4/14/2016 Disclosures • Medtronic • Spectranetics 2016 • Tenaxis Medical – SAB UCSF Vascular Symposium Societal, Clinical, and Radiographic • Volcano Corporation Definition of Venous Stenosis: • W.L. Gore James J Zimmerman, M.D. A Moving T arget? Palo Alto Medical Foundation Director Vascular and Endovascular Interventions at Sequoia Hospital, Redwood City, California Venous Insufficiency 2 Key Questions Prevalence An estimated 25 million people in the U.S. have varicose veins 2. What is the best • 4.5 million new diagnoses are made annually non-invasive method of studying patients for this • 2 to 6 million have more advanced forms of venous insufficiency (swelling or skin changes) problem? 1. When is • Nearly 500,000 have painful venous ulcers ilio-caval compression • Venous disease has a negative impact on QOL hemodynamically • Leads to diability and early retirement significant? • When is it responsible for symptoms? Only 1.7 million actually seek treatment $1-2 billion/year treating ulcers in the U.S. • 1
4/14/2016 Societal and QOL Impact of Ilio-Caval Stenting How do we find ICVO in this guy? Improvement in all categories of CIVIQ Sleep Work disturbance Effect on Leg pain related due to leg Effect on social leg pain pain morale activities The results are durable Neglen, P., K.C. Hollis, J. Olivier, and S. Raju, Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical, and hemodynamic result. J Vasc Surg, 2007. 46(5): p. 979-990 Options for Evaluation CT Venography • Thin cut 3D CT venography Duplex ultrasound • 1mm cuts • Lower extremity for obstruction and insufficiency • Iliac vein duplex for obstruction and trabeculation • Examined in multiple planes • Max % of narrowing of iliac or IVC CT venography recorded • CT 3-D reconstructions MR venography Ascending venography > 90% correlation with IVUS IF contrast IVUS bolus is well timed Marsten et al, JVS 2011;53:1308-8 2
4/14/2016 Incidence of Ilio-Caval Obstruction on CT/MRI Need for Pre-Procedure Imaging? Ilio-caval stenosis % of total cases Study Design MRV/CTV in 48 patients 100% 8.8% 80-99% 14.0% • + in 31 patients • 78 limbs in 64 patients 50-79% 14.0% • - in 17 patients 30-49% 5.3% • CEAP class 5 or 6 CVI Of those negative: 10-29% 17.5% • 11 were false negatives 0-10% 42.1% • IVUS demonstrated >50% stenosis • All tested with CT or MR venography for Correlating Duplex Exams ilio-caval obstruction >80% 23% false negative 11/17 (65%) patients who had a negative MRV/CTV were positive by IVUS >50% 37% false negative Marsten et al, JVS 2011;53:1308-8 Berland NYU Veith 2014 Venography vs IVUS Ilio-Caval Venography • Venography significantly understimates the degree of stenosis by 30% May reveal obstruction if in correct plane • Inaccurately detects obstruction in >70% of patients Degree of collateral development is • Superior in showing intraluminal details. useful • Trabiculations and webs Low sensitivity • IVUS sensitivity in detecting obstruction > 90% Raju D, NaglenP . High prevalence of nonthrombolic iliac vein lesions in chronic venous disease: a permissive role in pathogenicity. J Vasc Surg 2000;44:136-63. Neglen P , Raju D. Intravascular ultrasound scan evaluation of the obstructed vein. J Vasc Surg Marsten et al, JVS 2011;53:1308-8 2000;35:694-700. 3
4/14/2016 Factors Influencing Arterial vs Venous Pressure My Algorithm – Who Gets a Study • Unilateral swollen leg • +/- history DVT • No toe or forefoot swelling • Lower extremity duplex • +/- insufficiency • Positive iliac duplex for trabeculation or old DVT ARTERIAL VENOUS • C 4 -C6 disease unresponsive to conventional therapy • High pressure • Low pressure • Bilateral leg swelling with history DVT • High resistance • Low resistance • Vessels get smaller • Collaterals get larger • Geometry of vessel may matter 81% had >50% area reduction ~90% had symptomatic improvement Berland NYU Veith 2014 When is a Vein Obstructed Enough? My Algorithm – What Do They Get Qualifying patients receive ascending venogram plus IVUS % Compression Treatment “When a venous stenosis should be considered ”critical” is not known. In lieu of 70% Wallstent adequate hemodynamic tests, it appears that IVUS determination of morphologic 50%-70% ? significant stenosis is presently the best available method for the diagnosis of <50% No Intervention clinically significant iliac vein obstruction.” Post Pre ? ? 50% 70% 80% Venous compression Normal lumen No Consensus L Iliac Vein R Iliac Artery Post stent lumen Neglen and Raju. “Intravascular ultrasound scan evaluation of the obstructed vein”. JVS April 2002. Wallstent 18mm x 90mm 4
4/14/2016 Can Iliac Stenting Help? BEFORE: AFTER: Thank You! Jim Zimmerman, M.D. You Decide! Societal, Clinical and Radiographic Definition of Venous Stenosis: A Moving T arget? James J. Zimmerman, MD Palo Alto Medical Foundation Director Vascular and Endovascular Interventions at Sequoia Hospital, Redwood City, CA 5
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