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Objective
Objective
elderlyhematomassyndrome
Audience Response Question: Prevention of Post Phlebitis Syndrome
Audience Response Question: Prevention of Post Phlebitis Syndrome
2016ablationAngiodynamicscompressionelasticoccludedrandomizedsaphenoussbvSIRstentingsyndromeveins
Approach to venous disease | Tools of the Trade
Approach to venous disease | Tools of the Trade
2016AVIRchapterfull videoNonesbv
Major and Minor Complication Rates | Thrombolysis: Arterial and Venous - Scientific session
Major and Minor Complication Rates | Thrombolysis: Arterial and Venous - Scientific session
2016Angiodynamicsbleedingchapterclinicallycompartmentdilationembolisationembolizefull videogrowinghematomahematomasoccurredpatientsperforationsretroperitonealsbvSIRsyndromethrombolysisthromboses
Large Vein Occlusive Disease: The Magnitude Of The Problem In The Population
Large Vein Occlusive Disease: The Magnitude Of The Problem In The Population
2014accurateAngiodynamicscavalchroniccompressioncongenitalcorrectablecutedeepdiseaseDVTedemaembolismembolusepidemiologyfrequentfrequentlyhematomahemodynamichypoplasiailiofemoralincidencelargerlethalmagnitudemayomulticenterobstructionobstructionsocclusionocclusivepatientspercentpopulationproximalpulmonarysbvstudysyndromesyndromesthromboembolicthromboembolismthrombosisthromboticunderlyingveinvenavenous
Severe Illiac Obstructive PTS - Strategy  | Evidence Gaps in the Treatment of Chronic Venous Insufficiency
Severe Illiac Obstructive PTS - Strategy | Evidence Gaps in the Treatment of Chronic Venous Insufficiency
2016ablatingchapterfull videoHypertensioniliacimprovedrefluxsaphenoussbvSIRsyndromethrombosisveinvenous
Outcome by Treatment Mode and Primary Safety Endpoint | Thrombolysis: Arterial and Venous - Scientific session
Outcome by Treatment Mode and Primary Safety Endpoint | Thrombolysis: Arterial and Venous - Scientific session
2016adjuvantAngiodynamicsangioplastyarterialchapterfull videohematomasinterventionmechanicalpatientsPenumbrapercentpercutaneousperfusionsbvSIRstentthrombectomytpa
ATTRACT Study Of rt-PA For Acute DVT: Almost 7 Years And Almost 700 Patients, Almost Done: What Will We Find
ATTRACT Study Of rt-PA For Acute DVT: Almost 7 Years And Almost 700 Patients, Almost Done: What Will We Find
2015accpacuteadjunctiveattractcathetercomparabledeepDVTendovascularenrollevaluatingfemoraliliaciliofemorallimbpatientspercutaneouspostproximalrandomizationrecommendedriskroutineseveritysteeringstratifiedsureshsyndromethrombolysisthrombosisthromboticthrombusvedanthamvenousvillalta
Does Lysis Improve Quality of Life - Timeline | (SAM) Pulmonary embolism intervention - Self-assessment module (SAM) session
Does Lysis Improve Quality of Life - Timeline | (SAM) Pulmonary embolism intervention - Self-assessment module (SAM) session
2016Angiodynamicsapneachapterchroniccomorbiditiesconcludedcopddiastolicdysfunctiondyspneaembolismendpointexerciseexertionalfull videoheparinHypertensionhypotensiveintolerancelysedpatientspercentpersistentpressureprogressivepulmonaryqualitysbvSIRsyndromesystolicthromboembolicventricularzone
Who to Choose? | Patient Selection for CDT
Who to Choose? | Patient Selection for CDT
2016anatomicAngiodynamicsanticoagulationbleedingcandidateschaptercontraindicatedDVTfull videohemorrhagicintracranialpatientpatientspostpartumpreventprocedurerisksbvSIRsyndrometherapythrombolytic
Thrombolysis For DVT: Predictors Of Success
Thrombolysis For DVT: Predictors Of Success
2015accpachieveanatomiccavalchronicclinicalDVTfailureguidelineshypercoagulableiliaciliofemoralincompletelysislyticmalepatencypatientpatientspharmacomechanicalphlegmasiapredictorsprothromboticrecurredrecurrenceregressionsurgerysyndromethrombolysisthromboticthrombustreatedultrasoundvenousvillalta
Outcome by Treatment Mode and Primary Safety Endpoint
Outcome by Treatment Mode and Primary Safety Endpoint
2016adjuvantAngiodynamicsangioplastyarterialhematomasinterventionmechanicalpatientsPenumbrapercentpercutaneousperfusionsbvSIRstentthrombectomytpa
Upper Limb DVT | Medical Management of DVT
Upper Limb DVT | Medical Management of DVT
2016AngiodynamicsanticoagulationcathetercentralchapterdurationDVTextremityfull videoisispatientsproximalsbvSIRsuggestedsurgerysyndromethrombolyticundergovenous
Major and Minor Complication Rates
Major and Minor Complication Rates
2016AngiodynamicsbleedingclinicallycompartmentdilationembolisationembolizegrowinghematomahematomasoccurredpatientsperforationsretroperitonealsbvSIRsyndromethrombolysisthromboses
SVC Syndrome | Balloon Angioplasty and Tamponade | 29 | Male
SVC Syndrome | Balloon Angioplasty and Tamponade | 29 | Male
2016acuteangiogramangioplastyantegradeballoonballoonscardiochronicdilateddraininflatedintimalocclusionocclusionspericardialprogressedrenalSIRsyndrome
Audience Response Question: Prevention of Post Phlebitis Syndrome | (SAM) Management of chronic venous disease - Self-assessment module (SAM) session
Audience Response Question: Prevention of Post Phlebitis Syndrome | (SAM) Management of chronic venous disease - Self-assessment module (SAM) session
2016ablationAngiodynamicschaptercompressionelasticfull videooccludedrandomizedsaphenoussbvSIRstentingsyndromeveins
Severe Illiac Obstructive PTS - Strategy
Severe Illiac Obstructive PTS - Strategy
2016ablatingchapterHypertensioniliacimprovedrefluxsaphenoussbvSIRsyndromethrombosisveinvenous
Does Lysis Improve Quality of Life - Timeline
Does Lysis Improve Quality of Life - Timeline
2016AngiodynamicsapneachroniccomorbiditiesconcludedcopddiastolicdysfunctiondyspneaembolismendpointexerciseexertionalheparinHypertensionhypotensiveintolerancelysedpatientspercentpersistentpressureprogressivepulmonaryqualitysbvSIRsyndromesystolicthromboembolicventricularzone
Predictors Of Post-Thrombotic Syndrome After DVT: Which Patients Will Have Problems
Predictors Of Post-Thrombotic Syndrome After DVT: Which Patients Will Have Problems
2014adjustedanatomicalAngiodynamicsbaselinedataDVTfactorsfemoraliliacincreasedlateralmarkersmonthparticipantspatientpatientsplacebopredictpredictorsproximalrecurrentresidualrisksbvseverityslidestockingsstudiessymptomssyndromethrombosistreatingtrialvein
Post-thrombotic Syndrome | Patient Selection for CDT
Post-thrombotic Syndrome | Patient Selection for CDT
2016AngiodynamicschapterconditiondiagnosisDVTdysfunctionfull videohyperpigmentationiliofemoralpatientspoplitealproximalsbvSIRswellingsyndrome
Management - Post Thrombotic Syndrome | (SAM) Management of chronic venous disease - Self-assessment module (SAM) session
Management - Post Thrombotic Syndrome | (SAM) Management of chronic venous disease - Self-assessment module (SAM) session
2016ambulationAngiodynamicschaptercoagulationdevelopdiseaseDVTfull videopatientspercentprevalenceproximalsbvSIRsyndromeulceration
Physiology Of Large Vein Occlusion: A Hemodynamic Explanation For The Post-Thrombotic Syndrome
Physiology Of Large Vein Occlusion: A Hemodynamic Explanation For The Post-Thrombotic Syndrome
2014activationambulationambulatoryanalogousAngiodynamicsarterialcommoncomplexconceptscriticaldeterminantsdistaldownstreamelevationendothelialfemoralflowiliacinflowlesionsmanifestationsobstructionpatientspressurepressuresproximalrefluxsbvseriesseveresharpskinstenosissubsequentsyndrometransmissionveinvenous
Recurrent Hepatocellular Carcinoma, Arterioportal Shunt|DEB TACE, Coil Embolization|65|Male
Recurrent Hepatocellular Carcinoma, Arterioportal Shunt|DEB TACE, Coil Embolization|65|Male
2016arterialenhancementmonthpatientpatientsphrenicsegmentSIRsuperiortherapytumortypicallyvessel
Evidence for Catheter-directed Thrombolysis | Patient Selection for CDT
Evidence for Catheter-directed Thrombolysis | Patient Selection for CDT
2016Angiodynamicsanticoagulationcathetercatheter directedchapterclotcompressiondirectedfull videoiliofemoralmechanicalmulticenterpatencypatientspharmacolpreventproximalrandomizedremoverisksbvSIRstentsstockingsstudysyndrometherapythrombolysistrial
DEBATE: Ultrasound-Enhanced Thrombolysis Yields No Benefit Over Thrombolysis Alone
DEBATE: Ultrasound-Enhanced Thrombolysis Yields No Benefit Over Thrombolysis Alone
2014acousticacuteadjunctiveAngiodynamicsarisesassistedbleedingcatheterembolicendpointextrinsicfiberhistoryhoursidenticaliliacimplementingisispatencypatientpatientspercentprimaryrandomizationrandomizedrateremovalresidualroutinesbvsecondarystandingstatisticallystenosesstenosisstentingsubacutesyndrometherapytroubleultrasonicultrasoundversus
Ultrasound-Enhanced Thrombolysis For Older DVT: Update From The ACCESS Study
Ultrasound-Enhanced Thrombolysis For Older DVT: Update From The ACCESS Study
2016accessanesthesiaAngiodynamicsangioplastybaselinecenterchronicclinicalcoagulationcompressiondilatationdroppedDVTendpointsenrollmentflowiliacinterventionligationlimbslimitationslysismonthsmulticenterocclusionpatencypatientspoplitealprofundaregistrysbvscoressegmentsseveritystentedstudysymptomaticsymptomssyndromethrombosisultrasoundveinvenogramvenous
Audience Response Question: Evidence for Use of DCT | Patient Selection for CDT
Audience Response Question: Evidence for Use of DCT | Patient Selection for CDT
2016AngiodynamicschapterDVTfull videoiliofemoralrandomizedreducerisksbvSIRsyndromethrombus
SVC Syndrome | Balloon Angioplasty and Tamponade | 29 | Male | Treating chronic venous occlusive disease - Case-based workshop
SVC Syndrome | Balloon Angioplasty and Tamponade | 29 | Male | Treating chronic venous occlusive disease - Case-based workshop
2016acuteangiogramangioplastyantegradeballoonballoonscardiochapterchronicdilateddrainfull videoinflatedintimalocclusionocclusionspericardialprogressedrenalSIRsyndrome
Management - Post Thrombotic Syndrome
Management - Post Thrombotic Syndrome
2016ambulationAngiodynamicscoagulationdevelopdiseaseDVTpatientspercentprevalenceproximalsbvSIRsyndromeulceration
Transcript

Good morning, my name is Professor Kieran Murphy, I am going to discuss with you this morning work that I've done with my colleagues, Dr Sheila Waa, Amanda Chan and Agnes Sauter in the area of trying to identify typical radiological findings in the elderly who've been physically abused. This is an area that hasn't previously been investigated and yet there is significant evidence that this is a growing problem in our society. This investigation or work

began for me about 16 years ago when I was on call in New York and I was bothered by the large number of elderly people that we were seeing with subdural hematomas and periorbital trauma, and I began to suspect that there might be a syndrome there that was akin to the shaken baby syndrome or Caffe syndrome that we know occur in children. So to investigate this, we

reviewed reports in the medical literature on the distribution of physical injuries due to elder abuse. To see if we could characterize a pattern that would be useful for the diagnosis of this problem in the clinical setting or in a social context. In terms of background, abuse of older people by family members or are those known to them in their homes are in long term care institutions. Is it growing

are cosmetic next question for you here which of the following has been shown to prevent the progression of the post traumatic syndrome is it thermal ablation of saphenous veins stenting of occluded veins elastic compression and

tax a filing or none of the above who and the answer is that's correct the answer it's been shown at least two large randomized studies but the biggest are the probably the best of which done by prayer and Oni the elastic

compression prevents post-traumatic syndrome but i'm going to throw a big question mark in their reason I'm going

procedures other life state...saving tools of the trade that we've been able to implement over the years...

DVT. So I do not like venous disease I enjoy learning more about it I enjoy learning how to more efficiently treat my patients and buy by them other options. But the thing about venous diseases is it's oftentimes by no fault of the

patient themselves. So it's either hereditary or they were on a really long plane ride or something has happened. The problem with venous disease is once you form a blood clot in your leg it leads to a whole host of problems. And

one of the biggest problems is the development of pulmonary embolus. And so oftentimes these clots they won't stay stationary in your legs they will break off and will travel to your lungs. So this is a pulmonary arteriogram this is the right

pulmonary artery and you see all of these filling defects out here. And this is a patient that has suffered from some massive pulmonary embolus going out into their lungs. And so the early treatment for pulmonary embolus was

to perform either you would cut down on the cava and you would put on like a cable clip and what this would allow for you two for the patient to do is you would still have blood that was flowing through the IVC and returning back to

the heart but you had all of these kind of dividers that would catch any sort of large clot. Your body's throwing clot on a routine basis it's just throwing it at a small enough a small enough amount that you can deal with it.

So any sort of any clot bigger than what this cable clip would allow would would go through. And so what we can offer now to patients instead of cutting down on their abdomen and putting in a cable clip is we can put in what we call

an inferior vena cava filter. And the inferior vena cava filter goes in through either their internal jugular or the femoral vein and it's just it's in their inferior vena cava and it catches any and all ...well.. catches the majority

of the clot that anything that would come from below. And so we place these in patients that are many of our trauma patients that are going to be unable to be anticoagulated for long periods of time that are going to be immobile that

are high risk for DVT on patients that are going into surgery they're going to be immobile. Anyone who is at high risk for DVT or has a known DVT and we worry about that breaking off and going to their lungs they're all pretty good

candidates for an inferior vena cava filter. So in another big another big

11 patients representing 3.5 persons there was one day you to interest arable

bleeding and thrombolysis significant bleeding growing hematomas and retroperitoneal bleeding and compartment syndrome in three patients minor complications occurred in fifty-nine patients most frequently peripheral

embolisation in 40 but fortunately all of those embolize were removed by mechanical means during the procedures they were also six RT perforations related to rotor ex that were treated by long-term balloon dilation or by

implementation of colored stance clinically insignificant growing hematoma thromboses compartment syndrome MERS occurred in 36 patients conclusions

thank you very much dr. really it's always a pleasure to be here especially now when in Minnesota we are in the 04 sub-zero temperatures and i was asked by dr e to talk about largely no proceed disease met the magnitude of the problem in the general population of course

you'll know that there are a cute largely an obstruction and click clattering obstruction and in 2008 when we still had a surgeon general he called to action to prevent deep vein thrombosis and pulmonary embolus because

of the magnitude of the problem at that tim in this country had depleted from boces and pulmonary embolism about a hundred

thousand death that were related to a thromboembolic disease there were and there are many patients will have complications once they survive and the problem obviously vs as the population ages a Mayo Clinic community-based study

by dr. hey looked at the epidemiology of a cute deplane thrombosis and found that the incidence of venous thromboembolism exceed one per 1000 which is pretty much the same as the incidence of stroke in this country there ar

pieces that occur annually plus plus the additional cases our recurrences age is an important factor and in the population above each 50 meals are more frequently or 50 than females

it's a lethal disease 30-percent die within 30 days and then as I said record and deepen from boces major issue particularly in meals thirty percent will develop recurrence within 10 years these other people who are most

frequently affected those who have surgery and trauma immobility can sir and also those who have some underlying Venus compression or hematoma arterial abnormality or may Turner syndrome that we're going to talk quite

frequently at this meeting and it's important problem in women it really effects the population greatly and this is a great article by dr. zosh rad and more and you can read about prevention and the main issue which is identified

those who are at-risk largely inclusions are much more frequent than this style TBR accurate deep vein thrombosis and this is a population-based study that showed that most of the dvds are proximal this is a an important study

from dr dallas single showed that almost fifty percent of the accurate deep vein thrombosis and the chronic renal deep vein thrombosis or occlusion to our iliofemoral in locations which are important for us to know but of course

there are primary chronic clattering obstructions that we recognize with increasing frequency and this can be caused by congenital anomalies and the so-called compression syndromes are also primary obstructions the congenital

problems can be hypoplasia that involves the larger trains inferior vena caval really a Queen's that sometimes it's a three share sometimes we don't know really whether this is not a childhood deep vein thrombosis because they can

frequently be recognized or in some patients the occlusive disease is because of complete absence of the year alia Queens compression syndromes are more and more popular because we can do something for them me Turner syndrome

obviously is important and we are being more and more attention to not cracker syndrome this is a classic paper that shows again the magnitude of the problem of me Turner syndrome or non from particularly

accurate obstruction in this study marine akibi from Northwestern showed in 50 patients who had no thrombotic problems but had a CT scan the sixty-six percent had the greater than twenty-five percent compression twenty-four percent

of greater than 50-percent compression women are more frequently affected many patients have a cute DVT and about one out of four patients will have pain and edema and again major Turner syndrome can be treated and recognized well for

somebody construction is however the most frequent the occlusion and it can be anywhere from twenty eight percent in this study and up to almost 40% in this prospective multicenter study of dr. can there is significant hemodynamic

problems that is correctable underlying disease and that is why our societies recommend treatment of a cute the larger and inclusions in conclusion accurate remember is matt has a major effect on the general population because its

frequent and lethal post-traumatic syndrome is frequent and attempts to prevent DVD identify patients at risk remove from booze from larger is early and 3d underlying greenness obstruction must intensify thank you

rightly so post-traumatic syndrome i want to mention one thing this is that

the Venus also component of it we know it has a major impact on daily quality of life and on patients just ability to live their lives we know that thrombosis of the iliac are common femoral vein is often present not always but often

present people with the most severe post-traumatic syndrome as you see here and over the years some of us have started to apply basically a strategy of just reducing venous hypertension using standing of chronic me and iliac vein

obstruction reassess the patient and if they have significant saphenous reflux ablating the saphenous reflux to achieve a global reduction in venous hypertension and hopefully he'll also has an improved symptoms and improved

clinical signs of post-traumatic

you look again about fifty percent of those patients that were treated with a penumbra integral frontline only to me

two or three posted to go number into your treatment of from over eighty-one percent after intervention over ninety-five percent TPA and then use the number indigo again even slightly better results no significant change after

intervention with angioplasty and stent placement also as far as mechanical come back to me prior to remember again about the same with hundred percent perfusion post both usable for adjuvant TPM account therapies obviously these are

patients that we started out with those patients that we couldn't get lice we couldn't use a get other mechanical thrombectomy devices to use went to the number is the last ditch effort and obviously a hundred percent of patients

then we establish flow safety there was procedurally SI es in about seven percent of patients obviously none of those were device-related this is obviously a percutaneous arterial intervention vast majority of those four

hematomas at the site mostly in patients that are already previously had from political or other mechanical thrombectomy thermolysis so really none device related complications at all

[BLANK_AUDIO] Thank you Dr Wakefield, Dr Garcia. Ladies and gentlemen I'm pleased to represent the steering committee of the ATTRACT trial, and very importantly, pleased to represent Dr Suresh Vedantham who as as a principal investigator, I think, set a new standard for national PIs. These are the disclosures. [BLANK_AUDIO]

The ATTRACT trial is the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis, and this is an NIH sponsored trial. We know that in general management of deep venous thrombosis is guided by international guidelines, and arguably the most influential guidelines are those put out by the American College of Chest

Physicians. Now the eight edition, in 2008, were in play when ATTRACT was initiated, but I think it's important to look at what was in play when ATTRACT was designed and when it was funded. And in 2004, the ACCP recommended against the routine use of

catheter-directed thrombolysis. Strong recommendation, a little data to support it, and that catheter-directed thrombolysis should be confined to selective patients requiring limb salvage. It's very rare, exceptionally rare, to have a deep venous thrombolysis causing limb threat,

and they recommended against the routine use of, here we go, and they recommended that in selected patients such as those with massive iliofemoral DVT at risk of limb gangrene, they suggested IV thrombolysis. And we know IV thrombolysis has no effect in patients with extensive deep venous thrombosis.

And that IV delivery is of course minimally affected. So despite therapeutic anti-coagulation we know that post thrombotic syndrome occurs frequently, it's life long, and that patients are at increased risk for recurrence with PTS, and recurrent DVT increases the risk and severity of post thrombotic

syndrome. And we know that iliofemoral DVT is particularly bad. Now the objectives of the study design were to reflect the actual use of percutaneous catheter-directed thrombolysis in the United States, get an accurate answer,

have a good inflexibility in practice, results credible to percutaneous catheter-directed thrombolysis in terms of evaluating the results from the ATTRACT trials. We thought that this was a best fair test of this technique. And there was also a focus on items that affected cost and clinical

decision making. We attempted to enroll a representative cohort of patients and accommodate a diversity of practice in anti-coagulation as well as endovascular therapy, and the structural design of the trial promoted rigor integrity and balance in the evaluations.

And we are rigorously evaluating post thrombotic syndrome, quality of life, the safety of the techniques, and we have the limited ability to look at secondary issues. So patients with symptomatic proximal DVT involving the iliac to the femoral veins were included. They were stratified by thrombus extent, and in actuality 60% of our

patients had iliofemoral DVT. We excluded patients that are high risk of bleeding, with central nervous system lesions, acute limb threat symptom duration of more than two weeks, or post thrombotic syndrome in the same leg. And you can see when patients came in they were stratified to either

illiofemoral deep venous thrombosis or femoral popliteal, and when stratified they were randomized to either anti-coagulation alone, or anti-coagulation plus catheter based thrombus removal. There was operational separation of the PI from the study data. This was to minimize bias. There was comparable use of anti-coagulation,

anti-platelet therapy as well as comparable use of filters. There's equal surveillance of patients in both arms, central randomization protocol, and allocation was concealed for those individuals that were making the assessment of post thrombotic syndrome. Patients are evaluated according to the Villalta score. 692 patients

were randomized, and we will evaluate severity of PTS, quality of life, likelihood of pain relief, safety, and mechanism of post thrombotic syndrome which is badly needed, abstraction versus reflux. We're not looking at biomarkers, and we're not looking at biological

effects of catheter or devices on the vein wall. This is a photograph of the Steering Committee, and we received enormous support from the NIH, from the surgeon general, and from other major organizations. So I do think in early 2017 we will have important answers to these

important questions. Thank you very much. >> [APPLAUSE]

thing i want to talk about is quality of life and when we're talking about quality life and pulmonary embolism the primary determinant of that the best of

my knowledge is residual or persistent or progressive pulmonary hypertension which Rex exercise tolerance and cause shortness of breath first described about 90 years ago by young dal then toyed with by dale and Albert who

concluded that a chronic corporal manali the word used back then before CTF was even known is an extraordinarily unlikely complication of PE the late great can moser fault that maybe as many as four hundred fifty patients had this

syndrome of what he started calling chronic thromboembolic pulmonary hypertension but then rivière ok mout and showed that up to forty percent of patients post PE end up with high pressures that are persistent

progressive over the next five years pingo concluded that about three percent of patients went on to develop the full C tough syndrome and at the time this new england journal paper came out that number was about 10-fold most experts

thought now we're thinking more in terms of a transition where there's a larger number of patients maybe 25 to 40 percent that have a partial seat s syndrome not the full concrete in the lungs syndrome that causes the need for

the operation but progressive pulmonary hypertension that's not explained by smoking or sleep apnea or elevated left ventricular end diastolic pressure it's not just comorbidities this is work that I did where we took a hundred and

twenty-seven patients that had no previous comorbidities except we did not exclude obesity and smoking and we found forty-one percent of them either had a bad-looking echo or dyspnea at rest or exercise intolerance six months later

clock found the quality of life was not good after PE with numbers that looked similar to like COPD with over half of patients reporting exertional dyspnea and seventy percent having new or worsening dyspnea after their PE lots of

evidence that PE messes up quality of life including some in 2014 from our friends in Australia from challenge at all child at all that found a 25-percent had all of these things impaired exercise capacity heart rate recovery

pulmonary hypertension and raised PVR and right ventricular dysfunction is important point that he had is the corollary is they were apparently normal when you talk to them but was only when you provoke them did you find these

abnormalities we studied a cohort of patients of 200 patients that had some massive PE they were normotensive if they became hypotensive they got lice that's these patients this is the right ventricular pressure on the x-axis the

y-axis at diagnosis and six months later all the patients that got lysed had reductions in their systolic pressures on the right side of the heart these are patients that just got heparin alone the red lines are those that

increase the pressure that was one-third of all the patients that just got heparin alone plus a higher rate of exercise intolerance and dyspnea at rest and the topcoat study we looked at a composite of endpoints including bad

stuff on the front end and bad stuff on the back in what we considered a patient-centered endpoint and you were three times more likely to hit the bad end point with placebo compared to connect a place here it is shown another

way with bar charts that are just so horizontally patients want to be in the white zone they are more likely to be in the white zone if they were treated with connected place

- Now I want to talk about, as Chrissy mentioned AVM Classification System and it's treatment implication to achieve cure. How do I put forward? Okay, no disclosures. So there are already AVM Classification Systems. One is the well-known Houdart classification

for CNS lesions, and the other one is quite similar to the description to the Houdart lesion, the Cho Do classification of peripheral AVM's. But what do we expect from a good classification system? We expect that it gives us also a guide how to treat with a high rate of cure,

also for complex lesions. So the Yakes Classification System was introduced in 2014, and it's basically a further refinement of the previous classification systems, but it adds other features. As for example, a new description of

a new entity, Type IV AVM's with a new angioarchitecture, it defines the nidus, and especially a value is that it shows you the treatment strategy that should be applied according to angioarchitecture to treat the lesion. It's based on the use of ethanol and coils,

and it's also based on the long experience of his describer, Wayne Yakes. So the Yakes Classification System is also applicable to the very complex lesions, and we start with the Type I AVM, which is the most simple, direct

arterial to venous connection without nidus. So Type I is the simplest lesion and it's very common in the lung or in the kidney. Here we have a Type I AVM come from the aortic bifurcation draining into the paralumbar venous plexus,

and to get access, selective cauterization of the AVM is needed to define the transition point from the arterial side to the venous side, and to treat. So what is the approach to treat this? It's basically a mechanical approach, occluding

the lesion and the transition point, using mechanical devices, which can be coils or also other devices. For example, plugs or balloons. In small lesions, it can also be occluded using ethanol, but to mainly in larger lesions,

mechanical devices are needed for cure. Type II is the common and typical AVM which describes nidus, which comes from

multiple in-flow arteries and is drained by multiple veins. So this structure, as you can see here, can be, very, very dense, with multiple tangled fistulaes. And the way to break this AVM down is mainly that you get more selective views, so you want to get selective views

on the separate compartments to treat. So what are the treatment options? As you can see here, this is a very selective view of one compartment, and this can be treated using ethanol, which can be applied

by a superselective transcatheter arterial approach, where you try to get as far as possible to the nidus. Or if tangled vessels are not allowing transcatheter access, direct puncture of the feeding arteries immediately proximal to the nidus can be done to apply ethanol. What is the difference between Type IIa and IIb?

IIb has the same in-flow pattern as Type a, but it has a different out-flow pattern, with a large vein aneurysm. It's crucial to distinguish that the nidus precedes this venous aneurysm. So here you can see a nice example for Type IIb AVM.

This is a preview of the pelvis, we can here now see, in a lateral view, that the nidus fills the vein aneurysm and precedes this venous aneurysm. So how can this lesion be accessed? Of course, direct puncture is a safe way

to detect the lesion from the venous side. So blocking the outflow with coils, and possibly also ethanol after the flow is reduced to reflux into the fistulaes. It's a safe approach from the venous side for these large vein aneurysm lesions,

but also superselective transcatheter arterial approach to the nidus is able to achieve cure by placing ethanol into the nidus, but has to be directly in front of the nidus to spare nutrient arteries.

Type IIIa has also multiple in-flow arteries, but the nidus is inside the vein aneurysm wall. So the nidus doesn't precede the lesion, but it's in the vein wall. So where should this AVM be treated?

And you can see a very nice example here. This is a Type IIIa with a single out-flow vein, of the aneurysm vein, and this is a direct puncture of the vein, and you can see quite well that this vein aneurysm has just one single out-flow. So by blocking this out-flow vein,

the nidus is blocked too. Also ethanol can be applied after the flow was reduced again to reflux into the fistulas inside the vein aneurysm wall. And here you can see that by packing a dense packing with coils, the lesion is cured.

So direct puncture again from the venous side in this venous aneurysm venous predominant lesion. Type IIIb, the difference here is again, the out-flow pattern. So we have multiple in-flow arteries, the fistulaes are again in the vein aneurysm.

Which makes it even more difficult to treat this lesion, is that it has multiple out-flow veins and the nidus can also precede into these or move into these out-flow veins. So the dense packing of the aneurysm might have to be extended into the out-flow veins.

So what you can see here is an example. Again you need a more selective view, but you can already see the vein aneurysm, which can be targeted by direct puncture. And again here, the system applies. Placing coils and dense packing of the vein aneurysm,

and possibly also of the out-flow veins, can cure the lesion. This is the angiogram showing cure of this complex AVM IIIb. Type IV is a very new entity which was not described

in any other classification system as of yet. So what is so special about this Type IV AVM is it has multiple arteries and arterioles that form innumerable AV fistulaes, but these fistulaes infiltrate the tissue. And I'm going to specify this entity in a separate talk,

so I'm not going too much into details here. But treatment strategy of course, is also direct puncture here, and in case possible to achieve transarterial access very close to the nidus transarterial approach is also possible. But there are specific considerations, for example

50/50 mixture of alcohol, I'm going to specify this in a later talk. And here you can see some examples of this micro-fistulae in Type IV AVM infiltrative type. This is a new entity described. So the conclusion is that the Yakes Classification System

is based on the angioarchitecture of AVM's and on hemodynamic features. So it offers you a clear definition here the nidus is located, and where to deliver alcohol in a safe way to cure even complex AVM's.

Thank you very much.

down to really the clinicals very is it an urgent / emergent procedure in a patient with a threatened limb then of course you're going to place a stronger

priority on doing something for that patient is at a first-line treatment in a patient who you're really trying to prevent post-traumatic syndrome or is it a patient who has been on anticoagulation and now they've had

either progression of their clot or have not resolved their symptoms and you're using more of a salvager a second-line treatment to help that patient with their problem anatomic severity really the data shows

that LOL femoral dvt has at least twice the risk of developing post-antibiotic syndrome so those patients really are the ones at risk for the late consequences so they should highly be considered for additional therapy you

have to balance the benefits with the risks they're obviously the risk of increased bleeding using the from ballistic material or medication so many patients with an intracranial or spinal lesion any patient who is actively

bleeding or had a recent GI bleed anybody with Rumble side opinion recent trauma postpartum what I'll have increased risk of bleeding anybody who has uncontrolled hypertension adding the thrombolytic on top of that increases

the risk of hemorrhagic stroke and then anybody who has suspicions for in fact infected promise it's relatively contraindicated to do thrombolytic therapy in your patient selection the whole point is to help we prevent

post-traumatic syndrome and relieve their underlying our current swelling so patients who are bedridden at baseline or you know don't have that long of a life expectancy really are going to see the

long-term benefits of this sort of therapy so they would not be the best candidates patients who you know can't lie prone on the table lay still for an extended period of time or otherwise are going to be able to tolerate the

procedure would also not be good candidates for this procedure and then because there's not great robust data a lot of its going to rely on you know having a front conversation with your patient and what their values are and

where they fall on the spectrum of doing something more aggressive versus something a little bit more conservative so with that we go to the questions so

Thank you very much for the introduction. I have nothing to disclose. So in the way of a background, and you've heard about all this, catheter-directed techniques and pharmacomechanical thrombolysis are increasingly used to treat ilofemoral DVT because of the multiple reported advantages, as Tony has mentioned earlier. The clinical benefit continues to be debated, however, in terms of

what the guidelines tell us there is some conflict between the ACCP guidelines and other guidelines in terms of how aggressive we should be. Immediate failure has been clearly reported to occur in up to 20% of patients depending on which series you read. In our own institution, 13% of patients may experience immediate

failure. In addition to that, the two-year patency rate varies, there's a big range, 65 to 90%, that has been reported, and at our own institution the patency of the treated venous segment is 83% at about four years. This is why we decided to look at the predictors of immediate and

long term failure of thrombolysis for iliofemoral DVT, not only to guide patient selection to achieve the perfect outcomes, but also to set patient and physician expectations. This was recently published in JVS Venous. So this was a retrospective study looking at consecutive patients treated over a period of five years or so.

We looked at demographics as well as records, and the endpoints that we were mainly interested in were immediate failure as defined as 30 day recurrence or less than 50% lysis. Anatomic failure was determined by ultrasound, and this is how we looked at long term ultrasound patency, and the post-thrombotic syndrome was defined as a Villalta score of more than five.

118 limbs were treated in 93 patients. The mean age was about 49, almost equally distributed between men and women. 55% on the left side, and almost half of the patient had caval involvement.

Most patients were treated with a combination of catheter and pharmacomechanical techniques, and 56% required iliac vein stenting. Ultrasound follow up, which determined anatomic failure, was available at 16 months, and clinical follow-up to determine the post thrombotic syndrome was available at 21. Immediate failure was seen in 11 patients or 12%, and the causes

were as follows, seven patients had recent surgery and had to have a short lytic intervention because of bleeding complications, three patients had acute on chronic lesions and recurred because of their chronic DVT lesions, and one patient potentially had a hypercoagulable state.

In the logistics regression model, if you look at the predictors of immediate failure, and this included recent surgery as well as phlegmasia as an indication for treatment, there was a trend for male gender and age, but these were not significant. If you look at anatomic failure and DVT recurrence, so 72% were

patent at up to three years, and in a multivariate regression model incomplete lysis, and malignancy, and recent surgery were predictive of immediate or of anatomic failure at forty-eighth month. Similarly, if you look at the prothrombotic syndrome, this occurred in 28% of patients at 36 months. And in a logistic regression model the predictors of the occurrence of the prothrombotic

syndrome included incomplete lysis, male gender, phlegmasia as an indication, advanced age, and iliocaval involvement. When this was broken down however, by whether a patient had an immediate failure or not, you can clearly tell that the instance of a prothrombotic syndrome was significantly lower in those patients who were able to achieve successful lysis following treatment.

So in conclusion, thrombolysis can achieve high rates of immediate thrombus clearance and PTS morbidity reduction, yet a significant number of patients will experience immediate or late failure find as anatomic or clinical failure. And those are the patients who had recent surgeries, male gender, perhaps, phlegmasia as an indication

for treatment, and patients with a malignancy. And as we know from this series and others, lysis needs to be complete with at least more than 50% lysis in order to achieve the lowest rate of DVT recurrence and PTS. Thrombolysis for symptomatic iliofemoral DVT can be successful, and if the case is in the short and long term run.

And as Tony has mentioned earlier, we hope that the results of the ATTRACT file will clarify which patient will derive the most benefit from lytic therapy. Thank you very much for your attention. >> [APPLAUSE]

you look again about fifty percent of those patients that were treated with a penumbra integral frontline only to me

two or three posted to go number into your treatment of from over eighty-one percent after intervention over ninety-five percent TPA and then use the number indigo again even slightly better results no significant change after

intervention with angioplasty and stent placement also as far as mechanical come back to me prior to remember again about the same with hundred percent perfusion post both usable for adjuvant TPM account therapies obviously these are

patients that we started out with those patients that we couldn't get lice we couldn't use a get other mechanical thrombectomy devices to use went to the number is the last ditch effort and obviously a hundred percent of patients

then we establish flow safety there was procedurally SI es in about seven percent of patients obviously none of those were device-related this is obviously a percutaneous arterial intervention vast majority of those four

hematomas at the site mostly in patients that are already previously had from political or other mechanical thrombectomy thermolysis so really none device related complications at all

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

11 patients representing 3.5 persons there was one day you to interest arable

bleeding and thrombolysis significant bleeding growing hematomas and retroperitoneal bleeding and compartment syndrome in three patients minor complications occurred in fifty-nine patients most frequently peripheral

embolisation in 40 but fortunately all of those embolize were removed by mechanical means during the procedures they were also six RT perforations related to rotor ex that were treated by long-term balloon dilation or by

implementation of colored stance clinically insignificant growing hematoma thromboses compartment syndrome MERS occurred in 36 patients conclusions

So the final case is I think the worst complication that I caused, it's I feel awful about it and hopefully it will be a learning lesson for yourself it certainly was for me. This was a 29 year old who had a terrible SVC syndrome with advanced with spiritry/g compromised as well as chemosis and almost not quite

comatose but really in quite a bad way from his SVC syndrome. His background history was that he had chronic renal failure since infancy and had had two failed renal transplants and innumerable lines in his upper extremities in both his eye IJs. He was HIV and Hepatitis C positive from transfusion related issues. He was on aspirin at the time for cardio protection,

and he had two needs, one of which was an access for haemodialisis and then the second was treatment of this SVC syndrome, but he certainly needed access immediately. This was a CT that we did at the time, you can see the seclusion

here in his SVC. Very dilated azygos vein. We do quite a bit of SVC recanalization for access, for dialysis access, short gut syndrome, TPN, that sort of thing.

One of the things I will say to you is that when you're looking at the CTs, the level of the occlusion is really crucial. That the lower it is the more dangerous it is. And this is the illustrative case of that, that if the occlusion is higher up, it's outside of the potential for pericardial involvement to

can be a little bit more aggressive. When it's lowered down like this, this is where you can run into trouble. So we did what we usually do which is an antegrade access from a recanalized external jugular vein, brought a sheath down and you

can see the run here is showed really just enormous [UNKNOWN] stylation system feeding back with no evidence of an SVC at all. It actually wasn't that hard to recanalize, didn't require sharp recantalization again, most of these we do require sharp recanalization, but here a wire and catheter and a few sheaths managed to get us through.

And you can see the position of the wire in the SVC going down through the atriam/g to the IVC with the position of the [UNKNOWN] behind us. I then proceeded to ciliary dilate and started off with six and eight very tight ways to tuck her off, but it gradually began to

open with some high pressure balloons and I did intimate non geography to see how I was doing despite opening it to I think this is after a ten balloons zero antegrade flow through the system still all going down through the [UNKNOWN] Proceeded up with some further larger balloons, and at this point

I did another angiogram after this it was a 14 millimeter balloon and there was a finding that I missed at that time that is very important, and I'll give you a second just have a look at the angiogram yourself to see if you're better than me. And this is what it is. So this, what I believe was an intimal tear in the acute thrombotic

formation on an intimal tear of the SVC was on this one. I did not appreciate it at the time and proceeded with further balloon angioplasty because again there was no antegrade flow leading down into his SVC and into his right atrium at that point. Proceeded with further balloon angioplasty this is with an 18 balloon and got it up to full and then as I took it down he began to complain

of a strange sensation in his chest that rapidly progressed to him being [INAUDIBLE] that rapidly progressed to him collapsing cardio dynamically and then I performed this angiogram and you can see here as we go through the run this large rent/g here and free extravazation from the SVC

into the pericardial space and [INAUDIBLE] there. So this was complicated by an acute [UNKNOWN] immediately I would say within 30 seconds, he began to change [INAUDIBLE] with the chance of respiration within a minute he had arrested and was requiring

quite a bit of chest [UNKNOWN] followed by as you can see we put in a pericardial drain immediately I inflated the balloon to expand it and he ended up being shocked several times. The options were discussed with the arrest team, we felt that given his age given that he was 29 and this was an acute issue, we would to do our best

to preserve everything in it's place [INAUDIBLE] while that was being set up I kept the balloon inflated and there was a thought that perhaps his balloon tapered out enough release. This showed that no it wasn't, this is after 45 minutes of balloon tamponad/g you can see there is still this large hole,

this is not gonna be repaired by simply tamponading/g the hole, and I ended up placing a viabahn stent across the area. Unfotunately we didn't have atrian/g in this particular lab at that time.

So this sealed the hole and we were able to stabilize him at this stage the bright red blood that was pumping out of his tamponade/g drain that was pericardial drain ceased immediately, and he became [INAUDIBLE] stable again and we were able to move him upstairs. Unfortunately, he had a drastic postoperative course with a global hypoxic injury and actually passed away three days later.

So the take home from this case for us, for me in particular was to be very wary of dilating chronic SVC occlusions particularly those that are low down the super cardinal recess of the pericardium extends to the level of the [UNKNOWN] when you're chronic occlusions at that level to be very very particularly if the major clinical question is accessed,

they do not need to be dilated to 18 like I did, but in the access, settle in there, and you can always come back and treat the SVC syndrome at a different time, perhaps in a different way. But certainly it was a very [INAUDIBLE] point for myself. >>

are cosmetic next question for you here which of the following has been shown to prevent the progression of the post traumatic syndrome is it thermal ablation of saphenous veins stenting of occluded veins elastic compression and

tax a filing or none of the above who and the answer is that's correct the answer it's been shown at least two large randomized studies but the biggest are the probably the best of which done by prayer and Oni the elastic

compression prevents post-traumatic syndrome but i'm going to throw a big question mark in their reason I'm going

rightly so post-traumatic syndrome i want to mention one thing this is that

the Venus also component of it we know it has a major impact on daily quality of life and on patients just ability to live their lives we know that thrombosis of the iliac are common femoral vein is often present not always but often

present people with the most severe post-traumatic syndrome as you see here and over the years some of us have started to apply basically a strategy of just reducing venous hypertension using standing of chronic me and iliac vein

obstruction reassess the patient and if they have significant saphenous reflux ablating the saphenous reflux to achieve a global reduction in venous hypertension and hopefully he'll also has an improved symptoms and improved

clinical signs of post-traumatic syndrome

thing i want to talk about is quality of life and when we're talking about quality life and pulmonary embolism the primary determinant of that the best of

my knowledge is residual or persistent or progressive pulmonary hypertension which Rex exercise tolerance and cause shortness of breath first described about 90 years ago by young dal then toyed with by dale and Albert who

concluded that a chronic corporal manali the word used back then before CTF was even known is an extraordinarily unlikely complication of PE the late great can moser fault that maybe as many as four hundred fifty patients had this

syndrome of what he started calling chronic thromboembolic pulmonary hypertension but then rivière ok mout and showed that up to forty percent of patients post PE end up with high pressures that are persistent

progressive over the next five years pingo concluded that about three percent of patients went on to develop the full C tough syndrome and at the time this new england journal paper came out that number was about 10-fold most experts

thought now we're thinking more in terms of a transition where there's a larger number of patients maybe 25 to 40 percent that have a partial seat s syndrome not the full concrete in the lungs syndrome that causes the need for

the operation but progressive pulmonary hypertension that's not explained by smoking or sleep apnea or elevated left ventricular end diastolic pressure it's not just comorbidities this is work that I did where we took a hundred and

twenty-seven patients that had no previous comorbidities except we did not exclude obesity and smoking and we found forty-one percent of them either had a bad-looking echo or dyspnea at rest or exercise intolerance six months later

clock found the quality of life was not good after PE with numbers that looked similar to like COPD with over half of patients reporting exertional dyspnea and seventy percent having new or worsening dyspnea after their PE lots of

evidence that PE messes up quality of life including some in 2014 from our friends in Australia from challenge at all child at all that found a 25-percent had all of these things impaired exercise capacity heart rate recovery

pulmonary hypertension and raised PVR and right ventricular dysfunction is important point that he had is the corollary is they were apparently normal when you talk to them but was only when you provoke them did you find these

abnormalities we studied a cohort of patients of 200 patients that had some massive PE they were normotensive if they became hypotensive they got lice that's these patients this is the right ventricular pressure on the x-axis the

y-axis at diagnosis and six months later all the patients that got lysed had reductions in their systolic pressures on the right side of the heart these are patients that just got heparin alone the red lines are those that

increase the pressure that was one-third of all the patients that just got heparin alone plus a higher rate of exercise intolerance and dyspnea at rest and the topcoat study we looked at a composite of endpoints including bad

stuff on the front end and bad stuff on the back in what we considered a patient-centered endpoint and you were three times more likely to hit the bad end point with placebo compared to connect a place here it is shown another

way with bar charts that are just so horizontally patients want to be in the white zone they are more likely to be in the white zone if they were treated with connected place

thank you for the opportunity to speak today I have no disclosures so identifying predictors of post-traumatic syndrome is important for a number of reasons firstly to be able to counsel our patients with dvt on their expected prognosis and also to potentially

identify patients who might benefit from a more aggressive approach to treatment of acute pvt for closer monitoring after DVT and potentially for preventive strategies the next few slides i'm going to show you come from a systematic

review that we recently published trying to collate all of the data on predictors of post-traumatic syndrome this slide shows established risk factors for post-traumatic syndrome by established I mean that the data come

from either numerous and or large studies with consistent associations recurrent its lateral dbt is associated with the five to ten fold increased risk of developing pts we know that the more proximal the deep vein thrombosis is

particularly dvt affecting the iliac or femoral vein is associated with about a two to six fold increased risk of pts and both obesity and presence of varicose veins prior dvt have also been associated with risk of pts the next

slide shows possible risk factors for pts again from the same review where possible means that data come either from fewer or smaller studies or where associations across studies have not been consistent possible risk factors

include older age female sex residual dvt symptoms one month after dvt diagnosis and I'm going to come back to that factor shortly when I present to you some results on predictors from the Sox trial residual thrombosis as we

heard from the previous speaker valvular reflux or in competence asymptomatic DVT and namely found on screening mammography for example and post-op patients has been in some studies associated with risk of pts some data

suggests that if your INR is not therapeutic or subterra pubic in the first three months after treating dvt that there's about a 2-fold increased risk of post-traumatic syndrome there's also some suggestion that

treating dvt with low-molecular-weight mono therapy for a number of months worth of treatment is associated with the lower risk of post-traumatic syndrome and vitamin k antagonist and as to the

influence on new oral anticoagulants on risk of pts to date this is simply not known and then finally their number of various biomarkers markers of inflammation a d-dimer and genetic markers that might be associated with

risk of pts certain factors that have not been shown to be associated with pts are shown on this slide that includes whether the DVT occurred in an unprovoked or provoked setting the presence of thrombophilia in the

effective patient and also how long you treat a patient with anticoagulation for so whether they receive a three months six months or 12 month course that doesn't appear to in itself affect the risk of post-traumatic syndrome

I'm going to spend the last part of my talk giving you data from a sub analysis of the Sox trial that try to identify predictors of pts and these data were presented at last year's American Society of Hematology meeting so the Sox

trial was a multicenter trial of actor versus placebo stockings to prevent pts after proximal dvt patients were followed for two years and the primary outcome of pts was assessed at the 6-month visitor later

this slide shows to the baseline characteristics of the participants and you can see in the bottom panels at about forty percent of socks participants had either common femoral vein or iliac vein dvt as the most

proximal anatomical extent this slide shows you the predictors that were identified in the Sox trial the column headed by an orange shading shows hazard ratios adjusted simply for whether the patient got active or placebo stockings

and the pink headed column are is adjusted for that as well as all of the other factors on this slide and what you can see is that iliac vein DVT and the Sox trial was associated with a higher risk of post-traumatic syndrome and

interestingly the villa altos core category severity at one month was also associated in a dose-response fashion with this incidence of post-traumatic syndrome and this factor was found also in our previous veto cohort study

we did one additional analysis to see whether the villa alta score severity at the baseline at the time they were recruited into Sox trial was also associated with pts and indeed it was and we were not able to assess this in

the veto study because we didn't have a baseline measure of the go all to score this is my last slide to summarize there are a number of risk factors that predict pts the most important are the anatomical extent of initial d bt

recurrent its lateral DVT and interestingly the initial whether you look at baseline or one month severity of Venus symptoms and signs as measured by the villa altered scale despite this knowledge it is still not

possible to accurately predict an individual patient what their absolute risk of pts will be and they're likely a number of as-yet-undiscovered factors that are related to risk pts thank you

point where people normally show the nastiest picture they have of patients with post-traumatic syndrome

it is important to know that while ulcers you know are something that is part of the syndrome it is by no means the most common presentation of post-traumatic syndrome more commonly patients are just presenting with daily

leg pain swelling this heaviness and that combination of symptoms significantly in Paris quality of life you can also get some skin changes hyperpigmentation and fibrosis and for the Trude diagnosis of post-traumatic

syndrome you should wait till at least three months out from their initial diagnosis of their their dvt to not confuse some delayed effects with residual swelling from their acute episode and make sure that it's truly a

chronic condition because of some underlying a Venus damage involve dysfunction it is a lifelong condition that patients deal with the severity of course and impacts our overall quality of life

so who's developing post-traumatic syndrome not every patient who gets a DVT developed post-traumatic syndrome but several studies have shown that approximately fifty percent of patients with the proximal dbt that's you know

more proximal to the popliteal vein will develop a post-traumatic syndrome or patients with dvt specifically in the iliofemoral region that increases the risk to about sixty percent of patients so if you have a clock there and its

management of of dvt can be broken and very simply into ambulation blood thinners compression stocking pretty

good evidence that each at each level on the recommendation but we know that there is a need for more because we're seeing these patients with post-traumatic syndrome patients who have chronic disease and so what are we

looking at well its patients who have leg swelling and pain people who come in with the heavy leg syndrome and these are the sort of images that we know will see fairly regularly and these the ones that are usually association with

proximal disease in the video cable segments it's extremely common if you run the numbers somewhere between twenty and fifty percent of all patients who develop whoever dbt will develop some form of pts despite being on the best

our ad coagulation and obviously people who can't be out Greg later a higher risk and all those people somewhere about ten percent will develop a severe form of PTSD can go onto ulceration so that the probability of

one of us getting a DVT and that going onto ulceration is somewhere up to five percent so huge number when you think about the the prevalence of this disease and this has a as big societal costs so

good afternoon thanks known for the invitation to be here looks like a great session arm sure this works I'm although it was the blood described part earlier than me and Turner as far back is very callous man Turner attributed with doing the first systematic study of lesions at

the crossing of the right common iliac artery and left common iliac vein and in this series of 342 adult cadavers identified these Spurs at the crossing and twenty-four percent of patients subsequent bill marstons group has

specifically looked at this in patients with either healed or active venous ulcers with cross sectional imaging and found greater than 50-percent Elio cable stenosis in approximately fifty percent of patients and is Peter just showed you

I'm going to get looked at in normal patients that is those presenting with abdominal pain and found these lesions in about twenty-four percent of patients so clearly these are common lesions but at least in some patients have a bad

outcome and question arises is what constitutes a critical stenosis in the venous system and I would submit to you that we really have to abandon all of our concepts of arterial disease because our truthiness concepts of critical

stenosis aren't in any way analogous to Venus stenosis in particular arterial stenosis we all know where defined as those that result in a significant reduction or sharp drop in downstream pressure and flow while the critical

parameter and Venus cystinosis is not distal flow but its proximal pressure and the determinant determinants are much more complex than arterial disease with a list of the things shown here as an example in the graft on the top we

see venous pressure on the y-axis and inflow on the x-axis and you can see as inflow rises on there's a sharp rise in venous pressure within flow and in contrast to the arterial system on these determinants are additive on their

determined by the highest pressure component and oftentimes this is the Starling forces or what analogous to intradermal pressure on this graph we see the degree of pressure elevation on the y-axis as determined that various

degrees of stenosis and at very startling for the various Starling forces and you can see at low interest Domhnall pressures stenosis of it as small as ten percent caused a sharp rise in pressure while a high and tripped on

I'll pressures there's virtually no effective stenosis so i would submit to you that there is no definition of a critical Venus stenosis it depends on the clinical situation and we ought to abandon the arterial concepts so why not

just measure venous pressure to define and I think we all know that measuring venous pressure is incredibly complex collateralization tends to normalize pressures veins or capacitance vessels and the compliance of the wall varies it

depends on flow parameters and it's subject to a lot of measurement variabilities and this is demonstrated most recently in this series from case winds will be talking later in a very small series case tells me this is now

up to 16 although he wouldn't give me the updated data in the bar last night but looked at femoral and dorsal putting pressures walking on a treadmill in four patients with iliofemoral obstruction as you can see although this isn't very

user-friendly onto to show suffice it to say that there's no difference between obstructed legs and control legs and resting Venus pressures or endorsing foot pain pressures with ambulation and the only consistent

finding is a significant elevation in common femoral vein pressures with ambulation and I think this post calls to attention to the fact that distal pressures are transmitted in patients with in disqualification from proximal

obstruction and that this is not a clinically useful test we just can't measure venous pressure is very well so why doesn't everyone with apparel business thrombosis get and also really were interested in this at the

University of Washington almost two decades ago this is a series by Brian Johnson one of our fellows looking at the ultrasound findings in patients with post-traumatic skin changes and patients were asymptomatic after a DDT and you

can see that the common pattern in those patients with skin changes is a combination of reflux and obstruction which is much more common in either obstruction alone or reflux alone and negative energies you have proposed that

reflux is actually permissive for proximal obstruction to develop the distal severe manifestations of post-traumatic syndrome in this series of 487 limbs a hundred eighty seven of them had obstruction only about 260 a

combination of reflux and obstruction you can see those with reflux of an obstruction we're almost twice as likely to be post-traumatic and times more likely to get venous ulcer

I'm so it's the distal reflux that determines the effect of the proximal obstruction and this is shown in the patients with obstruction and reflux had a smaller drop in ambulatory venous pressure that is their penis pressures

were higher and higher reflux volume interestingly all those most of these patients were symptomatically better after stenting this wasn't reflected in an improvement in ambulatory venous pressure or in the volume of reflux

which again shows the fallacy of measuring distal pressures on for approximately obstruction so to put it together pathophysiological II when we have a proximal obstruction the distal reflux is actually permissive

for the development of the severe skin manifestations which results in pressure transmission to the microcirculation probably mediated by a decrease in endothelial wall shear stress with subsequent endothelial activation and

leukocyte activation and ultimately in alteration so in conclusion although a symptomatically a compression is commons clearly in a significant portion of patients this will lead to bad

manifestations the concept of a critical stenosis ought to be abandoned but if we're going to stick to it we have to define it by an increase in upstream pressure not downstream perfusion the determinants are very complex and will

determine what a critical stenosis is and severe post-traumatic syndrome is associated with both reflux and obstruction and reflux is likely permissive allowing for the transmission of digital pressure in the development

of severe manifestations thank you very much

So again this is what we did, right? 150 to 300 micron with 75mg Dox. This patient who had the ring of enhancement around the tumor, around our post study. We would just book him for one month follow up.

You can see here on the arterial face, I'd only show the arterial face image here, but the tumor is basically dead he has a small amount of perihepatic fluid following that. This patient then, after we would've typically seen him at one month, we would go into a kind of cue three month

follow-up pattern. Kind of sticking with the requirements that they'll need for transplantation, and allow them to gain their exception points. This patient maintained a CR up to one year, although he's not transplanted yet. At that time, at the one year follow-up, there was a new hypervascular lesion in segment two.

I guess I should have thought about not showing this case given Ron's talk, but this patient, you can see it's very high in their liver. It restricts diffusion, it washes out, certainly an HCC.

We went out into the hepatic lobe into segment two. Much like we would have done before. We are very selective, we're just treating this single segment two vessel with our standard mixture, same drug that we'd done before. It takes in my mind even greater

patience to actually get all of that therapy into this small distribution, but it can be done. We just need lots of time in between injections, a very slow infusion.And we start the clock over again. This patient did have pretty

good coverage. Again, looked homogeneous to us in our cone beam CT, we start the clock over, follow up again a month later, unfortunately these are arterial on top,

venous on the bottom, from superior to inferior. You can see for this gentleman, the very superior most aspect of the tumor continues to enhance and wash out, while the more inferior portions of the tumor are completely necrotic.

So, this is the type of patient who we would typically bring back and go looking for extrahepatic supply to the tumor. I don't think retreating would be a wise idea here. Again, lobar DEB TACEs is not something we do.

I usually give a patient two chances at the same therapy before switching the therapy type. Obviously the location of this makes it kind of absurd to consider ablation. It's very close to the diaphragm, it's already been treated, it will probably

be very hard to localize and treat appropriately. So, not surprisingly we found this phrenic supply. You can see this blotch of contrast here. Maybe I showed a really bad image, but there is some supply to the diaphragm here off this phrenic. We thought we could either,

as Ron said, we could consider bland embolizing from here. We could consider cooling off this phrenic vessel and then deliver our DEB TACE from where we're located. We could bring the patient back and do something different.

But I think really, you're already there, these are your options, you've already paid for your DEB TACE, so we are basically gonna try to coil this off and deliver it from here. Insert a coil, cut of the blood supply. The vessel's still there,

we missed our DEB TACE. This is our post-embolization run. You can see, again, neurostasis, devascularization of the tumor. And we're refluxing all the way back. Unfortunately, this guy ended up having another recurrence more

recently, and we had to go re-treat it again. This kind of brings up Dr.Golzarian's point that we're going back and back to treat this guy, and not infrequently you don't have to bring patients back to retouch them up after DEB TACE. So this is again the previously treated lesion. I see an area of enhancement with washout again, the phrenic is still closed off,

I don't know, I accidentally got into the thing so we just shot it. That fistula that we had coiled off is closed. Unfortunately, in the process of coiling that off we also sacrificed that vessel that ran out to that portion of the liver. But we were able to get out into this area here to find our tumor. [BLANK_AUDIO]

I'm gonna skip some details but then ultimately we [INAUDIBLE] therapy and get again good tumor staining. We did this a couple of months ago so we don't have any follow up yet. But in general from my HCC follow-ups, kinda showing you it's kind of a typical pattern that we'll see. We're following these patients every month with MRIs and CTs,

we always get lab values, we always see them in a clinic with each set of imaging, kind of just of refresh the patient on where we're going, how we're doing, touch base with our colleagues in transplant, see how close we are to transplantation,

there's a lot of variables that can go into that. Some of our patients we have on a large living donor program at Penn, so some of our patients would be much closer that you would think otherwise. Typically the only thing that alters this kind of cue

three month follow-up when someone goes for a very extended CR, with no new tumors for two years, and I kinda start to space out a little bit longer. And I just wanna remind everyone, if you're in those scenarios where you're actually down staging patients who are outside of Milan. You know, kind of look at their response.

You need to make sure you're re-addressing the status of the multi-disciplinary tumor board, to verify whether or not they've been reconsidered for transplantation.

leading to post-traumatic syndrome then if you remove the clot that should in theory decrease your risk of developing post-traumatic syndrome and that has been proved as a proof of concept with many studies when patients are put on

anticoagulation so if patients you know are decreasing their risk just with anticoagulation then if you remove the clot potentially earlier with the development and the implementation of catheter directed

thrombolysis and preserving the overall integrity of the vein is that really going to speed symptom relief is it going to spare the valve function is it good going to preserve the maintenance patency and is it going to really

ultimately prevent post-traumatic syndrome the very first randomized trial and to date the only randomized trial was a Scandinavian study out of Norway where they looked at patients specifically with high proximal dbt so

the iliofemoral dbt and they randomized them to standard therapy which was anticoagulation and compression stockings versus standard treatment with additional catheter directed therapy and they demonstrated an absolute risk

reduction of fourteen percent so41 per se forty-one percent of patients still developed post-traumatic syndrome when they got the additional catheter directed therapy but with some

significant reduced from those patients who just received the anticoagulation alone then of note there was a small increase bleeding risk associated with that therapy this therapy of our this study although it is good data doesn't

necessarily reflect the current practice of what we do today more commonly what we're doing is pharmacol mechanical from back to me or catheter directed from back to me so using you know different devices and

tools and stents to help improve the primary patency of the van once we re-establish flow that isn't really reflected in what this study was designed to do therefore the track trial which we all

know was really designed to address the form of mechanical components of catheter directed from therapy and really does that prevent post-traumatic syndrome against a multicenter study the control group was

the same as the region study with anticoagulation and compression stockings the treatment group was that in addition to the pharmacol mechanical therapy there followed for two years and overall it was a more robust study with

powered to test for a third reduction they have closed registration they had just under 700 patients registered and now we're just waiting for the follow-up in the data to come out on that in

determine ladies and gentlemen were a lot about this ecosystem ultrasonic assisted trouble is the question do we need that at all in our patients that I don't have any disclosures to make here we heard about the coven I think this is just a door reopen off for CDT that the

disadvantages that trials that the durational trouble arises was at a mean of 2.4 days keeping the patient on intermediate care and going along with the major playing rate of nine percent and another drawback of that study is

that the PTA standing right in coven was down to seventeen percent knowing that we have at least sixty percent on the lying stenoses of the iliac veins creating probably or being the reason for the trombones in these patients so

implementing that we routinely stint are that the residual Venus cells is either well this is true Moses or extrinsic stenosis it doesn't matter we do a routine standing and we are implementing ultrasonic assisted character director

criminalizes and fix those fixed timing of 20 milligrams per 15 hours in our Center since 2010 when you see we have a standing rate of eighty percent of the from the first series of 87 / patient's we heard about the arm ultrasound system

the mechanism is we have fiber in separation and acoustic drug delivery we have active drug delivery by acoustic steaming to intensifying the effect of CDT that's our meaning and that's our wish arm we separated a little bit how

good is trouble izes according to the history if we have a real acute few days history have a 89% slices up to 15 hours of more than fifty percent if you see if we go to acute on chronic or more subacute history in these patient goes

down to sixty percent if we have that what I said the routine standing we anyway have a primary patency rate of eighty-seven percent secondary Peyton cre8 at 12 month of eight ninety six percent and the process traumatic

syndrome development at 12 month into patients that makes six percent so the question now is it the standing horses ultrasound assisted trouble arises that gave the much better results regarding pay to see in our patients so

we started a randomized controlled trial that is completely independent of the industry is funded by the Swiss research research research foundation is the burn ultrasound assist Rumble Isis for healio femoral deep vein thrombosis versus

standard CDT trial so as you see here patients were enrolled according the acute DV te ephemeral randomization was either to echo system fixed dozing of 20 milligrams over 15 hours versus CDT alone so all patient got the echoes

catheter inserted but in half of the patient where it was switched on and the other half it was not switched on the primary endpoint was assessed by a blinded correlate that was there was the flipper feet after 15 hours duration of

the license so it was a percentage of rumbles load reduction from baseline to 15 hours of capitalizes pretty fair done randomization these patients secondary endpoints adjunctive trembles removal spending rate bleeding rate and a

3-month follow-up in these patients and this is the primary endpoint i leave you with that for a second so percentage reduction and promised load by the length adjusted trembles score done by core lap was completely identical if we

go to the secondary outcomes adjunctive therapy objective capital rumbles removal therapy was slightly higher in the CDT only group but there were statistically not significant a small number is twenty-four hours twenty-four

patients adjunctive stenting number of implanted stands completely identical in both groups and safety major bleeding in one of our patients 4.2 percent in the echoes arm vs 0 in the CTR that is not statistically significant and probably

by chance minor bleeding in one in two patients in each arm so secondary outcome at three months primary patency hundred percent 96 secondary patency hundred percent mean alot to score three points

your pres- three-point miners 1.9 class minnows 1.9 at statistically not significant so in conclusion ladies and gentlemen catheter directed traumatizes will fix those regimen followed by routine stenting of residual veena

stenosis is safe and associated with a high pregnancy rate and low risk of post-traumatic syndrome the addition of intravascular ultrasound seems not to facilitate Trump's resolution this is done in a industry independent

randomized small size truck tire the results of the beautiful try may not necessarily apply to other echoes indications including PE or trauma embolic arterial disease thank you for your attention

thank you again thank you dr. V for the invitation i'm going to talk about a study is near and dear to my heart my disclosures we all know and we've seen through the last several days at the VT and pts is a very prevalent problem likely millions of patients are

suffering from post-traumatic syndrome is is very costly to the society is can be very devastating for patients so it was a rationale for access pts well the intention here is that those patients suffering from PTSD underwent medical

management that was not sufficient when there are chronic venous changes in the vein restricting or obstructing flow venous pressure will increase the severity pts is known to be directly proportional to the degree of ambulatory

Venus pressures the higher the pressure the more severe the symptoms so someone has symptoms with chronic venous disease consider intervention the goal of intervening on chronic dvt is to relieve the obstruction by restoring flow

included segments thus decreasing the venous pressure and subsequently the severity of post-traumatic syndrome the question needs to be answered is can we reduce post robotics equality and improve the quality of life in those

patients from pts and thus we created access pts study how do we get there well it's really all came about in 2012 after presenting our data or single center Center registry data on a hundred six patients with all chronic dvt they

all had seep classifications of greater than or equal to c3 with complaining of lifestyle limitations we looked at two technical success endpoints one with the ability across the occlusion which we were successful in a hundred and twenty

of a hundred twenty-two limbs and the ability to restore flow which was in a hundred and eighteen of those intent-to-treat hundred twenty-two limbs we looked at the clinical success is symptomatic improvement with a mean

follow-up of over two-and-a-half years 97 or 93% of those patients reported significant improvement seven were unchanged but nobody got worse when we look at ultrasound patency we saw Peyton seas of almost ninety percent at six

months eighty percent of 12 months which dropped to almost sixty percent at 24 months we then look at allow two scores and we looked at population that we treat in 2013 and presented the

seriously meeting in Europe of 31 page since pre-procedure means alot two scores were 13.1 and at one month is dropped 25.2 at six months it was 2.1 and one year it dropped to 1.9 this then led to Ken oriel and syntax to look at a

pilot venogram clearance analysis he looked at the RL score American Venus registry score and martyr scores of all of the veena grams at baseline post angioplasty and post lysis overnight here is an example of a 65 year old

female 98 hysterectomy left iliac being ruptured of a surgeon was called in unable to repair so he like gated the the iliac immediately developed pain and swelling when she will from anesthesia had extensive left leg dvt was

antiquated with compression stocking standard of care for 12 years but she had severe limitations of activity and very poor quality of life so she was referred by the evaluation and management here is twelve-year-old dvt

that we saw you can see that the popliteal vein had some chronic venous changes I'm sorry here then there's collateral to the profunda here was the major problem she had a surgical ligation clip

here we were able to nudge our way through there and doing cereal balloon dilatation stented the central deck system equals the fam pop system this was overnight treatment and although it looks ugly and irregular there was

actually brisk flow through these segments back into the IVC here is her five-year follow-up ultrasound I saw her two weeks ago she had patency of the deep venous system she's extremely happy with the result she treadmills and

cycles all the time she's rare minimal symptoms and have alot of scores went from above 20 22 so we decided we're going to develop further incident evidence this is the steering committee for

access pts and it's a prospective multicenter study with patients with symptomatic pvt for at least six months documented by ultrasound fail at least three months of conservative therapy within a coagulation compression

stockings without the scores of at least eight the outcomes of treated thrombosis deep vein thrombosis with intervention from the ecosystem will be evaluated the primary endpoints are clinical reduction of four on the velocity scored 30 days

compared to baseline and at least half the subjects with technical end points also being increase in blood flow calculated by the time to wash out in the affected set minutes this is the list of the study

sites and enrollment to date as of last night enrollment we are 72 of 200 treated have been 41 and there was one failure to cross with the intent-to-treat so I'm can only say that imagine the value-added for this

landmark study the day that we can say we can eradicate at Radek eight pts with treatment thank you

catheter directed therapy in which of the following acute dvt scenarios is supported by randomized trial data a flag measure like measures really don't to prevent loss bidc thrombus see

iliofemoral dbt to reduce the risk of the post-traumatic syndrome d fanpop dvt to reduce the risk of the post-traumatic syndrome re none of the above the answer is C the iliofemoral dvt to

reduce the risk of post-traumatic syndrome that was our Comment study the

So the final case is I think the worst complication that I caused, it's I feel awful about it and hopefully it will be a learning lesson for yourself it certainly was for me. This was a 29 year old who had a terrible SVC syndrome with advanced with spiritry/g compromised as well as chemosis and almost not quite

comatose but really in quite a bad way from his SVC syndrome. His background history was that he had chronic renal failure since infancy and had had two failed renal transplants and innumerable lines in his upper extremities in both his eye IJs. He was HIV and Hepatitis C positive from transfusion related issues. He was on aspirin at the time for cardio protection,

and he had two needs, one of which was an access for haemodialisis and then the second was treatment of this SVC syndrome, but he certainly needed access immediately. This was a CT that we did at the time, you can see the seclusion

here in his SVC. Very dilated azygos vein. We do quite a bit of SVC recanalization for access, for dialysis access, short gut syndrome, TPN, that sort of thing.

One of the things I will say to you is that when you're looking at the CTs, the level of the occlusion is really crucial. That the lower it is the more dangerous it is. And this is the illustrative case of that, that if the occlusion is higher up, it's outside of the potential for pericardial involvement to

can be a little bit more aggressive. When it's lowered down like this, this is where you can run into trouble. So we did what we usually do which is an antegrade access from a recanalized external jugular vein, brought a sheath down and you

can see the run here is showed really just enormous [UNKNOWN] stylation system feeding back with no evidence of an SVC at all. It actually wasn't that hard to recanalize, didn't require sharp recantalization again, most of these we do require sharp recanalization, but here a wire and catheter and a few sheaths managed to get us through.

And you can see the position of the wire in the SVC going down through the atriam/g to the IVC with the position of the [UNKNOWN] behind us. I then proceeded to ciliary dilate and started off with six and eight very tight ways to tuck her off, but it gradually began to

open with some high pressure balloons and I did intimate non geography to see how I was doing despite opening it to I think this is after a ten balloons zero antegrade flow through the system still all going down through the [UNKNOWN] Proceeded up with some further larger balloons, and at this point

I did another angiogram after this it was a 14 millimeter balloon and there was a finding that I missed at that time that is very important, and I'll give you a second just have a look at the angiogram yourself to see if you're better than me. And this is what it is. So this, what I believe was an intimal tear in the acute thrombotic

formation on an intimal tear of the SVC was on this one. I did not appreciate it at the time and proceeded with further balloon angioplasty because again there was no antegrade flow leading down into his SVC and into his right atrium at that point. Proceeded with further balloon angioplasty this is with an 18 balloon and got it up to full and then as I took it down he began to complain

of a strange sensation in his chest that rapidly progressed to him being [INAUDIBLE] that rapidly progressed to him collapsing cardio dynamically and then I performed this angiogram and you can see here as we go through the run this large rent/g here and free extravazation from the SVC

into the pericardial space and [INAUDIBLE] there. So this was complicated by an acute [UNKNOWN] immediately I would say within 30 seconds, he began to change [INAUDIBLE] with the chance of respiration within a minute he had arrested and was requiring

quite a bit of chest [UNKNOWN] followed by as you can see we put in a pericardial drain immediately I inflated the balloon to expand it and he ended up being shocked several times. The options were discussed with the arrest team, we felt that given his age given that he was 29 and this was an acute issue, we would to do our best

to preserve everything in it's place [INAUDIBLE] while that was being set up I kept the balloon inflated and there was a thought that perhaps his balloon tapered out enough release. This showed that no it wasn't, this is after 45 minutes of balloon tamponad/g you can see there is still this large hole,

this is not gonna be repaired by simply tamponading/g the hole, and I ended up placing a viabahn stent across the area. Unfotunately we didn't have atrian/g in this particular lab at that time.

So this sealed the hole and we were able to stabilize him at this stage the bright red blood that was pumping out of his tamponade/g drain that was pericardial drain ceased immediately, and he became [INAUDIBLE] stable again and we were able to move him upstairs. Unfortunately, he had a drastic postoperative course with a global hypoxic injury and actually passed away three days later.

So the take home from this case for us, for me in particular was to be very wary of dilating chronic SVC occlusions particularly those that are low down the super cardinal recess of the pericardium extends to the level of the [UNKNOWN] when you're chronic occlusions at that level to be very very particularly if the major clinical question is accessed,

they do not need to be dilated to 18 like I did, but in the access, settle in there, and you can always come back and treat the SVC syndrome at a different time, perhaps in a different way. But certainly it was a very [INAUDIBLE] point for myself. >>

management of of dvt can be broken and very simply into ambulation blood thinners compression stocking pretty

good evidence that each at each level on the recommendation but we know that there is a need for more because we're seeing these patients with post-traumatic syndrome patients who have chronic disease and so what are we

looking at well its patients who have leg swelling and pain people who come in with the heavy leg syndrome and these are the sort of images that we know will see fairly regularly and these the ones that are usually association with

proximal disease in the video cable segments it's extremely common if you run the numbers somewhere between twenty and fifty percent of all patients who develop whoever dbt will develop some form of pts despite being on the best

our ad coagulation and obviously people who can't be out Greg later a higher risk and all those people somewhere about ten percent will develop a severe form of PTSD can go onto ulceration so that the probability of

one of us getting a DVT and that going onto ulceration is somewhere up to five percent so huge number when you think about the the prevalence of this disease and this has a as big societal costs so

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