SIR 2024
Venous Interventions
Arsalan Saleem, MD
Division Chief & Residency Program Director VIR
UTMB Galveston,Vascular & Interventional Radiology
Financial relationships: Full list of relationships is listed on the CME information page.
Payam Mohammadinejad, MD
Resident
University of Texas Medical Branch
Disclosure information not submitted.
Irfan Masood, MD
Assistant Professor of Radiology
University of Texas Medical Branch
Disclosure information not submitted.
Kent Harkey, MD
Emergency Medicine Faculty
University of Texas Medical Branch
Disclosure information not submitted.
Bagi R.P. Jana, MD
Hematology Oncology Faculty
University of Texas Medical Branch
Disclosure information not submitted.
Rohit Venkatesan, MD
Hematology Oncology Faculty
University of Texas Medical Branch
Disclosure information not submitted.
Eric M. Walser, MD (he/him/his)
Professor and Chairman of Radiology
UTMB
Financial relationships: Full list of relationships is listed on the CME information page.
Review the necessity and purpose of a multidisciplinary response team for comprehensive management of high-risk DVT.
Review the structure and operation of a multidisciplinary DVT response team (MDRT), its potential challenges, and opportunities for collaboration.
Review a single institution’s experience of establishing an MDRT and its impact on patient care.
Background:
DVT presentation and outcomes range from focal thrombophlebitis to phlegmasia cerula dolens (PCD), and pulmonary embolism (PE). While the majority are medically managed, high risk DVT may require a timely endovascular intervention to prevent loss of limb, life or post-thrombotic syndrome (PTS) {1}. PTS is overlooked with 200 million dollars annual cost, and 2 million lost workdays in USA {2}.
DVT in higher caliber, proximal and central veins with minimal collaterals is high risk. Resultant venous hypertension leads to valve injury and PTS.
Recently, significant effort has been made to implement PE Response Team to minimize mortality {1}. Yet, there has been little progress in the high risk DVT management, with the available literature questioning the endovascular therapy {3,4}.
Our interpretation of this data suggests a “one size fit all” approach is suboptimal, rather a stringent patient selection, for endovascular therapy is essential. Early interventions improve the venous patency preventing limb loss, PE, and long-term complications of PTS {5}.
Clinical Findings/Procedure Details:
Our MDRT consists of emergency medicine (EM), VIR and hematology with the goals of triage, stringent patient selection and long-term follow up. First, EM physicians diagnose and triage the patients based on the risk level. The VIR team is then consulted for high-risk DVT to identify patients benefiting from early thrombus removal (Table 1). Early thrombus extirpation remains treatment of choice for PCD. A closed loop post procedure follow up by VIR and outpatient hematology is done for medical management, assessment of the outcome and need for future interventions in the long-term.
Conclusion and/or Teaching Points:
A multidisciplinary team approach with strict patient selection is quintessential for comprehensive management of high risk DVT.
Future steps include investigating the clinical and economic impacts of MDRTs.
Further steps are needed to engage more of the frontline providers directly involved with DVT including IM, FM, OB-GYN, and pediatrics to advocate for the best therapeutic options available for patients.