In the late period, edema and ulcer develop due to the damage of the valves in the vein.
Figure 1. Deep vein occlusion
Questions to patients with suspected venous obstruction or those with venous obstruction;
Diagnosis of deep vein thrombosis
In patients who are considered to have vein occlusion, the final diagnosis is made quite easily by performing Doppler ultrasound.
Treatment of deep vein thrombosis
Vascular Opening Methods in Deep Vein Occlusion
There are two veins (veins) in the leg, superficial and deep, carrying dirty blood that has lost oxygen. Our deep vein carries 90% of the dirty blood from the leg. Acute deep venous thrombosis (DVT) is the formation of a clot in one or more veins.
60% of deep vein occlusion is observed in calf shadow and 40% in groin and intra-abdominal region.
Diffuse deep vein thrombosis causes acute pain, swelling and discoloration of the legs. This picture is also in the acute period;
In the chronic period;
In patients with chronic or obstructed venous insufficiency in the chronic period, the so-called posttrombotic syndrome is revealed. The problems we see in this acute period continue increasingly and chronically. In this table, due to the effect of high venous pressure in the leg veins; advanced edema, color darkening, hardening and ulcers develop especially in the wrist area. This table becomes more problematic unless action is taken.
For this reason, it will be very useful to open the vein early in order to protect the patient from the problems arising in the acute and chronic periods especially in the groin and above deep vein thrombosis.
Systemic clot-dissolving drug use (Thrombolysis)
The clots normally formed in the vein also activate the clot dissolving system and the associated clot may partially or completely dissolve. Drugs known as plasminogen activators that stimulate the clot dissolving system are used to accelerate this process and provide near opening. These drugs activate the plasminogen trapped in the clot and turn it into an active form called plasmin. Plasmin acts by breaking down the organized clot, fibrin. The broken fibrin products are removed from the body through circulation.
The plasminogen activator, which is given to the systemic circulation from the vein, is distributed in equal amounts (systemic thrombolysis) to all parts of the body. However, the drug given according to this application cannot penetrate into the clot in a sufficient dose and may cause bleeding in other parts of the body. Therefore, these drugs can be administered directly into the clot with the help of a catheter, both to increase efficacy and to reduce the risk of bleeding. Although this method is less, it can cause bleeding anywhere in the body. Especially in patients with previous surgery, the risk of bleeding increases.
Direct clot dissolving agent application via catheter
According to the studies published recently, the success with traditional anticoagulation in the treatment of iliofemoral deep vein thrombosis is 18%, while this rate can increase to 80% with catheter-directed thrombolysis. Especially in patients with iliofemoral DVT, the procedures for successful vascularization in time have been shown to seriously improve the quality of life by preventing the future posttrombotic syndrome.
In percutaneous mechanical thrombectomy, more penetration of the plasmid into the clot can be achieved by mechanically breaking down the clot. A device removes the small clot from the body.
If the risk of thrombolysis is very high, direct venous thrombectomy is recommended surgically.
For patients who are bedridden and very unhealthy, treatment with anticoagulating agents (blood thinning agents) alone may be recommended.
In the thrombosis that develops in the left leg of the left main artery due to compression of the left main vein, it will be appropriate to place a stent in the compression area in order to prevent it from forming again after clearing the clot.
Following the procedure, anti-clotting drugs are given intravenously for a few days and are given orally for long-term use.
Direct clot dissolving agent application via catheter
If the patient comes with deep vein occlusion, if there is no harm in using clot melter, a catheter is placed with a local anesthetic under the knee from the leg to the knee region, and locally anesthetized catheter is applied for 24-48 hours or longer. With this application, the vessel can be opened close to the vessel in a significant amount.
ECOS: Ecosonic system
By using low energy, high frequency ultrasonic sound waves, the permeability of clot dissolving agents to the clot is increased. A guidewire is sent through the catheter placed in the below-knee region under local anesthesia. This guide wire is advanced to the beginning of the clot by advancing the ultrasonic catheter and the clot melter is applied together with the ultrasonic sound waves. It is applied for about 24-48 hours. With this method, the success rate is slightly higher than direct application. Also, since the clot is not mechanically disintegrated in this method, the risk of embolism is low and does not damage the valves.
Angiojet pharmacomechanical system
Device that breaks down the clot and vacuums it from the environment. While the saline of the device that runs at high speed is broken down by hitting the clot wall, it is aspirated at the same time.
A very low amount of clot melter is given together, allowing the clot to dissolve more easily. Under local anesthesia, a local anesthetic catheter is placed from behind the leg behind the knee, and the clot in the vein is cleaned with an angiojet sent from the nose in about 10-20 minutes.
Complications during acute vein thrombosis cleaning
The biggest complication when applying systemic thrombolysis is bleeding. Most often, the catheter may bleed from the access point to the vein or from the areas where the vein was injured during the procedure. The most feared form of bleeding is intracranial (inside the brain) bleeding that causes stroke. During the procedure, pulmonary embolism may rarely develop, as the clot breaks down into pieces. These risks should also be considered when using mechanical thrombectomy devices.
Surgery is often used only in those who are very symptomatic or after other methods fail, so the expected results may not be impressive. Posttrombetic syndrome, 10 years after the attack, was found to develop in approximately 30% of patients who underwent surgery, and in 70% of the group using only blood thinners.
ANTALYA VARICOSE VEINS/Dr.İlhan Gölbaşı