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Transcript

we're okay so some of this has been taken from the are you ready or y 90 course SR has in the winter I think we're gonna do that again this winter it's looking good it's designed to help people become an authorized user arm and if you do this I was really really

strongly recommend you try to become an authorized user it makes getting things done much more simple arm so when I see patients these are the things I worry about post radioembolization syndrome happens commonly I tell everyone to be

expect to be really tired for a week or ten days not have a lot of energy liver toxicity the liver functions usually come up and come back down about three weeks out radiation do sliver damages is a different kind of Beast will talk

about that Hillary damage is relatively uncommon secondary portal hypertension is basically some scarring of the liver from treatment of pneumonitis is the longshot that gets too high and this is what keeps you up at night is GI

complications or non-target embo most radiation post radioembolization syndrome has a relatively common thing I mean it's something you'll see in about forty fifty percent of people were there is fatigue nauseous they can have belly

pain not getting an ulcer just keep that in mind at the end of an infusion sometimes you will have acute abdominal pain on the table that usually settles out about 15-20 minutes but some abdominal pain

for a week or so afterwards is not is not uncommon and in all honesty if they have it longer than that i have a low threshold to get a scope to be sure almost all those patients do not have an ulcer but it puts your mind at ease

because you're going to talk about an ulcer before you can send them and it also helps you feel more common you know everything's ok and this was this should get better on its own arm as far as incidence and management of this arm the

standard treatment is a medrol dose pack which you can repeat one time if they are diabetic be very very careful this this the screws this blood Sugar's up unbelievably you'll take someone that

they may have the TV at that point cause of blood sugar 400 nevermind the radio Radio embolization syndrome so if that's the case i give it to my talents like a break glass in case of emergency set up the other thing they go home with from

us is a proton pump inhibitor which they start three days before the infusion not the mapping but the infusion and start keep they stay on it for about a month biliary complications are pretty uncommon this does not include abscesses

in people with Whipple's this is a study from Northwestern this is glass and you see great 34 liver toxicity is about 6.8 ten percent that's kind of what we saw Jefferson we studied this arm and this is this is actually our paper from

Jefferson where we had some kind of toxicity mean great one or higher this is of liver functions in fifty-eight percent of people we had about five percent rate of great three toxicities in the one rld patient most

of these people did normalize completely back down the baseline normal labs in average about three or four weeks again that might argue to wait six weeks if you have the time to do so let's really get their legs back under them as far as

the docks this is a little bit of a higher number than I would have expected i don't think it's the lice device-specific I think it's just one of those things but you know you know by llamas are not really

common in my practice I don't know if you've seen a Bilaam instance about ten percenter like that it seems a little higher what i see so not very common in our i have had a patient get cause you know that his gallbladder out and have

microspheres in it so that can happen just you know try to be careful that and this is an example of bio- this is from wash you with a big metastatic adenocarcinoma and went ahead and treated it and just an enormous bilo

machine bloating three weeks later otherwise no symptoms we actually drain this and it would not shut down there was a officially the doc they try to your CP sphincterotomy and it just wouldn't shut down so eventually

we actually put a catheter down through here made this into an external external internal external drain so she can at least be capped off and not have you know 400 500 CC's a day out through the tube Patrick fibrosis is something

Riyadh has been talking a little bit more about this year where several years after treatment you can see continued change the liver volumes this was first noticed in 2008 when they noted that if they treated the right side not the left

the right side tend to shrink and the left side grew and they also secondary changes of portal hypertension where the portal vein diameter would increase in the spleen volume increased as well I talked about patients came back to

clinic with society's why I would always take a quick look at their spleen binds make sure their spleens were rapidly expanding cause that's something I was worried about nobody in this original descriptive study had clinicals equality

portal hypertension meaning specifically bleeding arm that being said we can exploit this a little bit this is a patient with the right multifocal hepatoma was originally referred for your vein embolization and

talk to our surgeons and this is like right on the right portal vein hyland i thought maybe trying to kill the party really would make sense to try first and what we ended up doing was the right lobe

fore treatment the 1280 post so it decreased by 250cc volume and the left lane expanded was over 51 percent of the total liver volume afterwards this patient was then eligible for a

hepatectomy and you may have heard this described as radiation go back to me it's effectively what we did here to help get this guy set up to to get curative surgery pneumonitis I want that take

was it how long did that take I took about six months and you know i think if you want to just pop up if you want to I particular look quickly portal vein embolization still faster I don't want to falsely advertised

anything but this guy i thought this thing was going to go into his portal vein by didn't try to kill it and I thought that if it vascular invasive HTC is a bad actor and we'll come back really quickly

after surgery so that's how that decision was made there this is something that's kind of new we're still figuring out who's best served with it abstract session yesterday it seems like it like Mount Sinai for the htc's are

doing more radiation a lobectomy is because you're not me a chemo anyway in this erotic sex it's a little tougher to make the future liver and growth portal vein embolization whereas colorectal they're still doing portal vein

embolization everybody i think it's a pretty reasonable strategy Kevin tell you that lobectomy not not with already be okay our radiation oh I'm sorry so on the northwestern group with glass

microspheres it just for the record my practice is primary HTC gets their sphere glass microspheres Nets get service fears or resin okay that doesn't mean it's that's not the Bible ok you can do it is number of people doing any

different things so I don't want to think that's a that's me saying that's the only way should be doing that but that's what we do the northwestern group had a paper out this past year I think with a look at

radiational back to me so 44 therasphere your typical dose will be a hundred twenty gray that's your target does she do that over volume i'll go through in a few minutes for the radiation a lobectomy series their target dose to

the to give us a hundred eighty they did boost a little bit arm and I don't know how that was determined prospectively retrospectively this is like we get away with this they bumped it up higher island of the exact details of that but

they were jumping the dose of little bit when they did that so we at the end of a whiny mapping we do get a l.a inject ma the patient goes nooks for a luncheon fraction on the current to cemetery models are pretty much automated to keep

you from causing this problem on the maximum recommended doses are 30 greater treatment some people suggested you can go up to 50 gray over several sessions the the residences for ifu says that you want to stay 25 gray or less

this is a real going back and looking at the patients that they treated multiple times and found 58 patients who had gotten more than 30 gray cumulative dose and had followed chest x-ray CT is part of their cock illogic follow-up 15 had

some kind of pulmonary visible imaging change or abnormality but only clinically only great one toxicities were identified so you can possibly push this up a little bit higher again starting out you know be conservative

and then you'll get comfortable with the technology before before pushing too hard there's a couple techniques that have been described a decreased lung showing these are pretty much all anecdotal so

this is a really high lung shan fraction 29-percent where the UCSD guys did keep mobilization to decrease the long Sun fraction brought the patient back there still viable tumor and that but the fraction was down to ten percent

afterwards for the record when I do do the lung shan fraction i calculate the dose like I want to give it and I look at the exposure to log ok because if you're doing a segmental infusion and you have a 20-percent lunch infraction

doesn't mean the ones going to get 30 gray right because that the whole thing about cutting down based on percentages which you know some people do is to me to protect the lungs so check and make sure the lungs aren't going to get hurt

if they're not gonna get hurt and i think i need that full dose to have an effective treatment that's what I do you just know you're going to have maybe 15 is that 10 gray but neither of those is gonna hurt hurt the patient with her

locks so just keep that in mind this is a really interesting thing we're done by the australian groups where they put a balloon up in in in a paddock being that they were getting a territory they're refusing hoping the spheres would stay

put when they put the balloon up the longshot did Rob at preliminary nuclear medicine they were able to do it I'm gonna talk about not non-target his ulcer right this is where he ends up in the stomach or

duodenum on you know the second patient i ever did with this got an ulcer and it was miserable the guy end up with the judging ostomy catheter and it was a mess so really be careful the mapping study

to me is the most of the work for this you know I I tell occasions the mapping side be an hour to an hour and a half and diffusion should be like 15 to 20-minute each because this is where you put your sweat in so when you get to the

actual fusion you're not stressing out worried about what you missed something this is no historical with external beam radiation 40 greatest stomach but you know with us where were the microspheres getting there is a symbolic effect as

well remember that the arteries the right gastric in GTA they go through the serosa and penetrate down to the mucosa so you have to have a pretty good penetration day to get all the way down

to get an ulcer but once it gets there it's really tough to get rid of this is a proper paddock order paper this is not from Stanford this is a different program where they did infusions from the proper paddock artery and the right

gastric artery is very important to this comes off the left hepatic artery probably about thirty-five to forty-five percent of time so if you have an account for that right cast recording injecting the proper your-your-your that

could be very troublesome ok and this paper they had you know 29-percent ulcers in this in this patient group most of these were in the pre pyloric stomach which goes back to the right gastric territory this program shut down

their operations after this they did this the Qi State shut down they just recently started doing this again like a year or so ago in six years without the ability to do these procedures another paper with no routine immunizations done

and patience 3-series severe officers one of the things that's important on this is none of these people had positive post-procedure spec studies for the GI tract so to me arteria grams and the experts et's I get

on the table are the important the important part of this I don't rely on the news part of that the only thing the new study does for me is lunch infraction I do not rely on that for GI contamination arm GD

embolisation you know if you have to you do this is like earlier in my career I was analyzing everybody you want to take this thing all the way up to here this is before i was using detachments now I would stick a detachable coil on their

arm I used similar stuff than I i actually Mickelson usually from my base cap and put a no 27 microcatheter in and and four coils always pushing was to start 185 word fiber Pusha balls and then detachable we have a couple

different options on the shelf I don't realize the right gastric artery and everybody but if I am NOT I am very very sure where it is before I put y 90 the patient so this is one where comes off the proximal left hepatic artery

this is a common thing there's a we talked earlier about when do you analyze these patients i am realizing that mapping for this reason getting into this vessel like this can cause a lot of spasm it can be a real battle and then

at the artery spasm down you probably have a harder time pushing all your microspheres and the time of treatment and if you get stasis your risk of also goes up as a possible reflux so one of the things you'll see

you know if you injected vessel you're not sure if it's going to stomach or not you inject it you will see drainage into the portal system the liver doesn't drain the portal system so if you inject an artery and it comes back into the

portal vein it's going to the gut somewhere ok and you want to embolize is the key to this is my zhing it close to the left of paddock artery not if you realize it way out here and

outputting coils back here not necessarily doing the right thing this is off the GDA right off the traffic ation here this is another common spot to look forward to see I've heard it's called a Kurdish a defect we

see these arteries hanging off it again selecting analyzing not that big a deal this is a little tougher so when you have this kind of thing doing like a 270-degree curve sometimes there are some angle

microcatheter is now which will use a little bit if this is turning into a struggle i have a very low threshold to select the left gastric and just try to flop a catheter and wire around here I'll up if I'm gonna do something like

this i'll swap out to 1024 smaller microcatheter and this looks bad but it you know the guide where sometimes a path will just follow the path of least resistance and gets out there sometimes it's harder but once you get the wire

out you can actually put a bunch of it into the right a paddock artery that will help you get support to get your microcatheter around and go ahead and memorize this is the second case I ever did that I talked about and in 2015 it's

very clear yeah I look at this and in kick yourself now but I mean that I didn't think this was the right gastric artery the time I made a major judgment error in judgment on you know i usually get one expert CT

over the left lobe just to see if anything's going outside the liver to the stomach and the other thing is once a while there will be a small falciform you may not have appreciated if you're you know if you're working quickly so

this got filled up and this guy got messed up and this is his EG say bye to their still spheres in the stomach this was a mess and so I I'll tell patients in clinic and the neuroendocrine population were planned embolisation you

know probably just about as good if I'm worried about treating the left side and the right side is ok i might be why 90 in the right side blamed embolisation on the left I don't think that's that's in an

appropriate way to go armed as far as refluxing and ending up places where you're going to go this is an HTC patient you can see the right gastric artery here we can we map this patient we put our microcatheter all the way up

to this bifurcation point i injected this about three or four cc's of second when we do therasphere infusions and we inject you know pretty much slower net you want to do 320 see pushes over three minutes so it's a pretty slow steady

injection we did not have a drop of reflux during that and so I decided that we did not need to analyze this right gastric artery in and the the way I talk about this to my fellow citizens I call this the landing

zone you know if it reflexes really easily here you better do something about this but this guy if these things are so vascular and such as something just pulled everything out this is another patient this patient actually

got a wine glasses welcome to the HTC his right gastric here but you can see it's still filling with the microcatheter about where we want to put it in this segment for artery i do not do a lot of Interior liver

redistribution I don't know how well that works and there seems to be a little bit of magical thinking with that arm this was a tough angle we actually ended up this is a coil that I tried to push

in there my catheter flipped out so we brought this back and put a detachable in arm if I'm a little worried about where things going to end up all use a very short coil to start because if something bad happens with a two-minute

2 centimeter long coil it very very rarely will box you out from doing the entire procedure if you put like something 14 centimeters long like a like Nestor something like that in there and it pops out you may have just ended

the procedure the possibility that patient getting treated and this is the coming back we used to know 24 microcast and put some detachable xin here and we inject you can see the coils been there a week and a half and didn't cause any

problems whatsoever able to go ahead and treat sometimes you just got to know when to bail this is a segment two branch arteries to liver then you see these curly type torturous arteries up here later imaging

it looks like a navy stomach the stomach the liver doesn't go all the way up in the left upper quadrant like the stomach does so we called these off with a bunch of coils and doing this now i would start way way way out here and coil back

further and the patient came back for infusion week and a half later and it already collateralized around the coils was filling the gastric artery again I put some more coils and I went all the way

back to hear it was still collateralized we stop this is not this this guy's not getting 194 going to dosing is any questions in the last few minutes anybody somebody alright so I'm gonna give a couple

examples of dosing so just remember from my previous comment any previously i use resin / service fears from that's so that the for metastatic neuroendocrine tumor the things that go in the dosing gonna show you the form that we use in a

second which makes life pretty simple you need to know patient height weight you need to have a liver volume an infusion volume and the percentage of the infusion blind that's replaced with tumor so this gentleman each of these

little orange circles is a 100cc tumor so this gentleman is five 780 which does not exist in Nashville as a total volume ght love 1600 left loves 600 500 CC's tumor on the right 400 the

left need to know the luncheon for this as well get seven percent long shunned we're going to use the right lobe and then the left lobe six weeks later so this if you google smack smac surtex you will have this app pop-up which you

can put on your favorites or whatever and this is this is plug and fly ok so this guy's 5 foot 7 67 inches you guys hide his way total volume so if you want to see how much you gonna give total this is

totally vol nine hundred species 400-500 longshot fraction at one lunch infraction 7% estimated lung mass for every single person has not had lung surgery I put one kilogram some people ask if they've got COPD change that I'm

not smart enough to do that if they've had a pneumonectomy I you put it down 2.5 alright so the right side we're going to treat 1600 CC deliver 500 CC's a tumor and so we do this 2216 hundred 500 yet 1.49 get back rolls

ok that's right that's your infusion dose for the right side left lobe 600 cc's live performance these two more everything else same 0.65 gigabit girls which makes sense right so much smaller part of liver so what

you'll find from this when you calculate all this the BMI actually have is the predominant source of the dose on this more than the liver tumor blind you just mess around with it you'll see that uh next patients colorectal you can see the

values here you know that's not going to change this is someone who's had every chemo drug known to man ok launch Hakeem we talked about dropping dose on this so so I'm sorry so he's got to write arteries here one here

one here and the GDA comes off in between so what you can do with resin microspheres is will coil this off obviously but we infuse we're going to use this artery here and then want to take the dose it gets delivered comes in

23 get backers vile will split that into vials and this the second one's gonna get done right about here so these are the numbers right loves 1900 cc's you see the volume of each of these things I dropped the dose on on

this patient 20-percent this is anecdotal all right there was a survey paper like multicenter survey Andy Kennedy was on it reopens on it and they said a lot of the take homes that visits actually a consensus document how to do

this stuff and there's commentary in there that many people will drop those twenty percent in people with heavy chemotherapy pretreatment so that is on this app and when you enter that so we enter everything else put twenty percent

in here and it goes from on the anterior segment from 1.4 0.83 posterior segment 4.85 2.68 so this will drop that for you on there if you're worried for neuroendocrine have not had any chemo I don't do any dose reduction whatsoever

ok but when someone had all kinds of chemo breast cancer comes in they had 85 different regimens I i have a very low threshold do stuff now alright so are you calculating these volumes are you actually calculating

them individually are you estimating dividing land no she considers me a friend like you coming with volumes but uh but we have a CT tech that uh does a lot of the stuff for us just to show you pneumonectomy

cases metastatic lung cancer Robo six-foot-three 260 pounds left pneumonectomy see all the other volumes your high lunge infraction so this case is a couple other other features here

oops we're going to drop the estimated lung mass down 0.5 all this other stuff been entered the way we did before you'll see the total activity here 1.94 and there's a there's a little red highlight here it says the activity has

been reduced ok this the app here will actually reduce it for you to keep you from hurting yourself and somebody else this this equation let you calculate how much actually goes to the lungs not that I do

this for entertainment or anything but with this weekend with this dose we find that we get a total lung dose of 23.5 gray so that if you're a treat somebody multiple multiple times you probably want to know that just accumulate make

sure you don't go over a lifetime high dose but you know this will reduce the dose for you for a single infusion to make sure you don't cause harm 30 the thirties generally considered that the threshold

that's 30 / 30 great for treatment but 50 lifetime but yeah but the that's constantly evolving you know I mean so see let's do it let's go through so there appears a little bit different in that it's not about the volume of tumor

it's just about the volume of the liver that you're going to infuse and you want to give that liver us set dose to that whole territory to the theory being that the hyper basket tumor will suck up more of it than the non hyper vascular you

need to know the function fraction as well so one of the early papers on this from about 12 13 years ago the first 15 20 patients were treated with doses of 7505 gray next group retreat somewhere between a hundred ten 230 or 40 the

latter group had much better response so that's kind of where this hundred twenty great came from I'll talk about heavy dosing in a second remember you don't need to know the tumor going for this so I don't really

care what these represents so this is the plug-and-play version for glass microspheres and target volume that's your liver volume desired us around 720 x invariant central time zone so it's one hour lunch infraction of 4% it

anticipated ways it's a one-percent to fall just like put that for everybody and then you punch all this in you get different numbers so the way sir Spears is delivered comes in a vial the nuclear pharmacy will actually pull off the

appropriate amount for the bball that you then infuse their spears gets delivered on monday and sits on a shelf and decays to you get it to where you want it to be so you can do treatment you can technically treat money tuesday

wednesday thursday friday but you have to make sure it's got the right activity so if I'm gonna infuse a big right lobe I'm gonna want a lot of microspheres and that because otherwise i don't think i'm gonna saturate everything ok if i'm

going to do a very tiny subset metal fusion they want to read with your microspheres ok so by calculating this we found that we wanted to give an activity administration of three-point 64 gigabyte girls

ok so he's come in different sizes vials you have 3 5 7 10 15 20 and you can order custom so if i have a five-day Becker vile and it shows up I could infuse on monday at delivery and then I'll get me the right activities are

given my hundred twenty gray another alternative if it's a great big void that you're infusing it may be more appropriate to treat on a Friday so I do actually most of my infusions on friday why wait let it sit to the second we can

do it on monday of the second week I like having I want to have a lot of fears going to saturate the tumors because I worry that there's not enough particle sometimes this is I think it's my last case so you've heard president

talked about radiation second attack me the northwestern group talks about this this is where you only need a small infusion so they just 275 cc's a total liver and what book will boost the dose up on this to 200 gray or something

sometimes even higher just gonna make it work because it's it's a fraction of the whole liver point so you know I first became an authorized user the new Connecticut endings were double-checking my work and making sure his quality

thing which is fine i realized that i was getting rubber-stamped when I did a segment ACTU mean somebody got 320 gray to like a 150cc volume and all sudden after the case was over I got a panicked call from one of the nuclear attending

st. you really want to do 320 gray and I'm like yeah it's ok you know so thats that's when I realized that they were trusting me least up to that point so hope anyway same kind of stuff you see 275 cc's behind etcetera this is all the

same and we want to give 1.8 giga becquerels so doing this you know with a 200 200 great target you can see we can do a three go back well monday or tuesday but you see how this spreads out through the week where you can do a

second week treatment if you want to and and do it like the second weeks is this is just different ways to play with this it's it's probably a lot to absorb here in a workshop setting but really not that complicated once so i'll

stop here any other questions weren't we can go on the cabin slides and any questions they would get their face melted butter the the 14 sir texts called the smack out smec their spirit when you are

distributing have to get IRB approval for when you get that they will give you the excel spreadsheet show you calculate

patients with pregnancy-associated DVD should be treated for the whole duration of pregnancy from the time of the

diagnosis of BBT until the postpartum period of up to 12 weeks as they're still kind of having pro quietly and difficult during that state and as long as the the the front body given to still present or whichever is longer you

should continue up to 12 weeks in the postpartum period not just during the duration of pregnancy and the treatment of choices is subcutaneous low-molecular-weight heparin and it for the paradox Eric's

that can be used in these patients but in patients with severe reactions to happen that is the only choice available for you a double-wide using newer anticoagulants there's no consensus on that there's no studies as of now

available on that recurrent dvt in spite

well that's much it thank you can we have the questions

of anticoagulation which is very commonly seen in patients who have recurrent dvt on warfarin therapy is being in the therapeutic range are on any of the newer anticoagulation and you

believe that their complaint with the medication it is suggested that they can switch to treatment with low-molecular-weight heparin at least temporarily with a great to see evidence and in patients who have a referent dvt

on long-term low-molecular-weight heparin and if you believe they are complaining we suggested increasing the dose of the low-molecular-weight happen by about one-quarter to one-third with the low-level evidence of great to see

extremity dvt how do you do with the investigations are sound diagnostic

criteria set usually proximal compression sound is the first morality and if there is compression or sound available we can compare it with the previous one that is suggested for us and if not you can do

d-dimer I say first and then do proximal compression or sound if that is positive the different findings including compressibility of the previously normal segment vain ordered an increase in diameter of the compost segment of the

weigh-in with a document promise if there is increasing the length of the trembles when compared to the previous on by five centimeters are increasing the diameter of the compressed Wayne x equal to or greater than four millimeter

then it's considered positive for reference and in recurrent dvt if the sound is negative we are supposed to do a serial testing in one week with repeat our sound are dude I'm are testing if the sound is positive then treat the

patients with anticoagulation and if the other sound is non-diagnostic but abnormal in recurrent dvt that is like if it is abnormal and the deep cut extension of the vein is like are the size of the main is not greater than 2

millimeters but less than four millimeters then you should recommend contrast monographie our cereal proximal to sound are possible d-dimer so these are all recommendation from the accp guidelines from the 9th edition which is

back into the fold this diagnostic part in patients with abnormal artists on findings in recurrent dvt if prior to sound is not available for comparison then again do of the contract monographie are d-dimer if the d-dimer

is negative no further testing is needed and if the d-dimer is positive then go ahead and do contract with toffee this is one leaf or recurrent dvt sounds a little bit busy and confusing but when you look through it

come quiet it it's pretty easy to

differentiate them from elliot green dvd-r compression from the uterus causing the deep venous thrombosis then if they show signs of swelling of the

entire leg with or without Frank the butter car back pain and there is no evidence of deep venous thrombosis in the proximal ultrasound compressional sound then they should get a mr monographie are either directly

interfered operates out of the equations to look for any activity approximately

this directly from the website saying inpatient acute EVT of the leg we recommend against the use of a filter in addition to anticoagulants which is

reasonable that's great when we evidence in patients like you approximately BTW of the leg and communications anticoagulation we recommend the use of ICT filter so this is in line with our

guidelines also it goes on to say in patient with a Q proximity of the leg and Ivy's filter place as an alternative to anticoagulation we suggest a conventional quarter of anticoagulant therapy if the risk of bleeding resolved

evidence great to be we do not consider that opponent obviously filter of itself is an indication for extended anticoagulation that's why hopefully a patient with a filter and with BBT and if i want to know whether patients say

on integration or not I usually further paid into the hematologist let's look at

which of the following is true regarding the use of obviously filters in pregnant women with dvt filter placement should be routine in the peripartum period for

c-section and vaginal delivery saporito position is indicated due to lower risk complications see indications for placement of the same as in the non-pregnant population d is increased rate of legacy for the complications in

this population compared to the non-pregnant population right times that now ok good so the answer is C indications replacement of the same as in a non-pregnant population like that people

refer to look at a hundred twenty-four patients and look at the overall thing and it seems very similar to the general population all right good okay I'm gonna go on to my next talk now

involving the actual more proximal rains it is suggested so it is not recommended it is suggested to do anticoagulation

rather than trumbull aces and in patients who undergo trumbull Isis they should undergo the same intensity and duration of the anti correlations in patients who do not undergo a humble Isis so if the patient has a central

venous catheter associated different rumbles it is suggested that anticoagulation is done without central venous catheter removal and if the symptoms failed to resolve or period then the CVC mobile can be considered

again it is suggested that the anticoagulation should be continued for at least three months are for the duration in which the central venous catheter is still present whichever is longer and at least three

months of anticoagulation is a property in patients who develop upper extremity DVD associated with pacemaker wire in patients who have drastic outlet syndrome or pages shorter syndrome which is related to approximately duty

thrombolytic therapy followed by surgery has been advocated but an optimal approach is still not clear although most of the people tend to follow doing a traumatic to be who our page sorter syndrome and then followed by surgery

with the scaling ectomy for stripper section in addition to traditional anticoagulation pregnancy-related dvt

on where these medications and how they act is happen and low-molecular-weight heparin unfractionated and elements lmwh act through antithrombin based McCann is Amanda clotting cascade at different

places and it proved ins the trauma information and war finax to the extrinsic pathway of the coagulation cascade and acts on these different factors by preventing the five information so that is for the

traditional anticoagulation then we go onto the newer oral anticoagulants are also cards noa sees there are direct inhibitors of coagulation and they have single side of action unlike the heparin and warfarin which have different sites

of action the derrick or fact enablers are these and then the Derek Dominator is Debbie get trend there are pattern to direct a time and individuals which we'll talk in a little bit and those thing acts straight here they are

patterned legends and not all agence and

pregnancy this month gir actually last month now much gir there was this article that I thought was very interesting well done they

review and 24 pregnancies with accuracy for replacement for DVT and what they found was there was no evidence suggests routine use in packing patient with dvt again use the same communication so i use the same absolute contraindications

in nonpregnant population was super interesting location location can be used

about the guidelines for prophylactic filters have a few out there the accp guidelines do not recommend use of

prophylactic filters at all the trauma guidelines says it's indicated in high-risk trauma patient cannot receive anticoagulation csir guidelines i said already picking a high-risk cannot receive anticoagulation and the

bariatric society guidelines for one at least say that uses like the filter is only method of prophylaxis before bariatric surgery is not recommend it but they do recommend it in patient who are team at greater risk for the really

complication so in the updated backed off a little bit you know they said there's no class 1 evidence and they don't even mention filter used in that patient population at all

they recommend all the type of prophylaxis so in conclusions i think you know patient in dt with dvt and who needs a whom i needed i see filter you need to approach them individually use this SAR guidelines as a reference for

patient with dvt I tried to stick it right as much as possible but you know once the item will deviate and if you deviate you need to have a reason why prophylactic use of thought is very controversial and retrieval filter

should be removed as soon as possible

where amputations in 15 patients and the correct amis in 13 there were also seven pro Cedars surgical procedures because there they were our significant complications bleeding complications that should be treated surgically at 30

days there was one death associated with from bhalla an amputation in 15 patients representing 4.7 personalization amputation free survival was 95 persons at 12 months we have available data from 199 patients representing 87 persons of

229 with 22 amputations and a death that we are not associated with mechanical therapy amputation free survival was 85 persons major complications occurred in

pick one study that we look at all the time people before this study quite a bit and what did it show it show a lower rate of P in patients with IVC filter

implant compared to the group who did not at 12 days however two years there was no difference in the incidence of PE or survival rate so what does that tell us why we say you know suggest that there may be an advantage to using the

people filters but that's from you know and I our perspective the pic one follow-up was an eight-year follow-up with results for the filter patients what show was there was no survival benefit the filter patients are more

likely to get tvt however they are less likely to have PE and you know you get questioned whether that moderate amount of less likely to have PE is a enough reason to put in filters and everybody the perfect two studies of more recent

study try to show the effect we will filter what they did was it was a multicenter non-binding randomized control study involving three and nine patients with acute symptomatic PE pvt and at least

one criterion of severity our patient i'll probably six months and patients were randomized to receive a filter with intention to retreat at three months so for the filter group they were underneath refilled insertion and after

three months the 153 retriever which is very very good little bit here so the study here shows we look at different variables and if we could look at the p-values obviously they were very similar and so no statistical

statistical difference in recurrent PE or mortality in the two groups so what does this tell us they conclude that it's finally do not support the use of this type of filter in patient who can be treated with anticoagulation let me

ask you how many of you would put a filter in patients who who is already anticoagulated and women fell anticoagulation are not too many rate so this study you know it doesn't get filter but it's a rather indirect study

so what do this

trauma inhibitors are they are very useful in hit patients as they do not

bind to the protective factor for and they are usually used in the inpatient setting and there are few of them which you can talk a little bit quickly and by valladine just used commonly in patients who are

either hit positive are allergic to hit allergic to happen there's a synthetic peptide which binds to the thrombin at the factor 10 to a level and it inhibits the enzymatic activity of trauma and the dosages point

75 milligrams per kilogram bolus followed by 1.75 million times it has a short half-life so if you're going to do a procedure with patients on that you just need to stop it for an hour before the procedure can be done you can be

monitored with activated carding time and PT are getting man is another director manipulator it half-life is also small less 42 a few minutes and it needs to be start for a couple of hours before you can do a

procedure the dosages 2 micrograms per kilogram per minute infusion it is usually done some modification in patients with hepatic impairment because it is done it is utilized in there in labor and it's very useful in renal

insufficiency patients this routine not commonly used it is mainly used as a Trumbull powerful axis but not for treatment purpose again the flavors chard and it inhibits Derek free and Clark ground ramen and B it's not

commonly used in the treatment part of

want to send a couple minutes on this to make it complete fucking use the filter

is using patient without currently te who are considered high-risk so now how do we know which patients at high risk the medical patients at high risk and the surgical patients at high risk and one of the risk assessment model that

you can use for the medical patient is called the module production score and what you do is you assign patient score 3-2 on one based on what they have and then you add them up and so the Wonder at high risk for a greater and the one

that a little wrist have a score of less than four so in this study what they did was they identified through patient and then they did a study the high-risk with one group received prophylaxis and the apt great was 2.2% on the other side

without prophylaxis the btu group was eleven percent is quite significant so you have a patient medical patient you want to know what kind of risk they have you use this score and then the for surgical patient what i like to use the

previous capri score and completely model to previous a chicagoland surgeon and you have signed a point value for each risk factor set up the score again so here's a sheet that you can use you can pull it off

line just check off the box and add up the points and see what you can come up with so incident rate risk level if you have more than nine points your wrist 6.51 compared to less than one if your wrists

very low so the cumulative incidence of VT by risk or you get 10 above it approaches a hundred percent so what

SI our guideline tell us they say that we should put filter in a patient with dvt who have fell anti-regulation and all who have complication of anticoagulation or in those who cannot

receive anticoagulation due to communication we have a few of the ones but in the protective category is also recommend that we use filter in patients who are at high risk for PE who cannot receive anticoagulation and then for the

suprarenal field replacement always want to point out that in patients who are pregnant supereeego placement is also appropriate in woman a bike childbearing age just make note of that because i get back to

which of the following statements

regarding diagnostic imaging studies is false in deep venous thrombosis d timer is considered as nonspecific but sensitive biomarker for venous thromboembolism duplex penis monographie findings of Defense thromboses are non

compressible lien which has echogenic material absence of floor color doppler had one page of CT monographie include ability to diagnose publican iliac vein thrombosis and can be done in conjunction with sleep already and

geography to increase the sensitivity and the last choices current guidelines recommend the use of CT and MRI navi for suspected first or record lower extremity DVT and your time starts now sorry start well that's great and

ninety-six percent of the people got it right which is the current guidelines do not recommend the key news of CT and MRI monographie for suspected first because the initial test is usually a d-dimer SI and then based on that it goes on to

other mostly proximal compressional sound based on the DMRC research and if democracy is not possible then usually proximal compression or sound is the first choice of imaging done in these people

ok

thrombosis early manifestations like swelling acute pain as we just heard the first line treatment is going to be anticoagulation therapy really what the

goal is for the anticoagulation therapy is to prevent either pulmonary embolus or propagation of the clot it really doesn't do anything to treat the underlying clock that's already there you're relying on the patient's own

intrinsic mechanisms to break up the clot that's already there because you're relying on the the patient to break that up symptom improvement of their DB T varies from patient some patients improve on anticoagulation therapy after

a couple of days some patients take several weeks to get resolution of their symptoms the difficulty walking and the limitations and returning to full functioning and activity in patients who are symptomatic from their deep vein

thrombosis the longer it goes on the more it impairs their quality of life and go looking at the veena Graham you know the acute plot setting you see extensive clot within the vein this patient is getting ready for a catheter

treatment those patients who get anticoagulation treatment only for their penis clots can end up with some of the

that's the mainstay medication for most of the patients it's a cheap and there are issues with it but it is basically a vitamin K analog and antagonists it

interferes with the videos vitamin k-dependent carboxylation mechana sins of various wagland factors including 27 9 and 10 as well as it has actions against the anticoagulant protein C protein s the dose is usually for 25

milligrams orally daily are sometimes basing on the patient's inre it's are just a little bit and it is usually monitored with patients will come in time and internationalized normalized ratio with

the therapeutic range expecting it to be between two and three in all the patients antidote so far our friend is vitamin K at those of one to ten milligrams IV or a record 20 to 30-minute period it is usually

introduced along the with the other a parenteral agents on the same day when the treatment is started and it should be continued apparently should be continued for at least the initial five days until the inr reaches to and then

the parent electrocoagulation can be started in the patient discontinued on water that's very important

the newer anticoagulant order agents are there are two classes available one is the direct ramen inhibitors and one is

the direct factor 10 individuals they are all oral medications and we can talk about a little bit of all these things it's pretty busy slide these r WK train which is a direct ramen inhibitor these three medications are our direct factor

10a inhibitors the wa time is a porter but the rest are all night and there are few things which you should be aware one is the patient interrogate ran it is not metabolize the liver better renal excretion constitutes a tea person or to

need adjustment in patients with renal insufficiency and one side effect it has dyspepsia this important but the rest of the direct effect any brothers do not have the side effect and in patients with topics a man it is least excreted

by renal so it is good for patients who have some renal insufficiency those are the painters there the dosing again Debbie get trend that we know studies done with a be a trend factor the drama individuals which is the direct one so

it is usually started after happen is given initially for the first five days and then you or lab this and then give it and that and for apixaban and drive rocks man there are studies with amplify and record trials where they're being

started initially from day one for the treatment that they're down bellow so they can start using apixaban dr rockso by an hour of these factors anybody right away but it rocks abandoned there's no trial using it as a single

agent from the starting treatment of DVD so you can be used at that point and later the doses are according to the patients need and the antidotes for these newer anticoagulants are in development and there's some exciting

news coming one of the antidote which is practice mind for products are WK trend is approved but we don't want to really get to that point where the patient is bleeding and you need to use these things and there are the and excellent

design of the 14 fact anybody still not approved but a lot of places in Europe was just using it and they specifically acts to reverse just the anticoagulant factor of activities of the 10 nanometers and it has some action

against the low-molecular-weight heparin

mechanical Catherine director formalizes for iliofemoral dvt when is the IVC

filter placement indicated a always routinely be in a single session PCT where the risk of parameters and its high C impatient the bloke cardiopulmonary reserve d b and c times that now

alright very good so the answer is d b and c obviously it's not usually only use it when I think that the patient is at high risk for DVT sorry for PE but in patients who received from oolitic a lot of the tunnel is closed circling around

and it's unlikely for you to see clinically evident PE next question

well that's much it thank you can we have the questions falling is false regarding medical management of BBT low-molecular-weight happen is the treatment of choice for DVD patients with end-stage liver renal

failure sorry that is choice a during long during long-term anticoagulation with coumadin warfarin and inr between is recommended as higher ratios do not increase the effectiveness and lowering his do not reduce bleeding complication

fact in a inhibitors and Derek commentators are not approved for prevention of record dvds following any shield therapy energized d is a and C 1 Lee and choice E is a B and C 1 Lee time starts there

little confusing with two questionnaires I guess so the answer is d which means the false statements are a and C low-molecular-weight happen is not treatment of choice in patients with end-stage renal failure because happen

is really excited and it cannot be used to simply and it is not the treatment of choice is the statement was right so they're not be part of the answer and factor 10 8 butters are approved based on the newest recommendation guidelines

for treatment of our prevention of record dvds following the initial therapy so let's move on to the next question which of the following anticoagulants is considered first line for long-term therapy for patients with

active malignancy chose a and fractionated happen choice B low-molecular-weight happen which I see dr rockso van choice de Coubertin choisi any of the wall time starts there

yeah lot of people got it right it is low-molecular-weight heparin which is supposed to be based on the studies available and trials that is the first choice medication for patients who have active cancer and none of the other

medications and really do well in those subset of populations next question

a case here 50 your man official DVT and PE despite anticoagulation we probably had our viewpoint that patient like this had a filter place one year ago private

presentation patient presented with shortness of breath and tachycardia nset was obtained which showed multiple bilateral pease that we see there so we get a villa Graham that show the filter has migrated from it in for me

opposition and now it crosses the renal veins and the a lot of clots in the actually as well so you know let's say you shown this case in court and you know you asked whether the clot called migration of the filter whether the

filter move that's why your PE it's hard question the answer so what we did was we went ahead and place another filter the law just to make sure that its position with the intention of taking out that the upper one and patient heady

equals thermolysis of the PE and also the plot in the icc was also manage life back to me and the filters filters now I kind of like one with the other they both move so we took both of them out and then we put a new one down

below with pretty decent result of affected me so what about filters in

extra are funded by knox is a synthetic pentas a curated is similar to low-molecular-weight heparin and it inverts factor 10a the plasma half-life is longer 17 to 21 hours and the typical

those is a daily subcutaneous injection based on the patient's body weight if they are five milligrams those for less than 50 kilogram and 7.5 450 210 milligrams or hundred kilograms it is monitored with auntie 10 a factor is a

and B because the PT and PTT levels are insensitive there is no known antidote forefront of paradoxes of now parenteral direct

please regarding the duration of anticoagulation therapy she was talking in the last few slides which of the following is true chose a in patients

with deepest traumas RP provoked by surgery recommended duration of anticoagulation is six months if there is no suspicion of records of risk factors choice be in patients with unprovoked DVD the recommendation is to

create with anticoagulation for at least three months in play and see is in patients with pregnancy-associated d treatment should extend to the second and third trimester pregnancy 1ly choice D in patients with the DVD of the lake

and active cancer the recommendation is for three months of anticoagulation therapy if there is no hi bleeding risk time starts now which of the following is true great so been paying attention

eighty percent of them got it right as a actually you don't need to the recommendation is not to treat for six months especially if there is no suspicion of Records as factors it's just three months is required and the

choice B is right in patients who have a pregnancy-related DVD you know we should extend it to the postpartum period up to 12 weeks that's important not just for the second and third trimester and interactions with active cancer they are

supposed to be on extended indefinitely are lifelong anticoagulation if there is no hybrid is so that choices also wrong what is stated here okay thank you

medical management basically anticoagulation is still the mainstay

for managing deep venous thrombosis it is typically DVD is separated into three phases acute long-term and extended i'll talk about it and it is usually the traditional therapies parenting based with the transition to order vitamin K

analog antagonists warfarin and the goal of the anticoagulation is to prevent trauma activation in the coagulation cascade which activates the final step the resulting in formation of fibrin which is basically clot and it is also

the goal is to prevent Clark from getting bigger and print Clark from farming newly so that is the goal for medical management and in the most of the guidelines are with respect to more for people in the outpatient setting but

in hospitalized patients usually the initial starting therapy is unfractionated heparin are low-molecular-weight happen because when you are inside the hospital there for procedural management it is usually

required that these anticoagulation is stopped for a little bit and because these you have hatch and low-molecular-weight are having shorter half-life that facilitate periprocedural management and the decision to

anticoagulated patients with deep venous thrombosis medically is too assess the benefits and pay the risks was in patients who have bleeding issues so it has to be a balance between that and patients who benefit more from

anticoagulation will go on to get

acute isolated disability it's always a

problem and in patients with severe symptoms are in risk for extension it is suggested that they get anticoagulation over cereal imaging in patients without serious symptoms they are preferable to have cereal imaging without a sound or

anticoagulation another recommendation if there are serial imaging is positive for extension from the isolated district ability into the proximal rains then you suggest anticoagulation and far extension just into the proximal rains

you definitely recommend anticoagulation with with a strong suggestion of great 1p if patients are treated the recommended medications are the same for Discipline dvt whatever you use for proximity VT

fractionated happened the anticoagulation it's basically a sulfated polysaccharide and the effect of happen is by inactivating the thrombin and factor 10 year by and

antithrombin mediated mechana some the doses weight-based at 80 units per kilogram starting with a follow-up of 18 units per kilogram per our intrusion doze and the non weight basis usually a

units per hour infusion it is monitored with activated pro trauma PT compressing time every six hours and the therapeutic range is 1.5 to 2.5 these times the control for each lab

and it is a low-cost medication it has a very short half-life and it is safe in renal insufficiency patient but in but the patient needs to get better because it's a parent of medication and needs to be monitored with the levels of apt and

it has a high potential for happen induced rumbos and thrombocytopenia the antidote is protamine sulfate which is used at 12.5 of the milligram IV toes based on the body p low-molecular-weight

guidelines which has come out in the chest issue or 2016 and for brevity of 2016 very important it has a lot of implications on how these patients are

managed so we need to know them really well in patients with proximal deep venous thrombosis long-term anticoagulation is recommended or no such therapy so anytime we have a great one evidence that means it is a strong

then whenever they have a give a quality of brca1 it is just suggestions more so if you realize in patients with deepest rumbles of the leg with no cancer for long-term anticoagulation they recommended newer oral anticoagulation

over-watering so that is a very important it's a new recommendations with great to be level of evidence and if you cannot treat them with the newer anti-coalition than warfarin is preferred over romantic

great so in patients with the defendant Thomas with cancer the suggestion is low molecular weight is forward or newer anticoagulants and our warfarin in patients will receive extra therapy the suggestion is no need to change

anticoagulation after three months that's also a new recommendation in the newest addition a importantly in patients with proximate dvt or PE provoked by surgery are a non-surgical friends in risk factor recommend

treatment is anticoagulation three months in patients with unprovoked anticoagulation should be at least three months is the recommended treatment in patients with first defense team buses which is an unprovoked proximal DVD with

the low-risk are moderate risk of bleeding that is suggestion of extended anticoagulation which is like in definite or lifelong and this is a new recommendation and in patients who are highest for reading three-month rupees

recommended and in patients who have a second probe DVD they are recommended to have extended therapy in patients with DVD & P and active cancer recommendation is extended anticoagulation therapy without hiatus for bleeding if they are

tie this for bleeding Vega treated with this suggested that they get addiction therapy but if there is then their extended therapy is annually re-evaluated and if they continue then it's fine if in DVD patients who are

stopping at the coalition that would suggest that they can take a sprain if there is no contraindication but it is not very good and controlling the in and getting these patients treated well

part is usually taken as between 0 to 7 10 days and a lot of options available for that and i will talk a little bit about all these agents seperatly and

then we'll go on to the guidelines later different options include and fractionated happen low-molecular-weight subcutaneous fondaparinux and/or Derek 10-year brothers and the pattern for direct ramen inhibitors when they're in

the inpatient setting that is usually useful for patients with hit long-term anticoagulation is considered when beyond the initial phase which is from like seven to ten day period to up to three to six months it is usually done

for a finite period so that is important you need to understand it is long-term anticoagulation but it is done for a finite period same agent can be used which was started are depending on the patient's clinical features it can be

transition from one medication to another and it is very important that we need to ensure that there is full anticoagulation when you're transitioning from one agent initially to the other agent and to minimize

interruptions so that you don't let this person getting more Clark's are propagate their Clark so the options are for long-term anticoagulation including direct ramen inhibitors are direct factor 10 hey inhibitors and warfarin

subcutaneous low-molecular-weight heparin as well as for the contacts are also used in some patients for long term usage extended are indefinitely anticoagulation there are some patients who will need extended anticoagulation

you can also say lifelong but their lifelong need actually needs to be evaluated annually for need for continued anticoagulation so there are in general or Atlantic islands are used which is a

the traditional warfarin all the new oral anticoagulants there is consensus that there is some subset of patients who need in definite or extended anticoagulation but there is no definite agreement on the proposed approach how

to deal with these patients little idea

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