Deep Vein Thrombosis John Moriarty MD UCLAMDCHAT Webinar

you good morning welcome to hue CA on John Moriarty from the department of interventional radiology and also of Medicine and what I'm going to do today is over the next 20 minutes or so talk a bit about something that were pretty passionate about here which is DVT DVT our cloths clots that can happen in your legs and your belly in your lungs in your heart and what I hope to share with you or some of the ways that we have been treating them helping people who have either acute or chronic problems with them and some of the nice nice neat tips and tricks that we've kind of learned along the way so a couple of housekeeping items before we delve into it we'd love to hear back from you to get you involved if you can follow us on the Twitter hashtag hashtag UCLA MD chat that'll be great some of the devices some of the procedures I'm going to talk about involve various different companies devices we are doing our best to bring you the most up-to-date equipment and procedures here in UCLA and so we've partnered with several companies and several of the companies you can see a peer sponsor some of my research and then we'd love to hear from you online but we'd also love to see in person so if you would like to see us contact us at any of our vein clinics here in LA we have one in Westwood we've got one in Santa Monica and then a third down in the South Bay in Manhattan Beach call us at any time that'd be great to to meet up with you and hopefully help you out with some of the problems that DVTs varicose veins vein problems in general can cause so over the next little while I'm going to be talking about DVT and DVT deep vein deep vein thrombosis are clots and I'm going to try and explain to you wash is a DVT how big a problem it is and then finally how do we go about treating if now in 2016 so clots are normal blood that becomes aggregated together into large or small clumps and they can occur anywhere in the body but they most commonly occur in the veins of the leg and you have a pretty complex venous system in the leg the blood goes down in the trees all the way to your toes comes back up through veins in your calf in your thigh and all the way back up into your pelvis and clots can form in any part of those veins now when you're looking at this yourself either because you've had a DVT yourself or you're looking around online you're gonna see various names for the veins and cells the veins themselves are important but it's more the group of veins that is most predictive of whether you're going to develop a problem and what sort of treatment you might need as well so when you're when you're examining someone who has DVT or when you're looking out for what the best treatment might be for that person we try and kind of risk stratify people into where they're they're clots might be so you might hear us talking about thoughts that are from the hip on up which would be called an iliofemoral DVT somewhere from the hip to need then would be considered a femoral popliteal DVT and then from the knee down to the toes would be called a calf DVT and in this way we try and group people who have similar symptoms similar outcomes and their treatment patterns together the veins of the legs come together in the pelvis to form the main vein out of the belly into the heart and lungs this is called your IVC or your inferior vena cava and people who have severe clots and we think that's about three percent of all people who have a DVT can have class within this IVC and this is a severe problem because it affects all the venous drainage out of the legs up to the heart and lungs and therefore people who have clots within the caiva the IVC can have severe leg swelling and so there are people who develop parts there there are people who are particularly prone to them and there ways that we have developed to either treat them or prevent cloth from the legs moving through the cave up to places where it can cause this damage and these will be things like IBC filters which you can see here on the screen these are small metallic cages that we can place into the vein that can prevent the cloud from moving from somewhere where it's still dangerous but to somewhere where it's life threatening up in your heart and lungs excuse me an IVC filters are a whole different discussion that hopefully have with you sometimes they're a very important part of the treatment and management of DVT removing these filters is increasingly important with large filter clinics like ours seeing people who have had filters for many years or filters that have become problematic and certainly if you have a problem with an IVC filter or any questions about it please contact us at the numbers that I gave you earlier on I'll give it to you again later on the end result of a class that is in the legs and moves through the cave is that it goes into the lungs this is called a PE or pulmonary embolism and this is a potentially very dangerous scenario this can happen to almost anyone young fed athletes Serena Williams Chris Bosh they both had pees and did well but people can get very sick and this can be a fatal event some of the techniques I'm going to show you we also use in clearing flower fire to the lung out of the the pulmonary arteries so it's applicable to multiple different areas but again it's kind of a different topic that I just want to make you aware of them that hope you will talk about again at a different time I told you that this is very common and this is a problem that is increasingly recognized as being a major associate in ah make the problem as well so one two three of or of a thousand people are going to develop this annually so little under 1% of all of us are going to get one of these this year that means there's almost a million cases in the u.s. very very common it's the third most common cause of cardiovascular mortality so you've got heart attacks you've got stroke and then you've got DB T's PE the rank the blankest umbrella term would be VTE or venous thromboembolism so this is a not only a very common condition but also very dangerous one that can can cause severe problems if you develop one of these problems you've got a 20% chance of dying within that year so this is a very very very severe condition now fortunately if you are otherwise healthy you tend to do very very well but the 20% of people who die tend to have other problems such as they developed a class and they also have cancer they also had surgery or they also have a stroke but it is a fact that if you have one of these conditions a DVT we really want to be watching you carefully treating you aggressively to make sure that you get a very good outcome once you have a class and I see you in clinic we tell people about the ABCs so the ABCs of treating DVT are something that have been around for a while they're changing but they're very important the a is ambulation activity walking so up until recently people who developed a class within their legs would have been put into the bed told to go to bed stay there that it's dangerous for you to move we now know that that isn't the case it's much more important that you're up walking getting going getting the legs moving again not only to prevent new clots from forming but to prevent some of those other problems that can happen if you do if your bed band such as the pneumonias problems with infection so we really want to get you walking it's good for now it's very good for predicting or preventing problems that could happen in the future as well the B stands for blood thinners this is the mainstay of treatment of DVT s for 75 years now there are multiple different types of blood thinners that are very commonly used you probably know a lot about them things like coumadin or warfarin drugs such as heparin have been used for four decades and then they're also newer ones that are only coming on to the market now that have been specifically designed to help people with this problem drugs such as Pradaxa as rlto adequacy are only coming here in the United States in the last five to ten years but show a lot of promise for for treating these sort of conditions and then the see is compression so after you've been told to get up walking after you're taking blood thinners we wanta them place you on compression stockings and what these are are not very attractive sometimes but the stockings that you wear on your legs they press the skin in to push some of that swelling that people often have up and out of the skin and into the blood vessels so that it comes out of your body out of your legs excuse me into your body and you can remove it that way there's been some change with compression over the last little while up until recently I would have said that everyone who has a DVT should be on compression for two years they wear compression stocking or compression hose for two years from the date they get their DVT there have been some trials recently the softs trial that have shown that perhaps that isn't necessary for either as long or in everybody but as of now our recommendation is that in order to prevent downstream problems we recommend you have the A's the B's in the C's all them together but there is the ability and the need for something more than this and so what are the different options for that there are people who can't take blood thinners they've either had a stroke they've had a bleed into their belly because they have had an ulcer they have certain genetic conditions there are lots of people who shouldn't have their blood thinned are there options that we can give them yes there are a number telling about them in a minute or two what if there is so much class that the ABS in disease won't treat all of us the ninth coagulation alone won't get rid of it these are particularly people who have class from the hip on up as I was talking about iliofemoral class and also IVC class that's a large volume of class that often won't break up on his own and needs a little bit of help from someone like myself and then there's the way that we think that we can make people feel better quicker in other words when you get a class on you go on while it would currently consider the optimum therapy a B and C is there something that we can add on to that that can make you get outta bed quicker moving quicker have less leg swelling get back to your regular life back to your regular work back to your regular play quicker if you're in hospital get at a hospital quicker move along the kind of path to help as quickly as possible and we think that there are some ways that we can help you with that the final thing that we want to talk about is is are the additional things that we're going to be describing techniques of the moving class dissolve involved are they better at preventing pts and pts is post-traumatic syndrome this is something that is under recognized but a huge problem that is going to be very important for all people with DDT post-traumatic syndrome is has many names it's also known as post labovick syndrome or venous stasis syndrome it's the most common complication of DVT and what happens is that you get a clot in your leg and over time that develops a chronic hard firm blockage to flow and when that flow is not good downstream problems happen within the leg and these can be from chronic leg swelling typically the leg is big bath heavy is its heart because it doesn't tend to sweat very well can be quite just quite a lot of pain particularly at night or after exercise during the day people get edema which is fluid buildup within the leg they can also get skin changes particularly on the inside of the calves close to the ankle these changes can be anything from discoloration to severe medical and surgical problems where the skin begins to break down with venous eczema or indeed venous ulcer and an ulcer is a terrible thing to happen it's a breakdown in the skin which can then go on to have an infection and indeed can lead to a lot of tissues also even in the worst case scenario an amputation and pts is extremely common we're already talking about a very common condition which is DVT and this is a very common complication of it somewhere between a quarter and a half of all people who have DVT will go on to develop some type of some form of pts despite being on the best treatment that's currently available in most cases it happens early people who get a class now will develop pts sometime in the next 12 months but there is a definite lag time there are people who we see in the clinic regularly who have PTSD who had a class back in the 90s and so what we're going to try and do now is predict the people who have a DVT today in 2016 that need better treatment more aggressive treatment so that we aren't having problems in 2036 the numbers are as I said somewhere between a quarter and a half of all people with clot are going to develop pts and somewhere around about five to ten percent we're gonna go on and have an ulcer so putting that all together of all the people who develop a class today a huge number almost a million people in the States this year but five percent are going to develop an ulcer over the courses of their lifetime that is a huge problem that is really gonna need to be treated not just on an individual patient basis which is always their goal to give the best patient care to you in person but on a societal basis as well over 2 million workdays are lost because the leg ulcers in the US every year huge economic problem when you take in the quality of life impairment people who have heart failure people who have emphysema or COPD these are people who will you typically recognized as having severe quality of life impairments but in fact having pts gives you as bad a quality of life impairment as those established conditions and it's more expensive if you have a heart attack an MI or myocardial infarction we estimated cost close to ten thousand bucks in medical expenses per year but if you have pts it's even more than that it's about twelve thousand books per year so we really want to try and nip this in the bud by being aggressive with our therapy inappropriate patients as early as we can so that we can prevent these downstream problems that can develop so not everyone who has a DVT develops cloth were not perfect about predicting who the people who who do who have a class will develop pts but there are some people who we know are already at risk so if you have obesity if you have a smoking history if you are older or if you are pregnant these are people who we know are going to be an increased risk of developing pts and we're really going to want to make sure that we take your care extremely seriously because we know that downstream 10 20 years there may be problems related to that so that's the background of all kind of DVT issues related to how often it happens what the standard of care treatment is what the reason that we think that we want to be a little bit more invasive is about removing clot how do we actually go about it here at UCLA well the first thing we do is if you come into the clinic where the classes we want to confirm that it's there and its extent we do that by imaging and we're lucky to have some excellent radiology faculty here whose were dedicated to this we start off with an ultrasound which is a painless test available widely in the community it'll show us the clouds very well typically from the hip on down to the toes excellent imaging of cloths such as you can see here on the screen the next thing we would do is evaluate where else is the cloud for example is it within the valley isn't within the chest and made a couple of ways we can do that a cat scan is very good again here in UCLA we have some of the most up-to-date cat scanning ability possible this here would be one of our scanners in silent our Santa Monica facility it's capable of scanning a six-foot guy in two seconds we can see the entire body get a very good picture of someone with advanced class like it had it there you can also do an MRI Paul Finn is a world expert in mr MRI of the veins and he works very closely with our group and his group have developed many novel techniques for this so that now we can use MRI to see these sort of cloths that are developing anywhere within the body using no radiation on a minimum of contrast that could be potentially damaging to any other parts of the body and you can see here we're able to develop these 3d road maps of the veins of the arteries here rotate them around coming up through the butt through the body up to the heart and lungs so that we're able to get a very good ideas to what your risk might be and if you need to do any intervention what the best way of doing that would be once we've imaged is seen the class seen the problem we need to decide what the best way of getting rid of it is and there are two main ways that we go about that the first is that we would use clock posting drugs the second is that we go and we directly remove the class or break it up that's called mechanical thrombectomy and sometimes we do a combination of the two but oftentimes we choose one or the other tailored personalized to your particular needs and risk factors how do we do license license of the other term for clot busting how do we go about it well what we do is we put a very small that are very thin tube like you can see here coming up through the body here a very thin catheter is placed into the vein directly into the class by an interventional radiologist the way it would be for yourself if you had a problem like this as you'd come in it's typically done as a one night overnight State we place this small tube into the into the veins directing along the line of the veins so they were able to go with these valves I would typically put the tube into the area of clot for example in the back of the knee like we do here and then we pass this very small tube much smaller than a pen navigating our way into the class around the areas that have been damaged and up into your your veins of your of your pelvis and chest and then we put in this aggressive cloth busting agent that breaks up the clash over a period of usually 24 hours and then the next day we're hopefully finished and we get these sort of results where you can see here people who have big cloths causing a lot of leg swelling that's going to be very debilitating very painful for them we put in the medication we leave it there overnight we do what we need to do and we're able to achieve marked reduction in leg swelling marked reduction in pain you can see this very nice they do the patient mind and a few months ago eight year old woman who had very large right-sided leg swelling she saw me in clinic two weeks later her legs were back to normal looking much better feeling much better mobilizing going about her business similarly people who have very large and flamed painful heavy legs can get very good results like you see here if we don't want to use that class top-posting agent or we think that it's better to use a different type of of approach then we have some different options to tell you about as well these are what's called mechanical thrombectomy the thrombus is removed usually using a device of some kind it's a more rapid way of doing it we don't need that overnight stay that I talked to you about it so it can be done as a single session or indeed as an air patient there are some benefits as we're versus that clot-busting agent when people have clocked for many months or many years sometimes it's not amenable to clock busting but rather we're able to use these mechanical agents to break it up or suck it out and sometimes we use a combination of the two again tailored to what the patient in particular needs and what we feel is appropriate for them so we have a lot of different devices a lot of different toys that we can use to remove these sort of thoughts I'm going to give you a quick flavor of just a few of them this would be one of them here that we use pretty frequently this is a small tube that we navigate into the clot as you can see on the animation when we're within the cloud we spray a very powerful spray of liquid directly out into the cloud which softens it up relieves a lot of the pressure that's within the cloud and then we're able to pass it again once it's been softened to directly suck out the cloud using a sort of vacuum sort of procedure it's very effective it works very well and it could be appropriate in people who have either clots in the legs or indeed within the pelvis as well another device that that could be appropriate is one that has a chopping up ability this is for a class that can often be quite thick quite firm we're able to move a device which will rotate around in an a traumatic way to the vessel in the class breaking up the class making much smaller allowing different medication or your body itself to start dissolving the cloth safely other devices work more by suction if they're able to get the cloth directly suck at it and remove it from the vein and bring it outside of the body in a rapid way neither have small caliber devices for use in veins below the below the hip or below the knee or indeed larger ones then if you've got one of these big clots in the belly and the pelvis or in the heart and lungs itself and we've developed quite an experience our group over the last few years and using these so we have we've got a large and diverse ability and practice that we try and tailor this particularly to your needs we have had good success for example this patient a very sick gentleman who had a big clash here within the heart this is the clout you can see it bouncing around on this ultrasound of the heart very dangerous if this pot were to move at all further within the heart there could be further damage indeed it could be fatal by blocking the heart and lungs completely so we went in we were able to suck on this card using one of those devices as I told you about you can see here the pre and the post the Cod is completely gone and indeed here it is in my hand I would in a filter big nasty cloth would have been very dangerous probably what it kills the gentleman had it had it not being removed so we have we fortunately have used this in many patients and some of them have kindly gone on to spread the word about this because we think that this is an important treatment that will hopefully benefit many other people and so we have been able to use media to to spread this out and not only in this country but also in other countries and many people are now traveling to UCLA for this type of treatment this is the sort of patient who may benefit from it someone who has a large volume class big clot that goes all the way from the knees all the way through the hip all the way through the belly all the way up into the main part of the of the abdomen and this is a big class this is causing huge leg swelling and we're able to go in you can see here this picture of some of the clap that we were able to suck out remove big volumes of class that otherwise would have been very difficult to treat just with drug therapy alone so I wanted to give you a feel for where we are with DVT and the in 2016 what are the current problems we have other part of a current scope of treatment and what are some of the nice things that we have to be able to to treat it with so if you remember we we thought that we talked about what is DVT and that it's clots within the veins and then you can occur anywhere in any vein but most commonly within the legs how big a problem is DVT huge huge from million patients many people in the United States this year and a lot of them are going to go on to develop problems with ulceration in the future we're going to try that using some of the techniques that we have discussed as well and how do we go about treating it well we go about treating it using the ABCs ambulation blood thinners compression therapy and then also some of the clot-busting drugs and devices that we described here today so I'll stop there but if you've any questions you want to contact us either in-person contest is anytime at any one of our clinics here in Los Angeles at the phone number of the out there and I'll hopefully be able to answer some of your questions from Twitter right now thank you very much great so the first question here is what is the difference between a DVT and a superficial venous promise so this is a really good question because this is an important thing that not everyone would recognize you have two venous systems one of them is the deep system these are the big veins that I was talking about they're the main trunk carriers of the blood then you have a more superficial venous system they're the ones you can see in the back of your hand during your legs and they typically when they develop clots don't cause the problems of clots moving either to the heart and lungs causing a PE or a class-leading - big-time leg swelling they can cause other problems but not to the same extent as a problem in the deep venous system which are the real bulk of the problematic veins problems with the superficial venous system can go on to develop varicose veins or an inflammation and infection but again they don't tend to cause the same level of problems and we treat them in a slightly different way typically with medication rather than with devices although that is changing to some extent next question what things can I do to prevent DVT well there are several reasons that people get DVT one is that you have a genetic abnormality that you born unfortunately there's not much you can do about that but there are other things that can predispose you to having a DVT such as stasis in other words if you're in mobile or not able to move if you're on a coach trip back to Ireland sitting in the in the back of the plane for a long time cause stasis and compose you to be more likely to get DVT so moving making sure the urine active that you're not either sitting in one position for a long time or that if you do have a medical condition that you are up and about as much as possible these are very important when it comes to preventing DVT some people who have that genetic condition some people who've already had a class should be on blood thinners to prevent further DVT but the majority of people it's keeping active keeping hydrated these are the important things for prevention of DVT next question do DVT run in families so yes there are some families that have a predisposition there are certain conditions that you may have heard of things like factor 5 protein C protein s these are grouped together to be called the thrombophilia we're lucky here in UCLA that we have a very very active very I would say internationally renowned group of hematologists who work with very closely with our group to make sure the people who have a genetic risk people of the family familial history that they are appropriately evaluated and that we can make sure that not only them but their families if necessary are counseled so that we can help them prevent these problems before they even happen is there a risk of DVT or PE after a liposuction procedure well yes and no so yes I would say that there is a risk of DVT or PE after any medical procedure and that is because people are in bed afterwards they're not moving around perhaps in pain therefore that they are are staying stable without all the usual compression of the veins by the leg muscles that we like to see because that's what keeps the flow going however while that is true the risk with most procedures is as low as can be made by making sure that people are up and about as quickly as possible if they need to be on blood thinners for the duration of the procedure they are and that importantly if someone has a risk either they've had a previous DVT or PE then we were able to see that from the off make sure that we are on top of it before during and after the procedures itself and final question then is when you see DVT in clinic are there any concerns about people who need to have more than just this treatment so that's true not everyone needs to have this treatment but what we try and do is we try and make sure that the people who need to have this treatment get it they get it in as quick and as easy a way as possible and that people who don't need this treatment do not need to do not go ahead and have it therefore we try and make sure that we see these people who have these conditions as part of a team there's our selves our group of hematologists group of nurse specialists we operate very much as a team to make sure we give the best most personalized care to each individual patient and I'll stop there thank you again for everything and hope to see you again