As evolving treatment modalities offer the potential for improved outcomes in patients with deep venous disease, the importance of patient selection and the need for high-volume expert treatment centres to treat these patients were underscored by world-leading experts during the Deep Venous Controversies session at the Charing Cross (CX) 2021 Digital Edition (19–22 April, online).
The need for an individualised patient focus was a central message of Joseph Caprini (Northfield, USA) who was recognised for his decades of work in driving the understanding and awareness of the risk of venous thromboembolism (VTE), receiving the first ever CX Venous Lifetime Achievement Award.
Presenting the award on behalf of CX Executive Board colleagues Manj Gohel (Cambridge, UK) and Armando Mansihla (Porto, Portugal), Stephen Black (London, UK) described the accolade as a fitting way to honour Caprini’s contribution to the treatment of VTE patients. “He has been enormously selfless, not only to patients, but also with his generosity of time to everybody who has been involved in this field,” Black said to an evidently humbled Caprini.
Caprini and Black participated in a lively roundtable session to close the Deep Venous Controversies programme on Wednesday, with Caprini giving attendees an overview of the complexity of VTE risk assessment and thromboprophylaxis in the COVID-19 era, and Black discussing the future of VTE research.
The session also saw Black offer his view of the future of VTE research. During his presentation, Black underscored the point that a patient-centred approach is vital, in the absence of a “clear winner” in treatment modalities for VTE. “Ultimately we need to focus on the patients themselves and understand what outcomes they need,” he commented.
Opening the session, Steve Elias (Englewood, USA) highlighted the importance of understanding patient history in his presentation, in which he defined inappropriate stenting for non-thrombotic iliac vein disease. Elias described this as the most important factor in determining if symptoms are vein-related and require venous intervention, “we treat patients, we do not treat veins,” he remarked.
Focus then turned to procedural planning, with panellists Houman Jalaie (Aachen, Germany) and William Marston (Chapel Hill, USA) debating the motion ‘pre-procedure anatomy is enough to predict outcomes after deep venous stenting’.
Jalaie told attendees that inflow is a key factor in predicting outcomes after venous stenting, and can be determined using tools including duplex ultrasound or direct CTV. However, Marston argued that while pre-procedure imaging is useful in identifying the type of venous disease and planning intervention, current methodology limits accuracy in identifying key information associated with procedural outcomes. Audience members voted by a margin of 39‒61% in favour of Marston’s argument, suggesting that evidence is needed beyond anatomy to direct interventions. A later poll suggest that 70% of participants were against routinely and specifically imaging the iliac venous outflow in patients with C6 disease.
The programme featured a litany of studies detailing the latest advances in deep venous interventions. In a Podium 1st presentation, early results were revealed from the CLEAR DVT Study—investigating the outcomes associated with contemporary endovascular venous intervention by Zelante pharmacomechanical thrombolysis in treating acute iliofemoral DVT (deep vein thrombosis). Presenting the findings Mitchell Silver (Columbus, USA), stated that, based on available six-month data, no post-thrombotic syndrome (PTS) was seen in 96% of DVT patients following pharmacomechanical thrombolysis, adding that the researchers’ attention will now turn to assessing the one-year data from this study, as well as discussions about setting up a randomised controlled trial (RCT).
Erin Murphy (Charlotte, USA) also presented insights from the ABRE IDE trial—investigating the Abre venous self-expanding stent (Medtronic)—and offered perspectives on the underlying causes on venous stent occlusion in patients involved in the trial. Following her presentation, CX Executive Board member and moderator Gohel asked Murphy to comment on patient factors such as obesity in predicting clinical outcomes and stent patency. Murphy commented that it is important to consider obesity when deciding on deep venous stenting.
In a presentation on the influence of endovenous modality and technique on clinical outcomes in C6 patients, Gohel later commented that the timing of intervention in C6 disease patients is “likely to be the single most important factor for getting a good outcome”, while the type of intervention used is “less relevant”. He referenced results of the 2018 EVRA trial, which found all treatment modalities to be equal in terms of clinical outcomes.
Prompt retrieval is necessary to reduce the risk of uncommon, but potentially “catastrophic”, complications associated with implanted inferior vena cava (IVC) filters. That was the view presented by Kush Desai (Chicago, United States), who also asserted that an individualised assessment over a “must retrieve at all costs” mantra is required in patients with older IVC filters.
The “de-prioritisation” of venous patients during the COVID-19 pandemic was also debated in the same session, with CX Executive Board member Black questioning if “as a venous community, we have to use this as an opportunity to be much more vocal about fighting for these patients to be prioritised equally with others”—a sentiment with which Sergio Gianesini (Ferrara, Italy) said he “totally agreed”, but added that the question of how this can be achieved is far more difficult to answer.