This article is one of four stories that highlights the venous components covered at the November 2014 VEITHsymposium. Here are the remaining three articles that highlight what was covered at the symposium:
- New Developments in Venous Disease Treatments
- Pulmonary Embolism: What's New at VEITH?
- Anterio-Venous Malformations
Large Vein Occlusion: From VEITHsymposium
by Kenneth Ouriel, MD
There has been a longstanding imbalance between the frequency of venous disease in the population and its attention in settings such as scientific meetings and journal publications. This disparity arose, in part, from the limited number of definitive interventional treatment options for venous disease, as well as the sometimes non-ideal functional outcomes after performing the interventions that were available.
A decade ago, the VEITHsymposium recognized the underrepresentation of venous diseases in academic forums. The members of the scientific committee sought to increase the proportion of venous presentations at the annual meeting. This intuitive was timely, corresponding to an explosion in new techniques to treat venous thromboembolic disease in general and large vein occlusion in particular.
Recent symposia have included dedicated sessions on venous disease and its treatment. One such group of sessions has been dedicated to large vein occlusions. The topics in these sessions are broad in scope, but include treatment of acute iliofemoral deep venous thrombosis, venous stenting, and inferior vena caval open surgical and endovascular procedures.
Acute iliofemoral DVT is a clinically important entity with a relatively high incidence, particularly in patients with anatomic or physiologic xx. These conditions include the May Thurner iliac vein compression syndrome and hypercoagulability related to genetic variants such as Factor V Leiden mutation, the prothrombin G20210A mutation and many more. Treatment of acute large vessel DVT was formerly restricted to open surgical thrombectomy or catheter-directed thrombolytic therapy alone. More recently, surgical thrombectomy has been virtually abandoned in favor of thrombolytic therapy with adjuncts such as ultrasound thrombolytic acceleration and mechanical thrombectomy. These newer adjuncts to thrombolysis, followed by definitive correction of unmasked anatomic variants and directed pharmacotherapy to address hypercoagulability, now offer options with the potential to improve long-term functional outcome and a reduction in the incidence and severity of post-thrombotic symptoms.
Chronic Venous Occlusive Lesions
When chronic large vein occlusive lesions are detected, treatment again was formerly limited to open surgery or balloon angioplasty. Stenting became more common beginning in the 1990s, but devices were limited to off-label use of stents designed for arteries (or in some cases, the biliary tract). Over the last decade, interventionalists and engineers realized the need for different devices for venous stenting—ones with larger diameters and greater radial force. While none have yet been approved for use in the United States, this is an active area of both pre-clinical studies and, more recently, clinical trials. This activity underlies a series of presentations on venous stenting, where indications, devices and early results are outlined.
Pharmacotherapy for Venous Disease
Anticoagulants play an important role in the treatment of virtually all venous disorders. In prior years, warfarin was the only option in this regard. Newer anticoagulants with differing mechanisms of action were developed and several are now marketed. The VEITHsymposium includes presentations on novel antithrombotic agents, outlining reasonable indications for their use in venous disease. Important topics encompass prophylaxis against rethrombosis after interventional therapy for acute DVT, pharmacologic adjuncts to thrombolytic therapy, and antithrombotic management during and after venous angioplasty and stenting.
Open and Endovascular Inferior Vena Caval Interventions
Inferior vena caval (IVC) open surgical and endovascular interventions play an important role in the management of occlusive disorders of the vessel, as well as for myriad malignant disorders that involve the vena cava—both primary and, more often, from extension of renal and other tumors. Open surgical approaches to the IVC reconstruction with autogenous and prosthetic materials are included in the symposium’s large vessel sessions. Percutaneous interventions for acute and chronic thrombotic IVC disorders are also covered, including the ever-changing devices that can be used to restore and preserve patency.
In summary, the large veins are a common source of morbidity. The magnitude of these problems has been underestimated in the past, as have opportunities for definitive treatment of the disorders. The VEITHsymposium large vein sessions seek to fill gaps in the understanding of large vein disorders, at the same time outlining traditional and novel pharmacologic, open surgical and endovascular treatment modalities.