Venous Disease Procedures
Deep Vein Thrombosis - Interventional Radiology Clot Busting and Treatments of DVT by MISS
The deep veins that lie near the center of the leg do most of the
work of the venous system. Nearly all (85 percent) of the circulating
blood is returned to the heart through these veins. DVT, the formation
of a clot (or thrombus) in any one of these veins can be a very serious
Typically, the clot comes on suddenly and without warning. If not
treated, DVT can block the blood supply to the legs and cause tissue
death or gangrene that requires the removal (amputation) of all or part
of the leg. DVT can also lead to valve damage in the vein and a chronic
condition, called venous stasis disease or varicose veins, that is
difficult to treat. Some patients with DVT may be treated with
mechanical or pharmacological thrombectomy using minimally invasive
Radiology Clot Busting Treatment can prevent permanent leg damage
from deep vein thrombosis (DVT). DVT is the formation of a
blood clot, known as a thrombus, in the deep leg vein. It is a very
serious condition that can cause permanent damage to the leg, known as
post-thrombotic syndrome, or a life-threatening pulmonary embolism.
In the United States alone, 600,000 new cases are diagnosed each year.
One in every 100 people who develop DVT dies. Recently, it has been
referred to as "Economy Class Syndrome" due to the occurrence after
sitting on long flights.
The deep veins that lie near the center of the leg are surrounded by
powerful muscles that contract and force deoxygenated blood back to the
lungs and heart. One-way valves prevent the back-flow of blood between
the contractions. Blood is squeezed up the leg against gravity and the
valves prevent it from flowing back to our feet. When the circulation of
the blood slows down due to illness, injury, or inactivity, blood can
accumulate or "pool" which provides an ideal setting for clot formation.
DVT is typically brought on by two major factors:
- Sluggish Blood Flow: caused by sitting still or lying down for long
periods of time, such as on long airplane rides or during prolonged bed
rest after surgery or injury.
- Clotting Factors: Substances that regulate the formation of
clots may increase in concentration after an operation or injury, as
well as during pregnancy, consumption of birth control pills, severe
infection (which causes an increase in red blood cells), certain types
of cancer, or injury to the vein itself.
It is not unusual for the blood to clot from time to time, but most
clots go unnoticed. They are small, cause no symptoms, are dissolved
over time by the body, and need no treatment. There are times, however,
when the body cannot dissolve the clot on its own, or the clot causes
health problems that must be treated. Clots that interfere with the
normal flow of blood or may affect organs that are vital to your health
and survival must be diagnosed and treated early to avoid serious
illness or death.
- Previous DVT or family history of DVT
- Immobility, such as bed rest or sitting for long periods of time
- Recent surgery
- Age above 40
- Hormone therapy or oral contraceptives
- Pregnancy or post-partum
- Previous or current cancer
- Limb trauma and/or orthopedic procedures
- Coagulation abnormalities
- Discoloration of the legs
- Calf or leg pain or tenderness
- Swelling of the leg or lower limb
- Warm skin
- Surface veins become more visible
- Leg fatigue
syndrome is an under-recognized but relatively common sequela, or
aftereffect, of having DVT treated with blood thinners (anticoagulation)
alone, because the clot remains in the leg. Contrary to popular belief,
anticoagulants do not actively dissolve the clot; they just prevent new
clots from forming. The body will eventually dissolve a clot, but often
the vein becomes damaged in the meantime. A significant proportion of
these patients develop permanent irreversible damage in the affected leg
veins and their valves, resulting in abnormal pooling of blood in the
leg, chronic leg pain, fatigue, swelling, and, in extreme cases, severe
skin ulcers. While this use to be considered an unusual, long-term
sequela, it actually occurs frequently, in as many as 60-70 percent of
people, and can develop within two months of developing DVT. There is
increasing evidence that clot removal via interventional
catheter-directed thrombolysis in selected cases of DVT can improve
quality of life and prevent the debilitating sequela of post-thrombotic
Left untreated, a deep vein thrombosis (DVT) can break off and
travel in the circulation, getting trapped in the lung, where it blocks
the oxygen supply, causing heart failure. This is known as a pulmonary
embolism, which can be fatal. With early treatment, people with DVT can
reduce their chances of developing a life threatening pulmonary embolism
to less than one percent. Blood thinners like heparin and coumadin are
effective in preventing further clotting and can prevent a pulmonary
embolism from occurring.
- It is estimated that each year more than 600,000 patients suffer a pulmonary embolism.
- PE causes or contributes to up to 200,000 deaths annually in the United States.
- One in every 100 patients who develop DVT die due to pulmonary embolism.
- A majority of pulmonary embolisms are caused by DVT.
If pulmonary embolism can be diagnosed and appropriate therapy
started, the mortality can be reduced from approximately 30 percent to
less than ten percent.
Symptoms of Pulmonary Embolism
The symptoms are frequently nonspecific and can mimic many other cardiopulmonary events.
- Shortness of breath
- Rapid pulse
- Sharp chest pain
- Bloody sputum (coughing up blood)
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Vascular Diseases Treatments
Treatments for Deep Vein Thrombosis
The traditional treatments for DVT are:
- Bed rest
- Elevation of the affected limb
- Pressure stockings
- Drugs to prevent blood from clotting (heparin and warfarin).
These drugs, called anticoagulants, keep the clot from growing larger
and may prevent clots from breaking off and traveling to the
lungs to form pulmonary embolisms,
but they cannot dissolve clots that have already formed. These must be
dissolved over time by the body's own system for breaking down clots, or
by a new technique called catheter-directed thrombolysis.
procedure dissolves blood clots in the veins without surgery. “Clot
busting” drugs (thrombolytic agents) are injected directly into the site
of the clot (the deep vein thrombus).
thrombolysis is usually performed in a hospital radiology suite by an
interventional radiologist. The physician inserts the catheter into a
vein in the leg and threads it to the site of the clot. With his special
training as a radiologist, the doctor is able to expertly guide and
watch the progress of the procedure on an X-ray video monitor. When the
catheter tip is in the clot, the clot-dissolving
drug (urikonase) is sent (infused) through the catheter tube.
In most cases, it takes a few days for the clot to completely dissolve.
The interventional radiologist can “see” and monitor the treatment using
special X-rays, called venograms, and ultrasound scans. With X-ray and
ultrasound pictures, the physician also can see if – after the clot
dissolves – the vein wall is narrowed or damaged, a condition that can
potentially lead to more clots in the future. Any narrowing in the vein
that might lead to future clot formation can be identified by venography
and treated with angioplasty and/or stent placement.
interventional techniques that combine drugs with macerating devices
are promising to greatly improve treatment for the extremely common and
potentially dangerous blood-clotting condition, deep vein thrombosis
At the 30th annual scientific meeting of the Society of
Interventional Radiology (SIR) in New Orleans in April, members
presented three new pharmamechanical clot-busting techniques that are
proving effective and also less costly and less time-consuming than
While the studies to date have been on
small numbers of patients, “the new combination techniques seem to offer
a significant advance in treating DVT,” says Suresh Vedantham, MD, an
interventional radiologist at Washington University in St. Louis and one
of the presenters. Vedantham also heads the DVT research committee
on SIR’s venous taskforce.
Approximately 10 years ago,
interventional radiologists developed a nonsurgical procedure to treat
DVT called catheter-directed thrombolysis (CDT). Performed under imaging
guidance, the procedure delivers medications directly to the clot
through a catheter inserted in the vein rather than through an IV in the
In the past few years, interventional radiologists have
tried to improve the CDT so they could still use it to treat DVT but in
less time and with fewer risks. They have since developed three new
techniques, all of which combine the direct delivery of clot-busting
drugs with devices that chew or dissolve the clot at the same time.
technique is the Power Pulse Spray, which injects a diluted
clot-dissolving drug to the area of the clot at high force. The
advantage of the spray is that it delivers the drug to more surface area
throughout the clot. It takes roughly a half-hour for the clot to
partially dissolve, and then the vein is sprayed again with powerful
saline jets. The jets create a vacuum that draws the thrombus into the
catheter, where it is removed from the body.
The Power Pulse
Spray technique is a new method of using the already existing AngioJet
device, says Jacob Cynamon, MD, director of vascular and interventional
radiology at the Montefiore Medical Center in the Bronx, N.Y. Cynamon
reported on his experience with the method at the SIR meeting.
A second technique uses the Trellis-8 Peripheral Infusion System
which uses an inflated balloon placed on both sides of the clot to
prevent pieces of it from traveling to other parts of the body. The
physician feeds a wire “filament” through the clot. The wire begins to
whip around, chewing the clot into pieces, which are aspirated into the
catheter and removed from the body. The FDA recently approved the
Trellis as a drug infusion catheter for vascular clots.
The third technique is the Helix Clot Buster Thrombectomy Device
in which a miniature impeller is housed in the distal end. The impeller
creates a recirculating vortex that breaks the thrombus into pieces
that can be flushed from the body. The HELIX is FDA-approved for
dialysis graft clots and is used off-label for DVT.Balloon Angioplasty and Stenting
If a vein has been narrowed or damaged, it may be necessary for the
interventional radiologist or other physician to perform balloon
angioplasty, a procedure in which a catheter is placed in the vein under
X-ray guidance to the site of the narrowing, and a balloon is inflated
to press open the narrowed blood vessel. In many cases, a small mesh
cylinder called a stent may be inserted through the catheter and left
behind in the vein to keep it open.
Balloon Angioplasty: A catheter is directed into the blood vessel and a balloon is inflated to press open the narrowed wall
Treatments for Varicose Veins
Behavioral changes can help prevent the formation of varicose veins.
- Cross the legs at the ankles instead of the knees when sitting
- Avoid high heels, which limit the use of the calf muscles.
- Avoid restrictive clothing which limit blood flow in the groin or calf.
- Avoid prolonged sitting or standing.
- Take breaks to elevate the legs or walk around to help move the blood along and prevent valve failure.
Existing varicose veins won’t get better without treatment. Treatment may consist of:
- Elevation of the leg.
- External support such as elastic wraps or support hose. Elastic stockings are preferred over elastic bandages.
- Laser treatment. A new laser treatment is being provided by
interventional radiologists as an alternative to surgical treatments.
The EndoVenous Laser Treatment uses a laser fiber to heat and seal the
main vein that is causing the varicosity.
- RF Energy. Radiofrequency (RF) energy is another new technique
provided by interventional radiologists as an alternative to surgery. RF
energy heats the problem vein from the inside, shrinking it. Nearby
veins take over.
- Sclerotherapy. In this treatment, a thin tube called a catheter
is directed to the vein and a substance is injected that causes the
veins to scar and close – rerouting the blood to healthier veins. The
affected vein forms a knot of scar tissue that is absorbed by the body
- Phlebectomy. In this procedure, varicose veins are removed
through a series of small holes in the skin under local
- Vein stripping involves removal of a long vein through small incisions in the skin.
- Endoscopic repair. This procedure is performed in advanced
cases of vascular disease involving sores or ulcers on the legs.
Surgeons insert an endoscopic camera into the varicose vein via small
incisions to visualize and treat the defects.
Treatments for Phlebitis
Thrombophlebitis in the superficial veins
is generally treated at home with periods of rest with the leg elevated,
pain relievers such as aspirin and, if needed, antibiotics. Warm
compresses may ease the inflammation and elastic stockings may be
Deep vein thrombophlebitis is treated with
anticoagulants (drugs that prevent the blood from clotting) or with
thrombolysis, a procedure in which clot busting drugs are infused to the
site of a blood clot. This procedure usually is performed by an
Treatments for Venous Stasis Disease
untreated DVT or other conditions may damage a valve in the vein so that
it does not close completely. When this occurs, blood flows back into
the vein below the valve and collects in the lower leg veins. Pooling of
blood in these lower leg veins may cause swelling and tissue damage and
lead to painful sores or ulcers. This condition is known as venous
Fortunately, prompt treatment of DVT or other vein
disease can prevent complications such as pulmonary embolism and venous
Treatments for Pulmonary Embolism
Embolism is a common event, especially in hospitalized patients. It is
estimated that more than 600,000 new cases of pulmonary embolism occur
in the United States each year and 200,000 people die of the disorder.
Treatment options include:
- Anticoagulation. Blood thinners are prescribed to prevent the clot
from growing or new clots from forming while the body dissolves the
existing clot on its own.
- Vena cava filters are devices that are placed in some patients
when there is a possibility of recurrent blood clots, or emboli, or in
patients with chronic pulmonary disease to prevent further damage to the
blood vessels of the lungs. Vena cava filters usually are placed by
physician specialists called interventional radiologists who perform
procedures without surgery by guiding catheters and other small
instruments through the blood vessels under X-ray guidance.
- Thrombolytic therapy is another interventional radiology
technique in which clot busting drugs are fed (infused) through a
catheter directly to the site of the blood clot in the lung.
- Percutaneous thrombectomy. In this procedure, a catheter is
sent to the site of the clot under X-ray guidance and a device is used
to break up the clot into small pieces that are easily absorbed by the
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IVC Filter - Minimally Invasive Surgical Solutions and Inferior Vena Cava Treatment
What is an IVC filter?
IVC stands for
inferior vena cava, a major blood vessel that returns blood from the
lower body to the heart. An IVC filter is a small piece of metal that
can be put into the inferior vena cava to prevent blood clots in the
legs from going up to the lungs.
A blood clot in the leg is called a deep vein thrombosis (DVT).
If the clot goes to the lung, it is called a pulmonary embolus (PE). A
large PE can be lethal.
Why does an IVC filter need to be placed?
you have a DVT, you'll probably need to take blood-thinning medicine to
prevent the clot from moving. Some people are unable to take blood
thinners because of bleeding problems. Others may have tried blood
thinners, but the medicine may not have worked properly. These people
may need a temporary or permanent IVC filter to prevent blood clots from
going to the lungs.
There are several types of IVC filters that are used today. The
Greenfield filter is one of the most familiar names. Some of these
filters are permanent; others are temporary and can be removed easily.
How is an IVC filter placed?
filter is placed by a doctor known as an interventional radiologist.
It's a minor surgical procedure. Since you are sedated for the
operation, you won't remember anything. A needle goes into a vein in
your neck or groin to put a catheter into your blood vessel. The
catheter is carefully positioned so the IVC filter can be inserted. By
using an x-ray, the doctor can see the filter and move it to the right
How long does the procedure take?
The procedure usually takes less than an hour. Most people go home within a day or two if there aren't any major problems.
What are the risks?
is considered low risk, so major problems are rare. Bleeding and
infection are possible at the incision. The risk of injury to other
organs is very small. Other risks, including death, are very rare.
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