RCP-SoPW 2019 – More image-guided surgery needed to combat under treatment of DVT

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by Rachel Pugh

Involving image-guided surgery experts in the care of deep vein thrombosis (DVT) patients as soon as the condition is suspected will optimise their immediate treatment outcomes and avoid long-term problems in the future.

Consultant interventional radiologist at Royal Glamorgan Hospital, Dr Chris Williams made this recommendation to make his point that DVT is being under treated in the UK, in his presentation to the joint conference in Cardiff of the Royal College of Physicians/Society of Physicians in Wales.

He urged for greater involvement in treatment, given that 20-55% of patients develop post-thrombotic syndrome as a long-term complication of DVT, particularly in femoral and iliac/caval cases. In addition, only 20% of thrombosed iliac veins completely recanalise with anticoagulation and 44% of patients with venous claudication have five-year post iliac DVT.

“You need an endothelial abnormality to get DVT,” said Williams. “That is what is not being treated with anticoagulation alone.”

The best outcomes using interventional radiologists can be obtained in DVT cases with:

*  A well-documented history and defined onset

*  Symptoms less than 14 days in duration - ideally 10 days

*  Reasonable life expectancy as treatment is expensive

*  Good functional status

*  Only treatment of proximal DVTs.

Great strides in radiology treatments of DVT have been made over the past five years, said Williams. He and his colleagues are moving away from thrombolysis, towards a greater usage of mechanical thrombectomy to minimise the risk of bleeding and are seeing immediate reductions in acute symptoms (pain, swelling, vascular compromise) and reduced thrombotic morbidity, when accompanied by the usual intensity and duration of anticoagulation therapy.

Gastrointestinal haemorrhages also benefit from image-guided surgery. In the case of upper GI embolisation is low risk. For lower GI haemorrhage, interventional radiology is the treatment of choice but only with proof of bleeding because of the serious risk of ischaemia.

Dr Williams pointed out that even within the medical profession, there is confusion about the role of interventional radiologists, so he clarified the role as being a subspecialty of radiology, which performs minimally invasive procedures, using image guidance, mainly for treatment purposes.

Main established techniques are IVC filters, haemorrhage control, embolisation, arteriovenous malformation (AVM), superior vena cava (SVC) obstruction, central venous access and vascular problems.

The Welsh Government’s Imaging Statement of Intent (1) recommends IR methods for

DVT/PE, chronic venous insufficiency, pelvic congestion syndrome and to assist other specialties.