The VTE Landscape and SIR's ACTiVE Meeting
Dr. Kush Desai discusses the genesis of the ACTiVE educational forum, VTE intervention, and IVC filter retrieval.
First, could you explain the genesis of the ACTiVE educational forum that the Society of Interventional Radiology (SIR) will kick off this October?
Venous thromboembolic disease (VTE) has recently become a major focal point of modern endovascular practice. Recently, we have seen the proliferation of pulmonary embolism response teams (PERTs), the results of recent landmark trials such as ATTRACT, the renewed interest in inferior vena cava (IVC) filter management/retrieval programs, and the rapid increase in development of deep venous–specific technologies. Despite these significant changes in clinical practice, there are relatively few focused learning opportunities for the entire spectrum of VTE. With ACTiVE, we are looking to create the first VTE-centric educational program to meet the needs of clinicians caring for these patients.
What led you personally to gravitate toward VTE as one of the primary focal areas of your career?
VTE is an exciting and constantly changing space. Management of patients with VTE has historically been medical; however, as we have increased our knowledge and understanding of VTE disease states, we have seen the emergence of a truly multidisciplinary approach in caring for these patients. Moving forward, specialists from endovascular, surgical, and medical specialties will need to work together to optimize outcomes for these patients; this collaborative approach is an underlying theme for ACTiVE. There is so much we have yet to learn! I believe we are just scratching the surface in management of VTE. For example, instead of applying arterial disease methodologies and treatments to VTE, we have seen the development of venous-specific approaches. As someone early in their career, I am extraordinarily excited to be a part of shaping the future in this space.
With the ACTiVE meeting being hosted by SIR, is it limited to interventional radiology faculty and attendees or open to all interested physicians?
Absolutely not! One of the key themes behind ACTiVE is multidisciplinary collaboration; it's how VTE patients will be best served. In addition to interventional radiologists, we have invited faculty from vascular surgery, hematology, cardiology, and pulmonology to enrich our program. We would be thrilled to have a diverse, multidisciplinary audience!
One current area of multispecialty collaboration is PERT. What do you believe are the key knowns and unknowns regarding pulmonary embolism (PE) and its current treatment paradigms?
More than any other area in VTE, multidisciplinary collaboration has been at the heart of the management of PE. A large part of the worldwide growth of PERTs has been the belief that PE management could improve, possibly with long-term affects for patients. Early studies have shown promise with catheter-directed therapy in select patients, with the potential to have a better outcome/lower risk relative to systemic intravenous thrombolysis. This gives us a foundation for future investigations. Some of the big challenges that remain include patient selection, identifying optimal treatment dose and duration, and defining measures for clinical outcomes.
Although much progress has been made in the field of VTE intervention, there are also several controversial therapies. How will ACTiVE address topics that lack consensus, such as which patients should have an IVC filter placed?
Debate is at the heart of inquisition and is necessary to move science forward. We have designed the ACTiVE educational program to show differing, sometimes conflicting points of view; each side will have data and trials presented as appropriate. In these cases, the goal is not to convince the attendee of a particular approach, but rather it is to arm them with the knowledge so that they can choose the best approach for their patients. In the example of indications for IVC filter placement, we will present data and trends that support differing approaches. Ultimately, it is up to the physicians to decide which approach would best suit a particular patient.
The program committee includes you and Drs. Robert Lewandowski and Robert Ryu, three faces at the vanguard of the movement to promote IVC filter retrieval when reasonable. Aside from the dynamics of “when” and “in whom,” there is also the “how.” What are some of the ways ACTiVE will distill lessons learned in challenging filter retrieval scenarios?
All of us on the program committee, along with the faculty in the IVC filter management session, have developed our current approaches to filter retrieval based on gradual learning through hundreds of cases. It's our job to highlight the procedural pitfalls and difficulties to the audience. We will set out to do this in both a case-based, interactive format and with a hands-on workshop with devices, filters, and three-dimensional printed IVC models.
Another area of great interest that also currently lacks consensus is pharmacomechanical thrombectomy (PMT) for deep vein thrombosis (DVT). With the presented ATTRACT data showing mixed results for PMT, how is the program committee framing its discussions of PMT for DVT at ACTiVE?
The final peer-reviewed manuscript has not been published for review; however, we know that we are still in the early stages of defining the role of PMT for acute DVT. We are excited to have Dr. Suresh Vedantham presenting at ACTiVE, as he will certainly have an impact on leading a robust discussion on PMT for acute DVT.
What do you think are the three biggest unanswered questions facing the field of VTE intervention?
VTE intervention is so new and young that the unanswered questions of today could change by next year! In line with our program, I would say three big unanswered (although by no means all-inclusive) questions are:
1. Catheter-directed PE thrombolysis: When, in whom, and how?
2. Treatment of acute DVT: What is appropriate patient selection and best practices?
3. Treatment of postthrombotic syndrome: How can we improve?
Beyond this year's meeting, what do the society and the program committee have planned for ACTiVE?
We are incredibly excited for our first program and to build on its success in years to come. In addition to incorporating feedback from this year's meeting, we are considering hands-on courses in areas such as ultrasound and, potentially, a course to obtain certification as a registered practitioner of vascular imaging for future meetings. >
Kush Desai, MD
Assistant Professor of Radiology
Section of Interventional Radiology
Department of Radiology
Northwestern University Feinberg School of Medicine
Disclosures: Speaker for and consultant to Cook Medical, Boston Scientific Corporation, AngioDynamics; consultant to Spectranetics Corporation.