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Line-associated DVT, Calf Vein DVT and Superficial Vein Thrombosis: What to do. Ian Del Conde, MD, FACC Vascular Medicine and Cardiology Miami Cardiac and Vascular Institute HeartWell December 12, 2015

Disclosures CONSULTANT Merck; New Haven Pharmaceuticals ADVISORY BOARD Merck, IC Sciences SPEAKER’S BUREAU Johnson & Johnson, BMS, Pfizer

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1. Line-associated DVT 2. Calf Vein DVT 3. Superficial Vein Thrombosis

Line-Associated DVT

PICC line

Hemodialysis Catheters And P-A-C

PPM/AICD

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Venous Anatomy of the Upper Extremity DEEP VEINS Brachiocephalic V. Jugular V. Subclavian V. Axillary V.

Distal

Proximal

Anticoagulation

Anticoagulation may not be necessary

Brachial V. Ulnar V. Radial V. SUPERFICIAL VEINS Cephalic V. Basilic V.

Line-Associated Venous Thrombosis: Epidemiology Overview • 50-60% of all cases of UEDVT are lineassociated. • Two-thirds are asymptomatic • Risk factors: – – – – –

Active cancer Radiation therapy, chemo, TPN Catheter tip not at atriocaval junct Catheter size (AICD/CRT) Prior central venous catheterization The DVT FREE Steering Committee. Circulation. 2004; 110: 1605-1611

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Symptoms and Physical Exam Symptoms: discomfort, pain, paresthesias, discoloration, swelling

Symptoms and Physical Exam Symptoms: discomfort, pain, paresthesias, discoloration, swelling

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Symptoms and Physical Exam Symptoms: discomfort, pain, paresthesias, discoloration, swelling

Questions to Address: Patient Factors 1. What vein segment is involved? 2. Is proximal extension likely? 3. Any indication of SVC syndrome? 4. Contraindication to anticoagulation?

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Questions to Address: Catheter Factors 1. Is the catheter still needed? (IV meds, blood draws, TPN, etc.)

2. Is the catheter functional? 3. Any evidence of infection?

Management of Catheter Associated UE DVT Routine catheter removal is generally not recommended • Difficult access, continued need for further IV access should be considered • Must be able to anticoagulate the patient

Removal is warranted in: • Malfunctioning catheter, infection, contraindication to anticoagulation, persistent signs and symptoms despite treatment.

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What do the Guidelines Say? • Anticoagulate for as long as the catheter remains in place. • If the catheter is removed, and the DVT involves the axillary or subclavian veins, anticoagulate for 3 months (longer if the patient has cancer).

Calf Vein Thrombosis Opinions differ: • Need to examine calf veins? • Need to treat?

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Veins of the Calf DEEP VEINS Anterior tibial V. Posterior tibial V. Peroneal V.

MUSCULAR VEINS Gastrocnemius V Soleal V.

SUPERFICIAL VEINS Greater saphenous V. Short saphenous V.

Observations: • With no treatment, 15% propagate to popliteal vein. • Pulmonary embolism rarely occurs ( 7 mm in diameter

2012 ACCP Guidelines

Calf Vein Thrombosis: Bottom Line • Who to treat with anticoagulation? • Symptomatic patients • Risk factors for extension • Full-dose anticoagulation, (same as for prox. DVT)

• • • •

Extensive > 2 veins Close to prox. veins > 7 mm in diameter

• If anticoagulation is not prescribed, serial duplex ultrasounds for 2 weeks. 2012 ACCP Guidelines

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34F, otherwise healthy. Acute R leg pain during a basketball game. Swollen, painful leg. Venous duplex: Acute thrombosis of the gastrocnemius vein.

Scimitar sign

Should this patient be anticoagulated?

Gastrocnemius Tear

No anticoagulation!! Repeat duplex US in 1 week.

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Superficial Vein Thrombosis

Common Femoral V. Femoral V.

Peroneal V. Ant. Tibial V.

Greater Saphenous V. (GSV) Small Saphenous V. (SSV)

Dorsal Venous arch.

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Common Femoral V. Femoral V.

Peroneal V. Ant. Tibial V.

CFV

Greater Saphenous V. (GSV) Small Saphenous V. (SSV)

GSV

CFV

FV

Dorsal Venous arch.

Common Femoral V. Femoral V.

Peroneal V. Ant. Tibial V.

Greater Saphenous V. (GSV) Small Saphenous V. (SSV)

GSV Thrombus

Dorsal Venous arch.

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Common Femoral V. Femoral V.

Peroneal V. Ant. Tibial V.

Greater Saphenous V. (GSV) Small Saphenous V. (SSV)

Dorsal Venous arch.

Risk Factors for Superficial V. Thrombosis Varicose veins

82%

Prior DVT/PE

22%

Cancer

6%

Immobility

8%

Recent Hospitalization

9%

Surgery

4%

Trauma

5%

Hormone

13% Ann Intern Med 2010;152:218

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What is the incidence of DVT/PE in Patients with SVT? 844 patients • Whole leg Duplex US Proximal DVT

10%

Calf DVT

14%

PE

4%

Total VTE = 25% Ann Intern Med 2010;152:218

SVT Epidemiology: Bottom Line • 1 in 4 patients will have DVT/PE US imaging in for all SVT patients CTA in selected patients

•With isolated SVT, VTE rates low @ 3 months: DVT 3% PE 0.5%

•Risk factors for VTE complications : Male gender, prior VTE, cancer, no varicosities

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How should patients with isolated Superficial Vein Thrombosis be treated?

Arixtra for SVT Treatment CALISTO Trial

1º endpoint: death, DVT/PE, SVT extension into SFJ @ 11 wks NEJM 2010;363:1222

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CALISTO Trial Placebo

Fondaparinux (Arixtra)

NEJM 2010;363:1222

1º endpoint: 1.2% vs. 6.3%; NNT = 20 (death, DVT/PE, SVT extension into SFJ @ 11 weeks)

SVT Treatment: Bottom Line • With isolated SVT, VTE rates low @ 3 months • Who to treat? • Severe symptoms • Great saphenous vein involvement (vs. tributary) • Long segment (> 5 cm) • Proximity to saphenofemoral junction (5 cm) • SVT extension/propagation • Risk factors for VTE complication (prior VTE, or cancer)

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SVT Treatment: Bottom Line • How to treat? Arixtra 2.5 mg QD (prophy dose) Prophylactic does LMWH Novel Anticoagulant?

• How long to treat? 6 weeks

2012 ACCP Guidelines: Superficial Vein Thrombosis •Lower limb SVT ≥ 5 cm in length, we suggest prophylactic fondaparinux or LMWH for 45 days over no anticoagulation (Grade 2B). •We suggest fondaparinux 2.5 mg daily over prophylactic LMWH (Grade 2C).

ACCP Guidelines 2012

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Thanks [email protected]

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