About Chronic Venous Reconstruction

After treatment for deep vein thrombosis, a condition know as Post-Thrombotic Syndrome may develop.

The newest treatments for post-thrombotic syndrome, or chronic DVT, provide hope for patients who have traditionally been told there is nothing further that can be done for their condition. RIA Endovascular offers chronic venous reconstruction for patients with post-thrombotic syndrome and chronic DVT.

What is Deep Vein Thrombosis?

Blood clots occur when blood thickens and clumps together. While most deep vein blood clots occur in the lower leg or thigh, they can also can occur in other parts of the body. Often, a patient might not realized they have a DVT. However, during an initial episode, the individual may experience pain, swelling, cramping, and leg tenderness.

A DVT can break free and travel through the bloodstream. The loose clot is called an embolus. If the embolus flows to the lungs, this complication is called Pulmonary Embolism (PE). PE is very serious. When the loose blood clot travel to an artery in the lungs and blocks blood flow, the embolism can damage the lungs, other organs in the body, and can possibly result in death. Blood clots in the thighs are more likely to break off and cause pulmonary embolism than blood clots in the lower legs or other parts of the body. While blood clots can also form in veins closer to the skin’s surface, these clots won’t break off and cause PE.

What causes a blood clot? Who is at risk for DVT?

Two-thirds of DVT cases occur in people who are hospitalized for surgery or a medical illness. Those who develop DVT are likely to have one or more of these risk factors:

  • Recent major trauma (e.g. car accident with bony fractures)
  • Recent major surgery
  • Cancer
  • Immobilization due to medical illness, paralysis, or other condition
  • Pregnancy
  • Hormonal treatments such as birth control pills
  • Blood clot disorders, which are often inherited

How common is deep vein thrombosis?

DVT affects men and women of all ages; it can also affect newborns, children and pregnant women. The risk of developing DVT increases significantly as one ages.

Between 350,000 and 600,000 people develop DVT each year in the U.S. Resultant pulmonary embolism is estimated to lead to more than 100,000 deaths each year in the U.S. About 30% of DVT patients will later develop additional DVT episodes. Post-Thrombotic Syndrome (PTS) develops in 25-50% of patients with a first episode of DVT, which is between 50,000 and 100,000 patients per year.

Can deep vein thrombosis be prevented?

YES. Injectable blood-thinning drugs and mechanical leg compression devices are highly effective in preventing DVT and PE, and are widely available.

PE is the most common preventable cause of death in hospitalized patients. Unfortunately, doctors and hospitals often fail to properly prescribe the above preventive measures for patients who are at risk. Most patients are not familiar with DVT and do not know that they are at risk. When being admitted to the hospital for surgery or a medical illness, patients and family members should ask their physicians and nurses what measures are being taken to prevent DVT.

What is Post-Thrombotic Syndrome (PTS)?

Those who have been treated for DVT by traditional methods often experience long-term pain, swelling, heaviness, fatigue, skin changes, and open leg sores. Such complications are referred to as Post-Thrombotic Syndrome (PTS). This is also referred to as chronic deep vein thrombosis, or chronic DVT.

Historically, how has deep vein thrombosis been treated?

Until 1998, therapy for DVT was blood thinners alone. There were no satisfactory options for clot removal. In the late 1990’s, studies began to demonstrate that placing a catheter in the clot and dissolving the clot allowed for resolution of symptoms faster. It also decreased the long- term symptoms that occur in patients with DVT using blood thinners. This procedure did require the patient staying on the ICU overnight – and sometimes for several nights – as the “soaker- hose” slowly dissolved the clot. The longer the treatment lasted, the higher the risk of bleeding. More recently techniques have been improved, allowing this process to be performed in a single setting or with minimal catheter time (overnight in the ICU) . This makes the procedure quicker and safer.

Research shows promising hope.

Researchers in Montreal (Dr Kahn and associates) have performed many studies looking at outcomes in patients treated with blood thinners alone and have shown that up to 50 % of patients develop “post-thrombotic syndrome.” The risk of these symptoms is related somewhat to the location of clot. Symptoms of post-thrombotic syndrome (PTS) may be:

  • Mild – occasional swelling and mild discoloration,
  • More-moderate – occasional pain and cramping or more significant swelling
  • Severe – recurrent infections called cellulitis, thickened skin, significant pain and ultimately ulcer/wound formation.

Possible Treatment Options

There are several possible treatment options depending on the severity and location of the clots, including:

  • Clots in the calf and focally behind the knee are almost always treated with blood thinners alone. Patients do very well with this treatment.
  • Clots that extend all the way to the main vein in the abdomen ( the inferior vena cava) cause moderate-to-severe symptoms in up to 85% of patients who are treated with blood thinners alone.
  • Many practitioners believe that all such patients without contraindications should be treated with clot removal. This is still controversial and hence the ATTRACT Trial which is expected to prove once and for all that clot should be removed.
  • The greatest area of controversy is clot extending from the calf to the groin. Most of these patients get treated with blood thinners alone, but many become chronically symptomatic.
  • Many practitioners believe that all of these patients without contraindications should be treated with clot removal. This is still controversial. The ATTRACT Trial which is expected to prove once and for all that clot should be removed.

For acute DVT, what are the newest innovations in treatment? — The ATTRACT.

The ATTRACT trial is an NIH-funded trial studying patients with DVT on blood thinners and compression hose alone versus adding a clot-busting treatment called Pharmacomechanical Catheter-Directed Thrombolysis (PCDT). This study, funded by the National Heart Lung and Blood Institute (NHLBI), is a Phase III, multicenter, randomized, open-label, assessor-blinded, parallel two-arm, controlled clinical trial.

Chronic Venous Reconstruction — Treating Chronic DVT at RIA Endovascular

There is a growing body of evidence to support removal of extensive clot in patients with acute DVT. At RIA Endovascular, we provide these patients with hope where there has been none in the past. There are few centers in the country who provide this service and we are leading in training others on this topic. We take great pride in working with these complex patients. Our team has developed a program which includes conservative measures such as compression hose and lymphedema physical therapy and-or compression pumps as well as blood thinners. The difference lies in our ability to perform a venogram and fix the underlying scarred veins with balloon angioplasty using special techniques. In patients with more extensive clot including the main veins in the abdomen and pelvis can be reconstructed with stents. The stents are much larger than stents placed in the arteries of the heart and kidney and leg that are commonly discussed in the media. Thus the incidence of blockage in venous stents is much lower. In fact patients as young as 10-years-old have been treated with these methods.

Long-term solutions — providing hope where there was none.

Patients at RIA Endovascular with chronic DVT have been reconstructed despite initial clot as long as 25 years later. Some of these patients have had ulcers for many years and are in and out of wound clinics. After reconstruction, massive ulcers have healed in less than a month and have remained healed for many years.

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