1	Acute DVT and the “Power-Pulse Spray” Experience: The Science and the Results George Meier, MD RVT FACS Chief, Vascular Surgery University of Cincinnati
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3	DVT Management Mostly unchanged for 70 years High rate of post-phlebitic syndrome particularly with complete occlusions Chronically debilitating outcomes Main technique: prevent clot propagation, long term external compression
4	Why Do We Need a New Treatment for DVT? Risk of post-phlebitic syndrome high in iliofemoral DVT using current regimens In young patients, significant morbidity long term
5	Case Presentation: ME
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8	Duplex of Lower Extremities
9	Treatment - 1
10	ME – Phase 2
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14	ME - 3
15	Traditional Management of Venous Thrombus Old version Standard treatment usually includes anticoagulation to prevent further propagation of thrombus New version Goal is to preserve valve function Catheter-directed thrombolysis Mechanical adjuncts to speed up the process and lower lytic dose
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17	Venous Thrombolysis - 1 Different than arterial!! Large clot burden Often associated with hypercoagulability Variable duration of onset, often acute thrombosis on chronic Urgency to lyse to preserve valve function Large volume for treatment
18	Venous Thrombolysis - 3 Duration of thrombosis Most commonly, prior DVT Onset may be several days or longer With lysis, almost always a younger and an older component Therapy directed at both components Acute component = bolus thrombolysis + mechanical Chronic component = infusion thrombolysis?
19	Venous Thrombolysis Valve Preservation If it is to be successful, lysis should be early in course of DVT (less than 7 days) In reality, how old is the clot? Progression (= acute) leads to symptoms Aggressive, rapid removal of acute component where valves are in greatest jeopardy
20	Venous Patency after UK
21	Bleeding Complications with Venous Thrombolysis Major Bleeding in 54/473 = 11% Intracranial bleeding in 2/473 (0.4%) Sheath insertion site bleeding in 39% Retroperitoneal bleed in 13% Miscellaneous sites in 28% Not defined in 20% Can this be reduced with mechanical adjuncts?
22	Concept Mechanical adjuncts may speed thrombolysis and limit total lytic dose and risk of bleeding
23	Percutaneous Mechanical Adjuncts for Clot Removal Possis – AngioJet Edwards – Oasis Spectranetics - Eximer Laser Bacchus – Trellis Others…
24	AngioJet Percutaneous Thrombectomy Less vessel trauma Less blood loss But is clot removal adequate using this modality alone?
25	The AngioJet^â System Has Three Components Family of Catheters
26	Power-Pulse Spray
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28	AngioJet versus CDT
29	AngioJet for DVT
30	Case: Initiation of Treatment
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33	Initial Therapy
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39	After 12 hours…
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52	Outcome of Venous Stents
53	Outcome
54	Ideal Indications for Thrombolysis in DVT Occlusive iliofemoral or femoropopliteal DVT with no contraindications to thrombolysis Symptomatic Young patient Acute clot (<10 days old) No prior DVT Left leg?
55	Conclusions Venous thrombolysis is an area for significant growth in the near term The combination of catheter directed thrombolysis with mechanical adjuncts is the current focus New thrombolytic agents may alter the balance further
56	Summary Both diagnosis and treatment of DVT are changing! Better diagnosis may allow more tailoring of therapy to individual patients Preservation of valve function may be possible in many DVT patients
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