Venous Disease Program Offers Cutting-Edge, Minimally Invasive Therapies

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Innovations in Cardiovascular Medicine & Surgery | Summer 2019

Venous disorders range from common but superficial varicose veins to rare but life- or limb-threatening deep vein thrombosis (DVT). More prevalent in women and individuals over age 50, chronic venous insufficiency in some form affects an estimated 40 percent of Americans.

Under the leadership of Michael Brown, DO, and Karem Harth, MD, MHS, RPVI, the Venous Disease Program at University Hospitals Harrington Heart & Vascular Institute offers a full spectrum of expert venous care, advanced diagnostic imaging and minimally invasive endovascular procedures, including treatment of varicose veins and valve reflux, stenting of venous obstructions, thrombolysis/thrombectomy, and treatment of arterial-venous malformations.

Michael Brown, DO Michael Brown, DO
Karem Harth, MD, MHS, RPVIKarem Harth, MD, MHS, RPVI

“Patients with chronic venous disease can present with a host of inconsistent symptoms, making clinical diagnosis challenging,” says Dr. Brown, Co-Director, Venous Disease Program, UH Harrington Heart & Vascular Institute; Director, Vascular Surgery, Harrington Heart & Vascular Institute at University Hospitals Geauga Medical Center; and Clinical Assistant Professor, Case Western Reserve University School of Medicine. “Our goal is to get out into the community to see patients and work with emergency physicians, primary care doctors and wound care specialists so that we are reaching people before disease becomes acute.”

 

ILIAC VEIN COMPRESSION SYNDROME (IVCS)

One example of an underdiagnosed condition is iliac vein compression syndrome (IVCS), also known as May-Thurner syndrome. This syndrome is caused by chronic extrinsic compression of the left common iliac vein at the crossing of the right common iliac artery, effectively crushing the vein between the artery and the spine. “Prior to intravascular ultrasound, IVCS was thought to be quite uncommon,” Dr. Brown says. “However, we are finding the prevalence is much higher than originally believed, causing significant impact on quality of life.” 

Patients who have lived with debilitating leg pain and swelling experience almost instantaneous relief when the culprit vein is opened via a minimally invasive procedure that places a stent scaffold through an ultrasound-guided catheter. “Immediately after the procedure, you can see the edematous flow out of the leg and a dramatic decrease in leg heaviness and swelling,” Dr. Brown says.

VEIN OCCLUSION

When a blood clot develops at the site of compression, intervention is required. Typically, the procedure to clear the clot and treat the compression has occurred over a two-day period. On day one, catheter-directed thrombolytics are delivered to the site. On day two, percutaneous thrombectomy removes any residual clot. However, in appropriate cases, UH vascular specialists are able to provide a single-session procedure. 

“Depending on the location of the clot, acute DVT and the culprit compressive lesion can all be addressed and treated in a single session,” says Dr. Harth, Co-Director, Venous Disease Program and Medical Director, Vascular Laboratories, UH Harrington Heart & Vascular Institute; and Assistant Professor, Case Western Reserve University School of Medicine. “This single session option allows us to avoid an ICU stay for patients and reduce the risk of bleeding associated with catheter-directed lytic therapies.” 

Venography with chronic DVT and occlusion of left iliac vein with significant pelvic collaterals and patent previously placed right iliac vein stent (patient in prone position)Venography with chronic DVT and occlusion of left iliac vein with significant pelvic collaterals and patent previously placed right iliac vein stent (patient in prone position).
Venography with recanalization and normal flow of the left iliac vein after catheter-directed thrombolytic therapy, balloon angioplasty and stenting (patient in prone position). Resolution of abnormal collateral flow.Venography with recanalization and normal flow of the left iliac vein after catheter-directed thrombolytic therapy, balloon angioplasty and stenting (patient in prone position). Resolution of abnormal collateral flow.

 

RETROSPECTIVE ILIOFEMORAL STUDY DRIVES FUTURE MANAGEMENT

An internal retrospective analysis of iliofemoral DVT is underway to review data from the past 10 to 15 years, looking across multiple specialties throughout UH. 

“How have therapies affected outcomes, symptom relief and overall patency?” Dr. Harth says. “We are evaluating practice patterns of our interventionalists who treat acute iliofemoral DVT to determine the best post-intervention protocols. Also, we hope to identify patients who require additional surveillance and develop follow-up regimens that get these individuals into appropriate clinics.” 

In addition to developing internal guidelines for future management of iliofemoral disease, the team plans to share their findings nationally. 

UPPER EXTREMITY DEEP VEIN THERAPY

Upper extremity venous disease can also require interventional treatment, as in the case of Paget-Schroetter syndrome. Also known as Effort Thrombosis, the condition is caused by compression of the subclavian vein at the intersection of the first rib and the clavicle. 

This rare condition is more prevalent in younger, athletic individuals, often developing slowly and causing chronic inflammation. It requires immediate attention when it presents with an acute DVT of the upper extremity.  

“Asymmetrical arm swelling, discoloration, heaviness or pain are symptoms of occlusion,” Dr. Harth says. “After thrombolysis, it is important to identify anatomic culprit conditions that require further surgical therapies to prevent compression of the vein that could lead to recurrent DVT.”

EXPANDING VENOUS CARE OUTREACH

In addition to state-of-the-art care offered at UH Cleveland Medical Center, University Hospitals is meeting the needs of patients within surrounding communities. A recent $5.34 million expansion of Harrington Heart & Vascular Institute at UH Geauga Medical Center in Chardon, Ohio was completed this spring. To expand venous care services, the addition includes a dedicated vascular procedure room, three diagnostic vascular suites, catheterization labs and spacious waiting areas for patients and families.  The expansion of vascular services also includes the addition of vascular medicine specialist Dr. Natalie Evans to the team of providers within the Harrington Heart & Vascular Institute at UH Geauga Medical Center.

For more information or to refer a patient to the UH Venous Disease Program, call 216-844-3800.

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