. recurrent and 2/3 involves Signs on physical examination include increased hospitalized patients. Nearly warmth, edema, and erythema and the presence 300,000 deaths occur of dilated veins (collaterals) on the body wall or limb. A each year. Deep venous life and limb-threatening manifestation of DVT, phlegmasia thrombosis(DVT) not only cerulea dolens, occurs most often in the setting of contributes to pulmonary malignancy, heparin-induced thrombocytopenia embolism, the most fatal (HIT), or other thrombophilic conditions in which the complication, but also to Michelle Lung, MD thrombus completely occludes venous outflow, Grand Traverse Radiologists, P.C. post phlebitic syndrome causing massive limb swelling, hypertension in the (PPS). PPS occurs in up capillary bed, and eventually ischemia and gangrene to 30% of patients 8 years following diagnosis of if untreated. Phlegmasia cerulea dolens is a vascular their initial acute thrombotic episode with signs and emergency requiring anticoagulation and if possible symptoms occurring as early as two years. One study thrombolysis or surgical versus catheter-based placed the risk of PPS after 1, 2 and 5 years at 17%, thrombectomy. Fasciotomy may also be required 23% and 28%, respectively. Of the patients with PPS, to relieve associated compartment syndromes. up to 25% will develop chronic venous stasis ulcers. PPS seems to occur in patients with more extensive Deep Venous Thrombosis of the Upper Extremity DVT in the proximal veins and is more frequent in obesity or with recurrent disease in the previously Upper extremity DVT is most often related to affected limb. Older patients, patients with central venous catheter placement, transvenous incompletely treated DVT or those with persistent intracardiac devices, or intravenous drug abuse. pain and swelling one month after therapy are at Other, less common causes include thoracic outlet increased risk. Post phlebitic syndrome occurs syndrome (also referred to as “effort thrombosis”) and from valve damage related to the development of hypercoagulable conditions including malignancy. thrombus and the resultant inflammation. This Patients may be asymptomatic, but more often they leads to valve incompetence and insufficiency. There complain of arm swelling and pain. Anticoagulation can also be chronic venous occlusions due to non- is indicated if there are no contraindications. recanalization. This leads to venous hypertension. Thrombolysis should be considered in younger patients with a low risk of bleeding and symptoms of acute onset.

Publication of Grand Traverse Radiologists, P.C. Treatment The Interventional Radiologists of Grand DIAGNOSTIC RADIOLOGY Traverse Radiologists, PC at Munson Steven Klegman, D.O. Once DVT is suspected, anticoagulation C. David Phelps, M.D. Medical Center have the expertise in Todd Space, M.D. should be started immediately unless there is a thrombolytic therapy that is necessary to contraindication. The main goals of treatment for treat patients with VTE and DVT. Patients DIAGNOSTIC RADIOLOGY/ DVT include prevention of pulmonary embolism, with acute central upper and lower CARDIAC CT post phlebitic syndrome, and recurrent Ryan Holmes, M.D. extremity DVT are the best candidates C. Paul Williams, M.D. thrombosis. for catheter based techniques. The goal in these patients is to try to prevent PPS. DIAGNOSTIC RADIOLOGY/ Anticoagulation COMPUTED TOMOGRAPHY After the syndrome occurs, treatments Steven Hodges, M.D. Anticoagulation remains the treatment for for PPS are limited and not always very thromboembolic disease. Initial therapy may successful at alleviating the symptoms. BREAST IMAGING include heparin (UFH), low-molecular-weight Deborah Crowe, M.D. ASA among other anti-inflammatories, Charles Weitz, M.D. heparin (LMWH), or fondaparinux (Arixtra) diuretics and exercise can help control Todd Wilson, M.D. followed by an oral anticoagulant such as a symptoms. Additional treatments for vitamin K antagonist (VKA). Once anticoagulation INTERVENTIONAL/ PPS include knee high compression VASCULAR RADIOLOGY with UFH, LMWH, or fondaparinux is begun, stockings 30-40 mmHg which can Frederick Brodeur, M.D. a VKA may be initiated. An overlap should be reduce the occurrence by 50% after Daniel Dall’Olmo, M.D. continued for a minimum of 5 days or until the two years. Michelle Lung, M.D. international normalized ratio (INR) is within the James Picotte, M.D. target range of 2.0 to 3.0 for 24 hours to permit Clinic and Resources MAGNETIC RESONANCE adequate depletion of vitamin K–dependent IMAGING For more information, please contact the Daniel Boss, M.D. coagulation factors. Interventional Radiology Clinic at 231- Jesse Johnson, M.D. Thrombolytic Therapy 935-2861. Questions or referrals can also Todd Kennell, M.D. be directed to any of the Interventional MUSCULOSKELETAL Thrombolytic therapy for acute DVT, symptoms Radiologists by paging us through the RADIOLOGY of less than 14 days, may be beneficial in select Munson operator. We continue to offer James Shirley, M.D. patients, and although it can be administered around-the-clock coverage for inpatients NEURORADIOLOGY systemically, local infusion under catheter and emergencies and are available 365 L. Nicholas Richmond, M.D. guidance is preferred. Both routes carry an days a year. We look forward to working David Steffey, M.D. increased risk of hemorrhage compared to with you and your patients. Edward Stilwill, M.D. standard anticoagulation. Although it has been suggested that use of thrombolytics promotes early recanalization and minimizes the incidence of the PPS, their role in the treatment of DVT without a threatened limb is still unclear. The current ACCP guidelines suggest that in selected patients with extensive central DVT (iliofemoral) less than 14 days duration who are at low risk of bleeding and who otherwise have good functional status and life expectancy of 1 year, catheter- directed thrombolysis may be considered if the expertise and resources are available. New endovascular techniques are available include Interventional Vascular EKOS which is a catheter delivery of thrombolytic Radiology Team into the thrombus with ultrasound to improve lysis and decrease treatment time and therefore From left to right: Michelle Lung, M.D., the risk of bleeding associated with thrombolysis. Frederick Brodeur, M.D, There are Trellis Catheters and AngioJet catheters James Picotte, M.D., Your Imaging Experts which combine mechanical and pharmacological Daniel Dall‘Olmo, M.D. thrombolysis to allow shorter treatment time and decreased lytic dose to decrease risks.

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