Questions On Deep Venous Disease!

LECTURE - Which Venogram-Occult Iliac Vein Lesions Should Be Treated?

LECTURE - Update on Pivotal Clinical Trials in Deep Venous Disease

DEBATE - Catheter-Directed Thrombolysis for Submassive PE: Use It - It Improves Cardiac Hemodynamics

DEBATE - Catheter-Directed Thrombolysis for Submassive PE: Not Ready For Prime Time

DEBATE - Catheter-Directed Thrombolysis for Femoropoliteal DVT: Use It Regularly

DEBATE - Catheter-Directed Thrombolysis for Femoropoliteal DVT: Don't Use It

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67 yr old male with history of recent left knee replacement surgery presents with a left femoro-popliteal acute DVT. He has no family history of venous thromboembolic disease. Last month, he went to his primary care MD and his age appropriate cancer screening returned normal. He had history of atrial fibrillation 4 yrs ago for which he was on warfarin briefly. He apparently developed a severe rash along with nausea and malaise. He was advised to stop the drug and was placed on Dabigatran. This was then stopped as he developed anemia and was tested positive for occult blood in the stools. The colonoscopy however returned normal. He underwent successful radio frequency ablation with resolution of atrial fibrillation and the anticoagulation was stopped. He did not have any issues with anemia for the last 3 yrs. What treatment would you recommend for this patient?

• An IVC filter placement

• Dabigatran for 3 months

• Rivaroxaban for 3 months

• Apixaban for 3 months

• Edoxaban for 3 months

Iliac vein compression is considered as significant

• When IVUS measured cross-sectional area is 80% of the adjacent normal vein

• When the external iliac vein is smaller than the common iliac vein based on venogram or IVUS

• When IVUS measured diameter is smaller at one vein segment than an adjacent segment

• When the common iliac vein is flattened on venography

A 35 year-old man with a first-episode, acute iliofemoral DVT presents to the emergency room. Which of the following treatments is not supported by rigorously designed multicenter randomized controlled trials?

• Subcutaneous injections of enoxaparin followed by warfarin

• Oral rivaroxaban

• Elastic compression stockings

• Catheter-directed thrombolysis

Which of the following statements about the CAVENT Trial is false?

• It found catheter-directed thrombolysis to reduce the risk of post-thrombotic syndrome.

• There were no fatal or non-fatal intracranial bleeds in study patients

• There were no major bleeds that prompted surgical intervention in study patients

• A significant difference was not observed in the risk of recurrent venous thromboembolism between thrombolysis and no-thrombolysis.

RV/LV ratio is significant in the diagnosis of submassive PE when greater than:

• 0.6

• 0.9

• 1

• 1.5

A 45-year-old female patient presents to the ER in cardiogenic shock. She is resuscitated with IV fluids and dopamine. A massive PE is diagnosed with a CTA of the chest. She is transferred to the ICU after starting a heparin drip. She suddenly becomes hypotensive in the ICU and systemic TPA is considered since she has no contraindications to thrombolytics. The correct dosage of systemic TPA for the treatment of massive PE is:

• 40 mg over two hours

• 200 mg over one hour

• 75 mg over one hour

• 100 mg over two hours

A 43 year old woman is diagnosed with a pulmonary embolus in her right main PA. She is tachpyneic and tachycardic. Her troponin and BNP are normal. Echocardiography demonstrates an RV/LV ratio of 1. Which of the following is true?

• She has a low-risk PE

• She has a high-risk PE

• Catheter-directed lysis will likely reduce her 7 day mortality

• Catheter-directed lysis will likely reduce her RV/LV ratio in 24 hours

The ULTIMA trial demonstrated which of the following?

• No significant difference in 24 hour echocardiographic outcomes between patients treated with CDT and those treated with heparin alone

• No significant difference in 90 day RV/LV ratio between those treated with CDT and those treated with heparin alone

• Lower mortality in patients treated with CDT

• Higher major bleeding rates in patients treated with CDT

A 45 year old man with a history of femoropopliteal DVT has a Villalta score of 9, 6 months after the acute event. This is his second VTE event. Which of the following should be part of his management?

• Hypercoagulable testing

• Cessation of anticoagulation

• Assessment of his iliac veins

• Round the clock use of compressive therapy

Which of the following is an inclusion criterion for the ATTRACT trial?

• Asymptomatic DVT

• SVC thrombosis

• Calf DVT

• Femoropopliteal DVT

A 45-year-old female executive with no past medical history, on oral contraceptives for last two years presented to the primary care physician with right calf swelling and discomfort for last three days. She had been on vacation to Europe and returned a week ago. She denied any chest pain or shortness of breath. On physical examination she has mild edema and erythema of the right calf without any varicose veins. She noted calf discomfort with dorsiflexion of her right foot. A venous Duplex shows that acute deep vein thrombosis of the femoral and above knee popliteal veins, without any involvement of Common femoral veins. What is the risk of her developing severe post thrombotic syndrome at 6 months on anticoagulation?

• 40 - 50%

• 50 - 70%

• 5 - 10%

• 10 - 15%

Based on current evidence regarding the use of catheter-directed thrombolysis (CDT) in isolated femoro-popliteal acute DVT, all of the following statements are correct EXCEPT:

• CDT is associated with higher bleeding rates than anticoagulation alone.

• CDT is associated with marked reduction in Post thrombotic syndrome at 2 years.

• CDT is associated with higher costs than anticoagulation alone.

• CDT is associated with longer length of stay than anticoagulation alone.

How Many Category 1 CME Credits are you Claiming?

• .25

• .5

• .75

• 1.0

• 1.25

• 1.5

• 1.75