Upper extremity DVT|Upper extremity DVT|56|Male
Upper extremity DVT|Upper extremity DVT|56|Male
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thrombosis. There're different flavors of radio, probably get to see another one

later from my colleague Dr. Saad. History and physical, 56-year-old male, who had recent diagnosis of small cell carcinoma, with some mediastinal adenopathy, and a small subsegmental PE. And he was initially started on Lovenox with transitioned to Warfarin.

Not sure how they did that, although there was a known diagnosis of malignancy. But that's how it is, when they go into the, not away from the main campuses, they go to the suburbs. People don't know the importance of having these people on, low

molecular weight heparin, who's a known candidate with cancer, and use DBT. He later presented with left upper extremity swelling, and severe pain. Physical examination showed that, he had swelling all the way from his shoulder, down up to his hands. And he had severe pain associated

with that, when he presented to the emergency department. And for some reason, a counsel was not sent to us initially. And his INR, at that time of admission in the emergency, was 3.1. And the Doppler evaluation was done at that time, which had shown upper extremity vein, you'll see the findings, upper extremity veins, Doppler was done. And for some reason, he was started on oral anticoagulants,

they're not sure why it was done that way. But Pradaxa was started, thinking that, okay, patient was on Warfarin, developed this possible venous thrombosis. So somebody decided in the ER, start him on Pradaxa, so he was already on Pradaxa. He did not improve. And this was the left axillary vein,

color Doppler ultrasound imaging, which shows some hyperechogenic material within the auxiliary vein. it was similar in the brachial vein as well. Is not a good color flow throughward, and it was not compressible. So all the findings consistent with deep venous thrombosis in the upper extremity. So based on the findings in ultrasound, and when the counsel came

through finally, with his symptoms not getting any better, we planned for doing a mechanical thrombectomy, to remove the clot burden. Since he was already on Pradaxa, with it's half life being anywhere between 17 and 21 hours, and we still don't have prax buying the antidote that, to reverse in these people right away, although it's available now, and

it's approved by FDA in October 2015. So we were in a bind, how are we gonna do lysis who's already on Pradaxa, with history of lung malignancy, and you don't know what's his status in the brain? We were a little bit reluctant, to kinda of do lytic infusion, or use a lot of lytic straight away. So it was not done on the initial

day. We stopped the Pradaxa, changed him to unfractionated heparin, while he was in the hospital. Then realized that he had some, kind of hit with some thrombocytopenia developing. He was changed to Argatroban. But once he came

to us, we did an angiogram through the left basilic vein, which was still patent, and a venogram was done. And initially, we did some mechanical aspiration thrombectomy with the CAT6, we didn't have CAT8 at that time. Like I said, we decided against lytic infusion catheter through the clot, because the effect of Pradaxa had not worn off.

This is the initial images. Here you can see access from the basilic vein. The initial angiogram showed that ready appearance, of the left basilic continuing as the axilla. And then the central veins were something like this. There's irregular eight years of filling defect within the vein. And then some irregularity

in this area, and a large filling defect in the left brachiocephalic vein. Here you can see the CAT6, going through the separator coming right here, We worked on for it for quite some time, without much improvement of

the appearance of the clot, in the central veins. You have to believe me, the actual CT sections did not show any mass lesion right here. There was some mediastinal adenopathy,

but there was none around the left brachiocephalic vein, to explain for this. So it was not just extrinsic compression causing this whole problem. It's cancer induced thrombosis, but he was symptomatic, so you're trying to help him

to relieve the clot burden. So once we did this on the first day, and Pradaxa was stopped there, we didn't do a lytic infusion. We were able to clear, most of the clot from the axillary region. And then at the end, only some part of the left brachiocephalic vein, and little bit in the subclavian vein

remained. Further work the next day, things seems to have gotten better. And at this point, he was off Pradaxa. We did an Angiojet pharmacal mechanical thrombectomy. At this point, since he was off Pradaxa for more than two days, we were a little bit more positive. And we did a little bit of lytic in a

pulse-spray fashion, with up to 68 milligrams here, and it cleared out more clot. And finally, this part in the left brachiocephalic vein, was very difficult to just suck out the Angiojet. We didn't have the ZelanteDVT at that time. So what we did was, we managed to use a cleaner, and hopefully because of the fact. that it was a little

bit soft. And although it didn't come out, with the help of Angiojet only, it kind of cleared, and the patient got better with that. And we were able to operate up completely. So now for the samp question. Which of the following is a finding in the setting of deep venous thrombosis?

Choice A, a non-compressible vein on ultrasound evaluation. Choice B, no detection of flow on color Doppler. Choice C, filling defect on direct venography. Choice D, presence of multiple enlarged

collateral veins. Choice E, is all of the above. Time starts here. [BLANK_AUDIO] Okay. everybody got it right, hurray, 100%. Okay, that

was a simple question. So little bit about the upper extremity DVT. Catheter-associated upper extremity DVT accounts for vast majority. So I'm talking here, only about the secondary forms of upper extremity DVT.

There is a primary form which you already know, it's a Paget-Schroetter. The secondary forms, it results mainly from indwelling central venous lines or portacads/g, and less frequently from pacemaker or defibrillator leads. Systematic screening however in these patients, reveal thrombosis in up to

two thirds of cancer patients, with central venous catheters. And patient-related risk factors include the presence of cancer, especially ovarian or lung adenocarcinoma, presence of distance metastases, and also a history of thrombosis or thrombophilia in these patients. Cancer

related upper extremity DVT, even in the absence of central venous catheter, it is usually the cause of secondary upper extremity DVT, because there are cancer-induced prothrombotic states or venous stasis, resulting either from venous compression, or from some kind of infiltration as the contributing factors.

So early thrombus removal and restoration of the patency, it aims at reducing the risk of post-thrombotic syndrome in these patients. And catheter-based therapy is recommended for patients, with proximal upper extremity DVT of recent onset, and with severe symptoms, and in patients who have low risk of bleeding complications with a good functional status.

so you need to TIPS this patient. We've now evolved and moved to doing things transsplenically now. It makes a big difference. So how do you TIPS this patient, cavernoma?

A lot of ascites. Now there's a lot of different feelings about draining the ascites. I don't drain the ascites usually but here it is right here in the axials. You it's complete cavernoma. I start with a wedge venogram and I use 20 cc of contrast and 40 of saline with a 60 cc syringe. You can see my cavernoma but left and right PVs are patent.

Now how do you do this? You identify on MR this spot right here. This is the spot that will go straight out the splenic vein. So you have to look for this area here, and under ultrasound guidance, this is

the spot that you want to puncture. That's the technique and this is published in TVIR so the techniques of this is published, and here's this case. I'll show you how I did this in a second. So again this is the same person,

puncture here and again straight line. You've got to stick the right spot. You don't want to get caught in the varices and tortuosity. People have had problems with it and have had bleeds so be very careful. 5 French sheath and again remember what the observation that I learned from years ago is this is your target now,

not this. It's here and I'll zoom that in in a second. So here it is, you pull back, wire goes straight up, very straight forward. There it is.

My catheter's now through so there's my thrombosed PV that you don't see on MR, you don't see on anything else. But we're through. We pull back, we pull back and then we advance into the right and I like to do very peripheral TIPS, even in general I do the peripheral TIPS.

So here I am in the right portal vein. That's my snare, we puncture through the snare, exchange length stiff glide, pull back, pull my sheath and there's the system. I leave a short stent as I mentioned before.

Notice how it's completely thrombosed. The PV is completely thrombosed. Notice again how you think you should be drilling back here, it's actually up above that works better. This is what it looks like at the end of the procedure.

No lytics, nothing fancy, no mechanical thrombectomy devices etc. This is pre and this is post-transplant. So there is this whole narrative of the transplant surgeons being able to transplant something like this and putting in complex conduits and endovenoctemies and arterial portal shunts etc,

but the reality is those outcomes are very poor by their own literature. Ideally your target when you talk to your transplant surgeon is, I will help you create an end to end anastomosis. This is a big thing for them cuz the survivals now mimic regular transplant survivals.

Survivals of these patients are about 50% to 70% worse than normal transplantation when you do conduits. So anybody can do anything, conduits, all sorts of things. The outcomes are just very poor. Thank you. >> [APPLAUSE]

actually fairly simple. It's really really simple. So if you think of the heart extending outward you all. The right corner artery travels in the atrioventricular groove. The circumflex coronary travels in the left

atrioventricular groove. An artery comes off the front between the right and left ventricle - that's the left anterior descending. The posterior descending artery typically off the right three-quarters of the time comes off

the right coronary artery. And so what we have is a cage right. That's all it is. The diagonals come off the left-anterior descending artery. And if you actually think about what a surgeon would see when they crack the chest

they see a vertical artery that's the LAD and an artery that comes off at a diagonal. Okay so they're surgeons you know sorry for the surgeons in the back of the room but you know it's like that what else would you call it - diagonal. Ok so

the marginal branches are actually because they come around the rounded margins of the heart. The lateral wall comes off...The vessels that come off the circumflex usually supply the lateral wall and they are the obtuse

marginal branches. So they're marginal branches. There is a marginal branch on the right side. It's a right ventricular marginal branch. Or an acute marginal branch and the reason is the right ventricle is flat the left ventricle is

round. And so that's actually the simple anatomy. So you think of the cage the right coronary in the right AV groove. The left coronary artery in the left AV groove. The circumflex. Anterior descending posterior

descending artery marginal. That's it. Simple. Now the difference is however how do we correlate that with what happens when the patient shows up.

>> [LAUGH]

82 year old female with a cold right leg and she had a history of claudication. That's good information right? And the usual. A feb is I guess important to note because the question of course always is embolic versus thrombotic, right? The angiogram from the left side shows this meniscus here. So obviously a lot of chronic calcific disease reconstitutes the popliteal,

which is pretty diseased, but is open. So what do you do here? So my approach with these, if it's a native occlusion and it's acute or chronic, I'll almost always try to complete it in one sitting and avoid thrombolysis So in these cases I'll always go Spider, oversized

a little bit, five French Spireflex/g, AngioJet, buzz it. If it opens up, fix the chronic lesion. And that's what this is I think. So here we have the wire. A-Jet. That's part of the contrast I guess at some point. Unfortunately the new AngioJet catheters are not injectable.

So that went backwards. The original Monorail AngioJet catheters were actually injectable which was great. But apparently a cardiologist injected air into a coronary and the FDA shut that down. So the new ones are not injectable which is annoying.

So anyway, we buzzed that up and got rid of most of the acute clot. There're some chronic lesions here that we know about. This is a long balloon we put up and apparently there's a waste here that we were unable to open up. So we use a cutting balloon there. I guess there's many other options. Given her calcific disease, Diamondback would be probably a nice option

as well. And then we ballooned the whole segment. And actually here you do see where the Spider was. And I think we got a nice result. Might be missing the proximal segment here. But anyway, that looked reasonable. Got it back to base line.

Didn't address the tibial lesions. I don't know. Would you go after the tibial lesions in this situation? >> I've got a question for you Dan. Many years ago, I know you guys used so much AngioJet. They came up with some sort of, it's called the GuardDog or something. You remember that? They-

>> Yeah, a balloon. >> Does that still exist and do you ever use it? >> No and no. >> Okay. >> [LAUGH] >> It was basically a balloon on a wire right? >> Right. >> Yeah. Not a bad idea really. I'd consider using it if it was available.

But no, it's pretty much filters are the only option. >> You ever use the Abbott filter NAV6? >> NAV6 yeah. Almost never because it's a pain to deploy. >> But it doesn't move.

>> It probably moves a little less. But I can't put it through my 035 catheter. So you've got to go through all sorts of maneuvers to get it down there. If you're doing like a Diamondback case and you're really concerned about distal embolization then it might be worth

the trouble but in most cases I don't bother. >> And it's more expensive. >> Might be, yeah. >> [INAUDIBLE] >> Right, that's a great option. Right.

So there are several atherectomy devices that do thrombectomy as well, right? Jetstream is one, the Laser, Phenox, they all have a component of aspiration. And my favorite of those for this kind of situation is the Jetstream

cause I think it has better aspiration than the other ones but it's really a far cry from the thrombectomy you get with an AngioJet system or a different thrombectomy system. So really only applicable if the clot or acute component is small, in my opinion. Otherwise you're gonna have to break out a thrombectomy catheter

as well. But the Jetstream is nice because you can use it over a Spider. And it does thrombectomize so it's a larger catheter. I think I might have a case of that coming up. I'm not sure.

>> So next case is a 65 year old male claudicant. Again, here's something that we see every day. Distal SFA to above-knee pop occlusion, chronic, recanalized with a catheter and wire,

placed a self-expanding non-covered stent. And he did great until four days later. He presents back with a cold leg and so again repeat left lower extremity arteriogram, demonstrates here like a shelf-like filling defect in the mid SFA and an occlusion just beyond there and reconstitution distally beyond the stent.

And so what do you guys think about next steps here? >> What stents are they using? [LAUGH] >> I think he knows our proteges. >> [LAUGH] >> I find myself at this point almost never use a bare-metal

stent in the femoral-popliteal segment. Because either you're using a specialty stent like a Supera or a PTX or more often these days is avoid stenting all together. >> Mm-hm. DCBs >> So I don't dare put a regular old bare-metal stent in the

SFA. >> [INAUDIBLE] drug-eluting balloons? >> Drug-eluting balloons or is it drug-eluting stents? >> Yeah- >> And maybe sometimes a covered stent in a long case.

>> Our practice is in a lot of smaller community hospitals who're trying to fight the battle to get some of the more advanced technologies, and it's an uphill one. But we're working towards that certainly. So for this case we ended up going with Ekos again. >> Did you consider just doing mechanical?

>> Again this is one given to me by one of my colleagues, but that's certainly something to think about. It's so fresh, you could just- >> What I would do in this case is I would put a filter below it,

A-Jet through the stent. >> Mm-hm. >> And in most cases I'd anticipate to be done, pretty quickly. >> Wow. >> [INAUDIBLE]

>> A Spider like a-. >> [COUGH] So in those cases, how often do you see the Spider having caught material? >> Often. >>Often? Okay.

All right. Yeah, I've seen The AngioJet throw clot distally quite frequently. So I'm kinda wary of about using the AngioJet in the arterial fields but- >> Yeah.

What I like to use is one of the Carmody/g devices. I use the 5 French Monorail device which tapers to an 014. So you don't have a situation where you're driving and 035 catheter over a 014 filter wire. So I used the 5 French Spireflag. It still has pretty good suction and tapers to that, so I think that reduces the snow-ploughing

effect that you might have. >> So this is after 24 hours of thrombolysis. You can see there's still residual thrombus throughout the stented portions. So we like to just proceed to another round of thrombolysis. Again you could go in there and try to do suction thrombectomy or

maybe AngioJet as well. And then this is the following day. You still see persistent shelf-like filling defect proximally and here, I think you that have several options.

You can maybe continue doing thrombolysis, although this is now two days into it, you could try aspiration thrombectomy or rheolytic with AngioJet, or try ballooning it. I don't know, what do you guys think about- >> At that point I might

consider a covered stent. >> Yeah. Viabahn's probably a good option there. >> Right. So that's exactly what we did. So we placed Viabahn over a Spider distal embolic protection device

and you can see here that the vessel looks great but the Spider is filled with some embolic material. And when we went to and try to recapture the Spider, it was so filled that we were unable to get it into the catheter. So instead of dragging it all the way back into the sheath,

we ended up putting a 5 French catheter into the basket and aspirating the material and once we did that it was able to be recaptured and looked - >> The other thing you can do is try and pull into a sheath

>> Like unless you're gonna drag it all the way back through the- >> No, you put a long sheath down. >> A long sheath. >> For example you take one of those tubular sheaths which has a dilator. So here you have a six sheath,

you can put a four sheath through that. Take it all the way down to the Spider and pull it into that. >> Oh, put it in your six french sheath. >> Right. >> Got you.

>> And then chances are you can get it out through that. >> Oh that's good- >> The other thing you can do is just pull the whole thing out. I mean the way this works is once you stitch the back end, that

top kinda narrows down. So most likely if you pull everything out, you're not gonna loose emboli. But you loose access. >> Hopefully you've done- >> [INAUDIBLE]

>> You watch it but I don't think that would happen. Cause once the top get stitched down it should catch, yeah. >> So this is, as everyone understands, this is an important point Dan's making. You don't have to retrieve the Spider with it's prescribed retriever

device. And so - >> Yeah. >> It is important when the filter is overwhelmed to use some other techniques to get it back. >> Usually, I'm able to get it with a 5 French catheter but it was

not able to be pulled out using that. So here's another case. This is a lady with - >> I'm sorry. Did you, the day after thrombosis of your stents, which otherwise looked fine two days after, did you check for Plavix resistance [INAUDIBLE]

>> Yeah, I think we load them with Plavix and gave them a prescription but I think this guy may or may not have been taking his antiplatelet therapy. So I've seen that several times before as well. >> I'm just curious [INAUDIBLE]

standard. They're in the room to check to see if someone's been taking their Plavix or if they [INAUDIBLE] >> Mm-hm. >> I've heard like up to 20%, 30% of people will be resistant

to Plavix. >> Mm-hm. >> A couple of my patients says I've had issues. [INAUDIBLE] I think that's something you should be doing more or so I mean obviously when someone stent thrombosis to the leg and have a stroke or die or have a heart attack and die. None-the-less

it's aggregating to have to go after you've had to work on this guy [INAUDIBLE] >> Right. >> I've had the same experiences where I have done it. But usually it's as a reaction to something that happens and not routinely. And then I put patients on something else if they're positive. But yeah maybe we should be doing it on everyone.

But then of course what do you do then? Put half those presents on Brilinta? Much more expensive. [BLANK_AUDIO]

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