4/18/2013 Venous Stenting: Different Diseases May-Thurner - PowerPoint PPT Presentation

4/18/2013 Venous Stenting: Different Diseases • May-Thurner • Malignant Caval Compression Tips and Tricks for Iliac Vein and IVC Stenting • Complications of IVC Filters • Post Liver Transplant Robert K. Kerlan Jr., M.D. University of California, San Francisco – The presence of a hypercoagulable state makes everything more difficult!!!! UCSF Vascular Surgery Symposium April 18, 2013 Common Themes TIP 1: Puncture a Gastrocnemius Vein • When using a lower extremity approach, • Puncture puncture a gastrocnemius vein rather than the • Negotiation of occlusion popliteal vein • Thrombectomy Catheter – Less muscle to traverse • Fibrinolytics – Less trauma to popliteal • Venoplasty • Stent 1

4/18/2013 TIP 2: Aggressive Fibrinolytics TIP 3: Aggressive Thrombectomy • Be aggressive with fibrinolytics early (20 to 30 • Trellis mg of tPA per session) • Possis – 10 to 15 mg per station with Trellis (8F 30 cm length) • Trerotola • EKOS • Suction Trerotola Device in Native Veins TIP 4: Stent Early • 25 patients with iliofemoral DVT • It never looks perfect……just stent • Trerotola thrombectomy catheter used as primary thrombectomy device • 1-year clinical success 92% • 1-year primary patency 85% • Valvular insufficiency 8% • No major complications Lee HK et al JVIR 2006;17:487-95 2

4/18/2013 TIP 5: Go Far Enough Into the IVC TIP 6: Use Long Enough Stents • For May-Thurner, extend the stent into the IVC or it will shorten and require re-stenting TIP 6: Use Long Enough Stents TIP 7: Use Stents of Sufficient Diameter 3

4/18/2013 TIP 7: Use Stents of Sufficient Diameter TIP 7: Use Stents of Sufficient Diameter TIP 8: Sharp Dissection Down, Not Up TIP 8: Sharp Dissection Down, Not Up • For cases of hepatic IVC occlusion, use sharp dissection away from the heart 4

4/18/2013 Unresolved Issues Stents Across Hepatic Veins • Stenting across hepatic veins • Stenting across renal veins • Stenting across IVC filters Stents Across Hepatic Veins Stents Across Renal Veins • 4 patients • Wallstents crossing the renal vein ostia • No evidence of renal failure on follow-up O’Sullivan GJ et al JVIR 2007;18:905-8 5

4/18/2013 Stents Across Renal Veins Stents Across Renal Veins Stents Across IVC Filters Stents Across IVC Filters • 25 patients with stents placed through IVC filter were compared with 28 patients where stent was placed immediately below filter Neglen P et al. JVS 2011;54:153-161 Neglen P et al. JVS 2011;54:153-161 6

4/18/2013 Conclusions • Use aggressive doses of fibrinolytics coupled with thrombectomy devices • It might be safe to stent across hepatic veins • It might be safe to stent across renal veins • It is safe to stent across IVC filters, but long-term patency is less 7