Vascular Surgeons David Dexter and Steven Abramowitz discuss endovascular treatment of lower extremity DVT, including patient selection and risks and benefits of catheter-directed therapy (CDT), mechanical thrombectomy, and pharmaco-mechanical thrombolysis.
this week on the back table podcast. At that point, the clock can be removed from the basket set off to the back table, and you can look at the morphology of the cloth. I think that's probably the most satisfying part about removing clot this way is that we can tangibly identify what we've taken out, and it's It's amazing that the different type of cloth that we can pull based on when patients had symptoms, you can really start to identify. What's fresh clot? What's clot as it starts to organize a week to three weeks later and what chronic things you can still remove after months of clot formation? Welcome to the back table podcast. If you are a new listener, welcome for our regular listeners. Welcome back and thank you for listening. Back table is a podcast committed to all things ir an endovascular. I'm Chris back, and I'm a private practice interventional radiologist based out of New Orleans. I'll be your host for today. We have a great episode lined up, but before we get to that, I would like to take a moment to thank our sponsor an aura medical and Nari medicals mission is to treat and transformed the lives of patients suffering from Venus diseases with purpose built solutions for removing large blood clots from the Venus anatomy without the need for throwing politic drugs. In our is pioneering devices such as the clot Trevor specifically designed for the Venus Anatomy and its unique clot morphology, you can find out more at an Army medical dot com without another way. Let's get started and happy to introduce our two guests today. We have Dr David Dexter and Dr Steven Abramowitz. Um, David, would you like to introduce yourself and tell us a little bit about the practice? Sure. Well, Chris, thanks for having us on the program today. We really appreciate the opportunity talking about Venus disease. So I was ah, vascular Surgery fellow From 2000 and 10 to 2000 and 12, New York University in Manhattan. I took my first job out of training in Coastal Virginia. I currently spend most of my time in Norfolk. I joined a group of slightly more than 20 vascular surgeons, and when I came to practice, they were specializing in complex aortic disease, Ph. D. Carotid stenting and dialysis access. They had a preexisting veins center, which was very, very well branded. But no one was doing advanced deep Venus work. So I found a niche fairly quickly within my first or second year of practice, developing a program for DVT, pulmonary embolism and Venus. Tempting. That's awesome. That's awesome. Stephen, would you take a moment and introduce yourself and tell us a little bit about your practice? Yeah, absolutely. Again, thank you for having both of us on the program. Uh, my name's Steven Abramowitz. I trained at Mount Sinai and finished up in 2014, where I came down. Thio Washington, D. C. To join MedStar Health and Practice at MedStar Washington Hospital Center. MedStar MedStar, Georgetown University Hospital and MedStar Montgomery Medical Center. And down here, you know, my practice is about 30 to 40% deep Venus, and the rest is arterial and, you know, similar to what David's saying. You know, there's a There's a very big patient population in most communities in most major metropolitan areas. And I'd say, you know, across the country of untreated post robotic patients who are suffering from the sequelae of acute DVT long term, and I think that what I found in D. C, especially in my hospital network, is that a large sum of these patients were being treated wound care centers with kind of no results in terms of their symptoms or their ulcer healing potential. And there's a huge opportunity for us to prevent that disease process from progressing by intervening on the acute state, which is deepening thrombosis. Yeah, okay, interesting. So in. And we'll kind of get into a little bit more. But in terms of your practice, um, I guess the question is, how did you get patients? It seems like you touched upon a little bit that a lot of these patients were originating in wound care. And then there was maybe a funnel, then to getting console to be the wound care service. Yeah, well, in my opinion, by the time someone's in wound care, they're already 5 10 years past the point of where we could have done something for their acute process that led to their chronic disease state So posttraumatic syndromes, the long term impact on the vein and its ability to carry blood in a low pressure kind of low flow state. Once the vein is scarred as a change that compliance from the inflammatory process that is instigated to deal with deep vein thrombosis. Then you kind of you're behind the eight ball. And so really, it's not targeting the wound care patients starting those patients that are presented with acute DVT in the emergency room in urgent care centers in the outpatient or inpatient setting to prevent them from becoming those chronic wound patients. 5, 10, 15 years down the line. Okay, David, can you speak a little bit about Thio? How What are some common referral patterns for your practice in terms of DVT? Yes. So Steve said it exactly right, which is the right patients don't come at the right time and the wrong patients come at the wrong time. Really? So when I started in practice, the first system wide initiative that I took on was to start an algorithm and a treatment paradigm for acute DVT. So our acute DVT pathway starts when any patient shows up either to one of our family practice doctors in our multi especially group or one of our urgent cares or one of our e. R s, and we've integrated this algorithm into electronic medical record. So once patients are divided up into high risk or low risk categories, we determine who should go home, who should be admitted to the hospital, and you should see an interventional list early. So I'm very fortunate that for me, referrals aren't necessarily directly to me, there to the right interventionists at the right time. Because I do such a large burden of Venus work and some of the more complex stuff that if my partners or my competitors see something they don't want to take on, they'll then send that on to me. But I will say that there is a huge unmet need for these DVT patients in the community, and coming up with a really well oiled system that gets them in and seen and treated and triaged appropriately is really important. Whenever you were first getting into your job and in first starting your practice, were you a part of that process we're trying to build in that infrastructure, whether it be physical or via the EMR to help with those patients getting seen by the right personnel? Absolutely. So when PS I 12 started about six years ago, the hospital saw that they might lose half a percent or 1% of their Medicare collection dollars if they have impatient acquired DVT events. So we decided at that point as the vascular service line to leverage that. So that was our opportunity. And I shared that with a partner of mine to come up with the treatment method that didn't just deal with the PS I 12 patients and the PSC. 12 patients are people who had an operation and then probably don't get the right prophylaxis and get a DVT. We used it to say, Let's use this as a springboard for all the tea TV tpe inpatient outpatient that sort of spread from there in both directions. Okay, um, switching gears a little bit and and moving over to Stephen, Um, can you talk a little bit about when a patient first appears in your clinic? Um, what does what does your evaluation look like in terms of one of the most important things you need to know one of the most important things about your physical exam in and I get it that it's broad based, but if you could drill down on a couple of things that are really like high target areas for people who are getting in thio deep venous work or potentially some intermediate experienced practitioners. Yeah, I think one of the most fascinating things about DVT is a disease process for me is how variable people and patients experience their symptoms. I'll have patients will come in with a D V T extending from the common iliac van all the way down to the T bills, and they'll have minor swelling and say that they are not in a significant amount of pain. And I have a patient come in with, you know, very isolated tibial DVT and, you know, writhing in discomfort with extreme swelling and tenderness on doors, reflection of the foot. So ah, lot of it is about finding a way to approach the patients that standardized to you. So in our clinic we tend to use the ball to score. You know, there's a Venus clinical severity score there, a variety of different scoring systems out there. But I think having a standardized way of approaching how you're assessing the symptoms of the patient is really key because, you know, in managing the patients in both their expectations for recovery in understanding how they respond to whatever therapy you choose, be it something that's medical or something. It's interventional. You have to have a way to follow them. And a lot of that has to do with some scoring system that you can use that in parts objective and in part, objective. Eso that's that's key, I think first, in terms of how you work up the patient also then coming up with an algorithm for imaging to determine the extent of the disease. Because a lot of times it's the extent of the thrombosis burden that's going to guide you in terms of what you recommend to the patient. That could be either a duplex or for some patients who may not be a higher risk for proximal propagation, private history of prior gvt instrumentation or an IBC filter that could be co axial images. Are there any specific lives that you're interested in terms of, like hyper quagga, bulwark up or or those things, um, sussed out by another service line, or like hematology, potentially, you know, in our group, for the most part, if somebody comes in and they're young on, they fit the risk profile for having a hyper quick global state will, of course, refer them to hematology on for someone who's older, if we think that it's provoked or we can come up with a reason why we think the DVDs provoked, we don't necessarily console hematology. But for patients who we think there may be, an underlying malignancy will absolutely bring their primary care physician on board to help guide that work up. But one thing that's nice about in terms of the D. V T treatment is you don't necessarily need to have that consultation in place to begin your independent assessment or your independent treatment algorithm. For the most part, patients who are getting intervention or who are not getting intervention are going to be on anti coagulation for at least 3 to 6 months, depending upon which guidelines you follow, if not lifelong, and so that gives you time to bring in other consul consulting services without the need. Thio. Have them guide your decision making process. David back over you. Same question. Um, can you tell us what it looks like when a patient shows up to your clinic and and how you initiate that process? That interview. Yeah, I'm gonna I'm gonna try not to repeat what Stephen said because he and I have been friends for a while and we see things in very similar manners. So I think that everything he said about the clinic work up would sound fairly, uh, wrote coming out of my mouth and he just said it. So I'll say when somebody comes to the e r. And we've now made the decision that they need to have their DVT treated, I think there's some very specific things that I'm interested in, uh, to make sure that I know that what I'm gonna do is gonna work it is gonna be safe. So the first thing that I do is a true bleeding assessment. So regardless, regardless of what intervention is warranted, it's important to understand how the patient's gonna tolerate anti coagulation and how they're going to tolerate a throng politic agent if you plan on giving one. So I do a bleeding screen questionnaire myself. So even though I have six fellows and a slew of residents and physician's assistants and nurse practitioners who do a wonderful job, I still in front of every patient asked the same Siris of questions we do a you know, nasal bleeding Orel bleeding, rectal bleeding, vaginal bleeding, urinary bleeding as well as a stroke check. And then we talk about cancer. We talk about whether they've had metastatic disease. At that point, some people may get a head C T scan before we go along and offer them an intervention. Sometimes we don't depends on what cancer they may have. And if they've had brain mets or or at least a risk of brain mets on. But I do that routinely is just part of the history that I dio. The second question that I always ask them is about their mobility. So when we talk about all the scoring systems for how active and how mobile they are, it really doesn't matter how mobile they are now. They have the clot, since they've been suffering for hopefully on Lee a couple days, but sometimes days, two weeks and on some horribly rare occasions, months. It's important that I look at how mobile they're going to be and help determine. Are they really gonna have post traumatic syndrome later? Are they gonna be ambulatory? Are they going to walk? What are they really trying to treat. And the more they walk, the more they're gonna help themselves. And then the third question that I always try to dive into on the prehistory is understanding why the DVT developed so very often the risks of re thrombosis identifiable on a thorough questionnaire of prior history of DVT prior family history of clotting conditions. I think the most interesting part of it is what they've had done for surgical interventions that may interrupt the Venus system. And it's amazing how many times in the past eight years I found someone who's had a central Venus injury where something was litigated Suitor two bladed and the patient was just completely unaware. It's that untoward operation during a total hip or during a spine operation where a common ephemeral veins seen laterally where the iliac vein is mobilized. And then legate and the patient just didn't know that they were immobile, didn't have much leg swelling, and then weeks later identified the problems. So those are the three biggest things I focused on, at least in the ER, and you kind of touched upon it that that's an interesting point. So are there some? Are there some common surgeries that you've seen as repeat offenders in terms of things that potentially result in some business injuries. Yeah, I think that any time you do a spine exposure, and I do, ah, quite quite a few of them. The iliac veins air usually mobilized, and sometimes you can just induce a DVT from that. But Venus injuries during anterior exposure to the lumbar spine are certainly, I don't want to say commonplace, but a well described complication. And if you can't repair them, they do get litigated from time to time. I think the things that we don't think about don't pay much attention to is the retro peritoneal strip ings that when someone has lymph nodes taken off the iliac vasculature, it's very common that the iliac veins get abused, beat up. They can clot either acutely, or they can become five Roddick from scar tissue later. Those are probably the two most common surgeries that I look at mask about. Okay, Stephen, if if you could kind of describe after you're finished with your initial assessment, can you kind of describe like if you had to paint a picture of, like the ideal patient who you think is gonna benefit from DVT treatment. Can you kind of kind of paint with that patient? Might look like not not your And then we'll also move on to, like what? It may be a more typical patient. Looks like this like your ideal. If you could pick the patient that's walking into the room what it would be, 03 unicorn. Uh, e telegram man, right? Yeah. The ideal patient is the young, healthy individual, male or female, who probably is hyper co available and had their first episode of of deep vein thrombosis, usually surrounding ah flight or sometimes in an atomic compression like the Thurman lesion, Um, they are mobile, healthy in shape, no contraindications to anti coagulation, usually their young in their twenties or thirties on Did you know with the proximal DVT? Let's say that treating them is going to give them symptomatic relief and also prevent post traumatic syndrome down the line, especially because there are at high risk for having a recurrent rahmbo symbolic event, a za result of the hyper quick global state. And what would be the ideal time frame in which that you would be able to see this patient and intervene. I like to think as soon as possible and in reality most of the time. By the time these patients end up in the emergency room, they've been swollen heavy, symptomatic for a few days. It's very rare that someone wakes up that morning and drags themselves to the doctor's office. So I think most of the time when when you're interacting with a patient, even if they say they've only been symptomatic for a few days, probably the clock we're dealing with us a week, week and a half old. Okay, Um, David, rather than describe the typical patient, are the ideal patient. Can you describe someone who's maybe, um or typical patient that you're used to seeing in your clinic like one of them or regular players? Absolutely. So I think the more regular people that we have in this region are the people that had a nine BC filter placed some number of years ago, and it was for gotten about or it was permanent. And we have a catastrophe with the number of permanent trapeze filters that got placed and left in very young, otherwise healthy, usually women, for some reason that have now gone on to throw from both their i V C both iliac veins. Unfortunately, most of my patients aren't compliant. So when you guys were sitting there discussing the unicorn and I think boy, that'd be a great patient have were taken care of. What? But the biggest What is fine is that we've done our job. We've gotten the clock out. We've found the culprit lesion. We've stenton underlying lesion and affordability of the novel Orland equivalents is a real issue nowadays, particularly in the Medicare population. When they just can't afford it in our region or they're not going to take it, stop it on their own. I've had two young women, both in health care. Both stopped their anti coagulation on their own because they knew better than we did, and both went on to re thrombosis, which was a shame. But yeah, most of my patients are people that I think were avoidable to begin with. Mhm uh, often many of our patients are chronic, and they haven't sought help for years. And as Steven was mentioning in the very beginning of the wound care center, there are hundreds of patients in my community probably thousands in New Orleans in Washington, D. C. Of patients that have had a prior DVT, and they didn't know where to get help from. They got put on anticoagulants shin for three months, six months, depending on what protocol they were following. And they were out in the wilderness and they were doing OK. And they didn't realize that the heavy a Keith Robbie leg they were dealing with for ages beautiful. And they also didn't know that they could have a new acute event on top of their chronic obstruction. So I think there is a need to educate the patient population in the position population on who should be referred in taking a left turn a little bit and giving them a little bit more technical. And the procedure discussion. Stephen, can you talk about a little bit about like, let's get into, like, the procedure, components and unease E way toe to initiate this is start out with, um, you can either describe your typical or or ideal patient and just start with um, where you treat these patients and maybe potential access sites where you're gonna access these patients, or how you begin to think about, um, where you're gonna access and how you're gonna initiate the procedure. Yeah, it's a great question. I think that, you know, there's a lot of debate as to access site selection, and I think one of the key things is whether or not you fall into the camp that every single, uh, inflow vessel needs to be treated or that you need to treat them the major inflow vessel being the ephemeral Patil Spang segment to the common term role or the external iliac. Uh, for the most part, I would recommend your access site being either the PayPal Thiel bein the smallest half in this van Or if you buy into the treating the tibial inflow vessels the P T. As an access site. Because, really, if you're doing catheter directed probable isis, that's going to give you the maximum kind of bang for your buck in terms off Claude exposure to the T. P. A. You know, if you're using some of the mechanical from back to me devices, you know, kind of expands your access side selection. I think that in some cases you can come from the internal jugular vein, but still really then you're really focusing on the pop little veins and access site because Muslim mechanical from back in the devices are going to be supported tibial veins. And if you enter into the coming from real vein, you really are running a risk of mixing missing a lot of that proximal DVT. So I would really focusing on the pop. It'll vein or the tibia or the poster tibial vain if you're doing catheter that symbolize us. And if you're really focusing on mechanical from back to me, such as using the N R. A device or number device, then you can focus more on the internal jugular or the PA patio. Okay, David, same question with you. How do you Oh, um, also tell me, I guess both of you guys are opting, operating in like an endovascular sweet or maybe Noor hybrid? Not sure, but David kind of tackle the same question. Just kind of tell us where you're operating. Sure. So I think from ah, location of patient access location. I think again Stephen said it right. You want to expose as much of the clot to therapy as you possibly can, and I think that some of the some of the confusion when the attract trial results came out where I think many people said, We're not going to treat them It'll pop little DVT s and with the subset analysis saying, maybe iliac is the place that most of us are going to focus our energy, our time on the patient care that we're doing in those patients. We often don't know where the clock is, so I think not getting appropriate inflow is a giant giant complication. But Thio pivot as you said and talk about where I operate again, I'm very fortunate. I worked in a big system. I have to We can call them IR Sweets, but I have to fixed imaging, uh, labs that are adjacent to our I R labs that are vascular surgery dedicated, available seven days a week, 24 hours a day for the vascular team where I work. We have two hybrid cars as well. But for the most part, DVT intervention can be done awake with good moderate sedation in the prone position in the lab. I very rarely find the need to do a DVT case in the hybrid O r. Unless I'm using the Angio Vac where I'm trying to really move large burden clot out of the I V C. Both really expose the morals and those people I do under general anesthesia in the hybrid o. R with profusion. But pretty much everybody else is in the lab. Stephen, what percentage of your cases are you using? I vis 100%. I think that it goes back to something that we were talking about earlier, which is it's really surprising the number of cases you do where you do the sending venogram. And you think, Wow, that looks great. You throw intravascular ultrasound catheter in there, you say gs. You know that's got 30% circumferential or partial from Moses of the vein on DSO. I think that without intravascular ultrasound, you're really under assessing the extent of disease and the potential an atomic compressive lesion that may be leading to the disease. Uh, there are plenty of patients that come in where we get a CTV diagram on them and it'll show extensive clock. Ferdinand. I'm not that impressed with the degree of compression, but then I throw knives Catherine and I'll say, Jeez, you know, that's that's 60 70% cross sectional area reduction of that of that central vein that must have contributed to the robotic state. So intravascular ultrasound, I think, is really necessary in all these cases, David. Same question to you about intravascular ultrasound. I again like Steve and I are boring people, I guess, Ah, 100% of cases. You trash water sound. But I get why wouldn't you? I mean, it's not like we're getting duplicative imaging. The images provided by intravascular ultrasound can tell us what the clock morphology looks like. You could show us scarring on the wall that can show us external compression. You don't know what you're not treating until you look. I would I would start to say that it's It's beyond the standard of care at this point that if you're not operating with IV's when you're doing a DVT case, you're you're breaching standard of care. I would think in 2020. What do you think, Stephen? Absolutely. Completely A great So also getting into some of the techniques. So So David, um, it broadly speaking, in terms like, how do you approach your patients in terms of trying to decide, or how do you treat your difficult patient with either Catholic directed or go ahead, take it from there. Yes, so I started to break DVT therapy down into three generalized buckets. So thrown politic therapy or PharmaKom Mechanical therapy, where we're delivering a drug plus remind us a mechanical device to break it up is sort of bucket. A Bucket B is pure aspiration technology. I think Stephen made mention to penumbra already there probably the the biggest horse in the race for that, for pure aspiration. And the third bucket is purely mechanical, where we're not necessarily aspirating and we're going to eliminate the use of T P A. Uh, to really get the clot out with some mechanical means. I think at the end of the day, I look at a patient and say, If I can leave the case with an open vein with the least amount of residual promise behind, I'm gonna be really happy. So the second thing I'm going to say is that what are the risks of the procedure that I'm going to dio so thrown politic therapy has the bleed risks that makes some of us uncomfortable, but that's probably Onley. True in frail patients, elderly patients recent surgery patients, which make up probably half of my practice. So in half of the patients that show up, I may be able to offer them to throw politic therapy in the other half. It's just sort of off the table. The next point is, how fresh is this clot? The fresher the clot, the more likely I am to have aspiration work. So if somebody did clot yesterday in the Unicorn shows up to the hospital with cloth that formed yesterday, aspiration may be very successful. But unfortunately, as we've all said, these people don't normally show up in a day, and they show up usually at the beginning of the second week, day 789 where they've been at home, taking some time off from work, elevated, compress their leg and they just can't seem to get back to normal. And they've usually been on an anti coagulation for that period of time, where they got seen in the ER, put on a novel or lead equivalent and come back to me. And that's where I found that a purely mechanical device has given me the best results, at least in that population. Yeah, I think that timeframe McLeod is really key. There are plenty of patients who come in with a delayed presentation. Um, you know, taking a step back again from that unicorn and really focusing on that 50% of people who have something else going on in their health that caused them to develop a lot. For the most part, what we're seeing are oncology patients coming in with lower extremity DVT. Uh, they either have or do not have metastatic disease, and those patients are really not good little candidates. Otherwise, we're seeing patients who are already hospitalized who have either had prolonged hospitalizations, orthopedic surgery with proximal DVT and then the last are those people coming into the ER with some hyper questionable state presenting with their first or there other recurrent DVT state. So for patients who are coming in and they have a Contra indication, Thio license or politic therapy for the most part of the crew, necessity becomes a little bit important, as Dave mentioned, because there's that sort of collagen base layer that gets, you know there's college in that gets deposited in the clock transitions of the clot. Starting around day 4 to 5 on. Really, once that collagen starts to organize a matrix within the clock burden, it becomes a lot more challenging toe mobilize with a device that, you know, purely suction based on. That's where you know, I start thinking about using something like the clock, Trevor, like the n r A flow Trebor gets in the IBC where you know, if I'm thinking about the number of and I have to say, Well, what am I gonna do to break up some of these college and based it tendrils or tethering pieces that are gonna keep that clot attached, the vein wall and organized months itself. Sometimes you have to mass right using the balloon for patients who are presenting in the more acute phase. You know, less than two weeks if I'm going to use catheter to crumble, Isis, uh, then you know I can put a clot in, and I can see how the clock response I can use intravascular ultrasound again to see if there's any scarring, a residual clapper, and that's a different ages on. Then target that specifically using mechanical, come back to me or some sort of second front back to me device. Yeah, so So. One of the things that I've done that has changed my practice recently is that as the world's added Mawr devices to our armamentarium for the things that we can use, we've certainly all been faced with failures. So you put a thrum politic catheter in whether that's a standard from politic catheter or an ultrasound enhanced from politic catheter in and you go back the next day. In some cases, you get an amazing technical result, and on venogram on I vis the clot is gone, and in some cases you have residual clot. So in those cases, the question is, what do you move on to next? But I think that that's one of the one of the areas where we say, Well, maybe at this point from politic therapy has failed. So switching from Trumble itics too far. Michael McConnell Politics Probably not the right pivot for me, and that's where I think what Stephen was alluding to is you now have all these dense pieces of fiber and these tendrils struck to Venus wall on. I need to find out some way to physically remove them from the wall, and five years ago I think that was, uh, angio jet and balloon angioplasty, plus or minus a filter. And some of those pieces just kind of got mashed out of the way. Some got more slated. Some m belies to a filter when one was placed. Theoden Shin of all these new mechanical devices has now allowed us to pull things off the wall. I'm gonna show next week at the American Venus Forum. Our 1st 10 in our Oclock favor cases which were not part of the trial, were not part of the registry, and the majority of them were done for failure. They were done for failure of a different Trombetta Me device. And that's sort of when I started to make my change over from being a throng politic based intervention list to a mechanical based intervention list where I was trying to leave the operating room with as much of an open lumens, I could pulling out as much clout as I could. And I really try to reserve from politic therapy for those where I don't think that mechanical is going to give me adequate inflow. So if I have someone that has six tibial veins and for calf muscle veins there from boast and a pop in a small staff and as a feminine iliac. I don't know that mechanical is gonna make me terribly happy because I'm still not gonna have calf level in flow going into whatever I from victimized. And that's really where I push Frontline from politic therapy. But otherwise I've moved to mechanical pretty early. Well, there's also key to what you just said, you know, and it comes down to what you're going to do if you do see some sort of an atomic lesion, right? And if you have A if you have, if you have to send these patients, you really wanna make sure you have as little residual thrombosis possible. I mean, there's a lot of emerging data and a couple of good papers out there that have said, you know, the degree of thrombosis that remains on that vein wall. Even if it's 10 15 20% is associate ID with instant thrombosis. We don't wanna call instant restenosis but instant thrombosis, and it's really challenging to treat that down the line. And that's gonna predispose. Are Venus patients toe recurrent DVT? So you know, I really believe in and what you were just saying, which is using whatever tool available to get as much of that promise out by intravascular ultrasound is possible. Yes. So it's interesting that you said that, Stephen So 234 years ago. And I think you were in some of the same Venus denting trials that I was in. We couldn't even stent acute DVT. At the time of throwing back to me, we had to wait a minimum of 90 days, depending on which stent which trial we were looking at. And I carried that into my home practice that if it was good enough for the trial, it was gonna be good enough for my daily life. And very frequently I've been timid to stent in the early setting because of exactly what you said. That new data shows 10 2030% flow limitations. You know, clinging to the wall may give me this test Pelosis later. So 1000% agree IV's venogram needs to be completely clean for me to want to stand somebody the time of throwing back to me So talking a little bit about you guys have both referenced moving to mechanical throwing back to me earlier. Do you have any devices that I mean? I think there's There's a lot of devices out there, and sometimes it just means you have tow. Learn either what you have access to and then no it inside it out. Or sometimes you like to try different things in different settings. Do you guys have any potential, UM, tips or or go to devices or techniques that you like, um, that you kind of developed over your practice? After some, you know, trial and failures, I try to size the device to the cloth that I'm removing. So I'm still a bit of a dinosaur, despite the fact that I'm just in my early forties. So the first true mechanical device I was exposed to was the Angio Vac by Angie Dynamics, and I still use it on average, once a month for complete occlusion of the I. V. C. And I have tinkered with No Steven just made mention to using the flow Trevor device in combination. Sometimes the clot Trevor to pull out clots from both iliac in the I V. C. I have certainly done some successful cases with the eight French penumbra catheter the cat ate. Um but neither of those devices are yet really purpose built for the I V c. And fortunately, both those companies have have up and coming new toys coming that are meant to tackle I, V, c and I V C filter thrombosis. But at least for now, in my algorithm, because I could get to a hybrid Oh, are so efficiently and I can use perfusion. That's still my my toy of choice in the I V C in the iliac veins knowing the average iliac veins about 16 millimeters. I've used both the pin number device mechanically and the clock Trevor device to clear out a acute or a sub acute. Uh, iliac. I've certainly not. I've certainly found the honoree device could pull out very, very age old things, which has surprised me given how soft this Cory element truly is. I've not seen a lot of Venus wall damage from it, but knowing it goes to 16 millimeters for on average 16 millimeter iliac vein, that's probably my go to device there. And if I am gonna pull out something isolated in the fem pop segment, I'm probably going to select the eight French penumbra and stick as Stephen made mention to yet again the small staff in this vein. I think it's a great access point to do. Ah, fem pop throwing back to me in isolation. But again, it's a moving target. I mean, you turn around, there's a new device coming out. Uh, Stephen, same question. Yeah, I think a lot of it has to do, you know, again, not that interesting were very similar in a lot of guards, but for me also, the other thing I would take in consideration are some of the consequences of each device. And I would just put out there Ah, dealing with an angio jet. You may have a patient who already has acute kidney injury or chronic kidney disease, and you may not want to deal with the potential issues of Hamal, ASUs or or acute kidney injury as a result of the the analysis caused by the agitation from using, like a salon t catheter. Um, if you have a patient who has really scarred federal papa till segment that has had DVT in the past and this is their second session, you may not want to use the collateral for device because of the sheath size and the potential need for having to go back in the Venus system down the line in the mayor to be scarring. And you could potentially that scarring. So in that instance, you want to switch back to the salon T or the engine jet there. There are the great thing about having all these tools now is that you really get to think about each patient, what their diseases and with our co morbidity czar and come up with kind of the best device for them. And one thing that keeps coming up, at least in terms of, you know, some of the device in our blood losses. You know, right now there's no way to reintroduce some of the aspirated material that would take out with, let's say, a number or a clot River flow Trevor device. And if you have a chronically ill patient who's been hospitalized, who's, let's say, you know, has anemia, chronic disease or Nina another reason or just had a major surgery of blood loss, you may not want to ask right 456 of those large syringes of blood within inability to give it back. So these devices have really changed how we've been able to think about not only treating DVT, but what else is going on in the patient. What's the best device for that patient? At that time, we mentioned the N R A clot retriever. Can you can you talk a little bit about the device and anything that you particularly like or dislike any advantages or disadvantages? Thio Using this device? Sure. So I started using the N R. A. Clot. Trevor. Um, about a year and a half ago, give or take. And it's a pop little access sheath for me that has a night in all basket that opens up inside the pop little or femoral vein. We then put a large retrieving device inside this sheath, and we're able to advance it past the thrombosis, so from a popular till we can get it all the way up to capture clot from the terminal I V. C. Somewhere several centimeters below the renal veins usually open a 16 millimeter core ing element, and then above. This scoring element is a basket that will collect whatever clot gets pulled off the wall and sort of funnels inside the basket. You pull it all the way down gently through until you reach your sheath. And once that's done, you can close your Cory element down and pull the device out. In my practice, it takes me between four and nine passes to get a vein completely clean at Viva in November, I presented the Clout Registry, which is the 1st 50 patients that were done in the U. S. As part of the registry data. And the average number of passes that most positions took was three. If my memory serves me right, um, so it's a fairly efficient procedure. At that point, the clock can be removed from the basket set off to the back table, and you can look at the morphology of the cloth. I think that's probably the most satisfying part about removing clot this way is that we can tangibly identify what we've taken out, and it's it's amazing that the different type of cloth that we can pull based on when patients had symptoms, you can really start to identify what's fresh clot? What's clot as it starts to organize a week to three weeks later, and what chronic things you can still remove after months of clot formation. Right, Stephen? Same question. Over to you. Pros, cons, advantages, disadvantages to the n r. A clot retriever, you know, I think there are a lot of prose. I think one thing I would say is expanded patient selection again. There's a very large oncology PF population that we were ignoring is not the right word, I would say under treating a za result the fact that they could not receive uh, frontal Isis. And I would say, You know, I've had a couple of my most emotionally satisfying patients in the last few months have been patients with Google, EOS or Astros Natomas who are coming in with extensive billy of formal DVT. Poor quality of life who would have been treated but just anti coagulation or a filter on sent on their way. Um, and so you know, the ability to treat people without through analytic therapy, using these devices and getting a very, uh, a very good result with excellent promise. Resolution on IBIs is it has been great. Um, you know, and I think there is something very satisfying about it in this day and age of seeing the clock you're taking out, you know, Catholic Record crumble Isis. It's kind of delayed gratification, but we all like the ability. Oh, pull this device out because I feel like I'm trawling for fish on the back of a vote because I put up, you know, the basket and it's full of clot. It's it's It's a great feeling. You know, you're doing something for these patients when it's indicated. Um, I will say, though, that I've had a couple of patients who due to the sheet size, you know, I've had seen I've seen some mawr neurologic complications. I haven't had anything permanent but a za result of the sheet size and accessing the papa till vein. A few more patients complaining of numbness or Paris teaches down the back of the leg into the foot. But again, nothing that's been permanent nothing that has made me question of the device or question the access you size. So yeah, so the biggest pro that I have has nothing to do with the device. It has to do with the company so we don't have data on the vast majority of DVT devices and interventions that are used today, and I think that those of us who sort of eating sleep in the Venus world look a device and go well in my hands. In my experience, this is how it works. This is the results I can expect. But, I mean, even the amount of internal research and tracking that I do and Stephen does, I don't know that we can honestly tell you what many of these devices do. A. Nari has made a dedicated effort to invest in the Venus space, sometimes to their successes and sometimes to their own detriment. The Clout Registry has an extraordinary amount of data points that they are trying to actively collect despite being a registry. I mean, most registries air not nearly this robust. They're really just there to encourage use of a device on, maybe gather some data so they can put an end point saying, Well, here's here's how it did. But the number of data points we have and the long term follow up that will hopefully be generated about this should set the bar for all devices that come to say We need to figure out how to treat DVT. We need to figure out what happens with these patients long term. And then arias, you said with the little ad you did in the beginning is A is a Venus company. So it appears that they're doing the same thing in the pulmonary embolism spaces? Well, they certainly seem to be data driven. Or at least, uh, scientifically motivated and curious to find the right answers. Sure. Speaking a little bit about the data. And I think, David, you may have brought this up earlier Has the attract trialing um changed your clinical practice at all, or maybe even changed referral patterns to you. So I'm young enough That attract came out when I was only a couple of years in practice and when I had started in practice, I was really focusing DVT treatment on people who had large burden clot in the I, V C and the iliac and for the most part, was not treating isolated, ephemeral pop little dvt alone. And I think that's probably true of most people at the time that attract came out who were doing a large number of Venus interventions. So I don't It has not changed my practice because again, I'm doing the highly symptomatic large clot burden patients that typically have extensive iliac and or I v c involvement. And very rarely do I do an isolated femoral vein alone. That's fair, Stephen. Same question to you with regards to any changes with regards to the attract trial, I absolutely agree. And I think the one thing I would say about the attract trial in a way it's been, uh, I'll be like very silver lining about it. It's been a positive because when I do talk about the treatment for DVT ah, lot of times based on either journal clubs or what people have read or misunderstandings of the attract trial, people will come back either in the emergency room or the primary care environment. Say Oh, but wasn't there that trial that said, This doesn't work? And the nice thing about that is you. You can use it as a springboard to say Well, actually, it's a little more nuanced on that. Let's talk about the disease state and let's talk about the limitations of the trial, and it's really been a good opportunity to have a conversation with referring providers. But that's very silver linings. Uh, the the reality is, I think, for most people who were doing Venus intervention, the attract trial didn't necessarily changed their practice pattern on e think that it was. You know, there's some limitations in the trial that you know people have widely discussed but don't necessarily correlate with what we're doing in the real world right now. Now that we've kind of discussed devices techniques, When do you consider a procedure over or when? When do you like in the ideal patient, and also in your typical patient? Like, when is the procedure done? You know e ideal world. It's when the clots removed. When I see you, I try and tell my residents and fellows less than 5% was residual promise. And, uh, in the federal capital segment or the Ilia Federal segment. Um, sometimes you know it's you. No matter what you do, you're not going to achieve that goal. You have run your angio jet. You've done catheter to tremble, Isis, you past your clocks river device or you have used your you know, your caddy. You've used all devices at your disposal and you haven't hit that goal on does cases. You know, you go back to kind of what we're talking about earlier, where sometimes you put the patient on, Lovenox says some anti inflammatory properties for 34 weeks. You can always bring them back, re image on you, see how they're doing from a symptomatic standpoint. But my goal is generally as much clout as possible. That's fair, David. Same question. Yeah, so I don't think that there's a such thing is good enough. I think that this is one of those operations where tenacity is probably fairly important. Um, the advantage of again having a hybrid or if we need it or general anesthesia, if we need it, is that if the patients get uncomfortable from what we're doing, A. We can always change with different device. So if we've chosen to do a mechanical thrown back to me by any device we've mentioned so far and were unhappy with the results, we can always park a little Catherine and come back the next day. And we've talked about the ideal patient and the ideal timing. Um, but very little that has to do with our personal schedule. And I think that's probably important to say that there's never a better time to take clot out than now. So a patient comes in every day that you leave that behind. It just makes your job that much harder. Um, I like Stevens. Number of 5% clot left behind. I don't know where he got that one from. I probably the same place that I would have pulled that same number out of which is I want to just see it completely clean. I think a better question is, what do we do when we aren't done? When No matter what we've done, we still have a large burden of rhombus behind, and I think he's sort of alluded to it, which is in a coagulation and regulation and regulation. I will probably back out to throw politic therapy, park them for a day, come back, see what's chronic, and do everything in my power not distant today. If I could help it and, you know, clarify, I'll tell you where the 5% came from and talking to the residents and fellows and in talking to people in our community here, if you said oh, very, very little clot, oftentimes you'll run the Ivies catheter through the cable segment and, yeah, I'm sure we've all seen it. It's that very, very thin line of residual from bus in the vein. And people are like, Oh, yeah, throw my stent in that And that's exactly what I don't think you want to throw a stent into. So you know, if you say like, 10% or 15% or a little bit, people see that that rim layer left and then they think it's OK to proceed. So that's why I usually say 5%. Because usually that triggers a another level of concern for people like Oh, that's almost nothing. That's really what you want. Like we're saying almost nothing. Yeah, I mean, the hard part is that the longer we're in there, the more likely we are to cause damage. So some of that damage is true. And some of that damage is three theoretical. So most of us cut our angio jet time off of 300 seconds because 300 seconds, we think the homologous risk probably outweighs the added benefit of further thrown back to me with a pin number device. The more passes we make, the more blood loss there is with the flow Trevor Device, the more passes, we make them more blood loss. There is with a clot, Trevor device. The more passes we make, the more likely we may be to have some interval disruption. And again, those are all theoretical. I can't prove to you that we're doing anything wrong, any of those situations. But at some point, we all suffer from the laws of diminishing returns. Absolutely. Eso David, you touched, uh, touched on it just a little bit in your last statement. But let's say you're finished with your patient. You've removed as much clout as humanly possible. You have good inflow. You have good outflow. What is your any coagulation protocol look like for these patients? And does it vary depending on either stent, no stent or acute sub acute plot? Talk a little bit about the anti coagulation that patients are going home on? Sure. So the best thing that I have done today is we created separate preoperative instructions for our Veena grams because venogram often fell under standard angiogram instructions and our angiogram patients were holding their anticoagulants pre op. And I will do just about any Venus intervention that I plan to dio on therapeutic anti coagulation. So assuming a patient has come in on an anti coagulant that they seem to be happy with and they're not failing, I want them therapeutic on it when they hit the door. I will question them in pre op holding if they've taken it. Because, as we know, there are assassins everywhere who will look to, you know, ruin our day. And someone told the patient, Oh, please stop your Xarelto, your Lovenox, your eloquence on They held it for a day. So if if they have held it, I give them a dose of Lovenox before they get on the table. So, at the very least, I've got an aural 10 A or an injectable 10, a therapeutic during the procedure during the procedure. If they're on anticoagulants, I'll still Bullis 5000 units of of I V heparin just to give something acute onset acting while I'm doing my work. If it's a terribly high risk case when they get off table, I will give them another 5000 years. Ivy Hepburn. I typically just managed these patients post off whatever they were on pre op. I have not migrated my practice to 3 to 4 weeks of Lovenox, which I know a lot of people are doing right now. I don't seem to have a terribly high number of failures where I think it's necessary. But any time I see a failure, Lovenox is my go to back up drug post procedure. If they got a stent, everyone's going to get 300 mg of Plavix. I have not moved to the cardiology world of 600 mg. If they're a terribly high risk patient where I'm really worried about their stent, I will send a verify now lab specific to Plavix on. I will check it before they go home to make sure there are Plavix responder knowing that 20 to 30% of our patients are non Plavix responders, I only want to put people on FB and or Berlin tha on those who I think really need it on the last. Yeah, the last thing I do for anti coagulation is I coach my patients that if they're on l acquis or Xarelto, they're on a higher dose when they walk out of the hospital there on, uh, twice a day, dozing of eloquence for seven days there on the higher dose Xarelto dozing for 21 days. So I tell them all on day eight or day 22 depending on what drug Your on. If your symptoms come back that day, I want to call immediately the office. I'll probably just tell them to take the extra dose before they come in and they come in and get duplex imaging immediately because there is a very clot thrown window after we do what we're doing. And I have not found a perfect an equivalent for any of these people yet. And Stephen anything with regards to activity or compression assed faras after the procedure? Yeah, so I am not. Some people talk about purse strings or suitors. If you're in the political access, I generally tend Thio, leave the sheath in. At the conclusion of the case, I'll wrap the leg with a layer of curl X. I'll put a compressive sort of dressing right where the sheet has removed the sheath and I'll wrap a co band all the way up the leg. And at that point, if the patients not ambulatory, I'll even put in S e D. On so that we get almost a simulation of that calf pump muscle moving right away. And I want the people to be up and active as soon as possible, if if that is possible. If not and they're still in the hospital or the bed bound, then I'll keep it s c D on just to keep the blood flowing through the re catalyzed being a segment. Because again, it's that Stasis that's going to cause recurrence of disease. Even if the patient is fully anti coagulated, blood has nowhere to go. It's static. It's going to reform votes. Okay, Excellent. Um, afterwards, David, once you finish the procedure, you have a successful procedure. How are you tracking these patients or not necessarily tracking, But what's what's your typical follow up? How often are they seeing you? How often are you getting any follow up imaging and just talk a little bit about your post procedural care? Yeah, Happy Thio. I want to go back to what Stephen just said, because I don't want people who are listening and wanna learn how to do some of these treatments to miss what he just said. Uh, the addition of S C. D. S. Perry procedurally is incredibly important. We really don't know how well, most of our anticoagulants are working throughout their stay in the hospital. So on a case that I thought was a difficult from back to me case, I will strap those s C. D s the minute the pop little sheath comes off in recovery and make sure they're running before I walk away from the patient. So I again, I know Stephen just set up, but I want to stress the people who are out there listening that if your your recovery unit doesn't have STD machines and sed sleeves, you need to get them. I think it's really important because acute failures I don't we don't talk about our failure is very often publicly. I know Steve, Steve and I have been on panels together where we're willing to to talk about all the bad things we've done in the bad outcomes we've gotten. But the utilization of STDs, I think, has saved my tail more than once. So you asked me about follow up. So again, I'm very lucky in my office. I have nurse practitioners, fellows and residents to see people either with me or independently, so we can use a fairly rigid follow up scheme. So in the first year they have seen it a month, three months, six months and 12 months. And in the second year they're seen in 18 months in 24 months. And then from that point on their seen once a year, I've only been here eight years, so I have not found the ability to get rid of most of my patients yet who are who have had DVT s unless there truly symptom free resolved. And I've taken them off anti coagulation. When I see them back at every one of those visits, I do a Venus duplex of the segments that I treated. So in some cases, that's just in IBC Duplex Another, that's an IBC duplex and a lower extremity duplex. Very rarely do I add lab work on. Obviously, if someone's on warfarin, they're going to get Ni and our. I do an awful lot of anti 10, a levels for people that are on Lovenox. If I'm worried, there's an occult clot that I just can't see on Duplex again, I think much like New Orleans, the Hampton Roads patients, the region where I work are a bit larger than the average American, So seeing the iliac veins is often a challenge. I will add a di dimmer from time to time to see if that pops higher. If I'm. If I'm highly concerned, there's a clock. But typically, if I'm that worried, I'll just do a venogram and look with anonymous uh, Steven. Same question to you with regards to follow up of your patients. Sure, you know similar algorithm. The one thing I'll add is for patients who I do perform deep venous stenting on. I will get some co axial imaging at least once a year, or and or an X ray a plane film if they don't want the C T scan. And on that I'm looking for any stent deformations or changing the confirmation of the stent, which would be indicative of scarring in the vein on a chance for failure. Uh, where I'm looking for thrombosis, that's that's a realigning the stents on that type of imaging as well. But I'll go back and emphasize if you've done a good Villalta score or the C S s score. Oftentimes that's the first thing to change. And so, you know, in addition to that duplex that you're getting into 369 months. If you're asking the patients how they feel, symptomatically, oftentimes you know the same way that you would imagine an A B. I would change if someone had recurrent arterial disease in the lower extremity for after an intervention, you'll see that that VCs s score that ball to score, start to change, and patients know their body. And it's remarkable the number of times on the text message or a call from a patient. This, unfortunately, give my phone number out way too much. But, hey, you know, I'm really noticing that, you know that that my skin is getting shiny or it looks a little red or it's getting a little more Woody on and they'll come back in and they know that they have some recurrent disease. Sure, sure. All right, guys, we covered a lot of topic today. A lot of material, anything that we failed to mention or anything any stone that we didn't turn over. David, you know, just say that the Venus work is a team sport, and you were gracious enough is an individual's radiologist to have to vascular surgeons on your podcast and I sort of went through who you've had in the past. I don't know that you've ever done a pair of surgeons on here, and it's it just sort of goes to show that, you know, this is all of us who are participating in this care. There's certainly mawr disease in the Venus base, and there are physicians to do it. And I think I'm just happy to be part of the conversation. So thank you for the invitation. Yeah, of course. 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