Chronic Iliocaval Venous Occlusive Disease David Rigberg, M.D. - PowerPoint PPT Presentation

none Chronic Iliocaval Venous Occlusive Disease David Rigberg, M.D. Clinical Professor of Surgery Division of Vascular Surgery University of California Los Angeles Chronic Venous Occlusive Disease Chronic Venous Occlusive Disease Venous Compression Syndromes Less well-characterized than atherosclerotic and non-atherosclerotic – Non-thrombotic venous stenosis – Associated DVT secondary to venous arterial disease compression Multiple etiologies: Post-thrombotic Disease – Congenital iliocaval atresia – Chronic occlusions following DVT – Malignant stenosis or obstruction – Partially occlusive chronic mural – Dialysis related changes secondary to incomplete recanalization of thrombus – Venous compression syndromes – Post-thrombotic venous disease 1

Clinical Spectrum Venous Compression Syndromes • May-Thurner Syndrome Nuisance Leg Swelling – Left CIV compression by right CIA Debilitating edema – Compression/webs in symptomatic pts (under-recognized) Skin changes • External Iliac compression Venous ulceration • Compression of right or left EIV by crossing hypogastric arteries • Extrinsic Compression • Malignancy • Fibroids and benign lesions Wilengberg T, LINC 2014 Interventional Management of Venous Occlusive Disease Options for Percutaneous Intervention : Chronic Venous Occlusions / Stenoses – Venography with Intravascular Ultrasound RCIA LCIA – Venous angioplasty and stenting LCIV Compression 2

16 x 90 Wallstent 3

4

14 x 40 Atlas Balloon 5

Post Stent IVUS Immediate, 3, 6, 12 months and annually… 6

Procedural Details Procedural Details • Popliteal / femoral + IJ approach • Careful sizing with IVUS • Diagnostic venography • Stents • IVUS in all patients without chronic total occlusions • Stainless steel stents (IVC, CIV) – Wallstent, Visipro • Self-expanding nitinol (EIV, CFV) - Protege • Patients without known DVT • Diameters: 14-22mm, IVUS-based sizing • Angioplasty and stenting alone • Dual antiplatelet Rx • Anticoagulation • Intraoperative ACT at >250 sec • Patients with acute DVT • Post-op anti-platelet therapy • CD-thrombolysis / perc mech thrombectomy • ASA 325mg, Plavix 75mg • Angioplasty and stenting of underlying lesions • Post-op anti-coagulation • Lovenox/Coumadin and dual antiplatelet Rx • Lovenox/Coumadin (DVT, hypercoaguable states) Deep Vein Thrombosis Deep Venous Thrombosis Late Sequelae � Incidence : up to 100,000 cases/yr (inpatient samples) Venous Reflux Venous Occlusions � < 50% complete clot lysis with anticoagulation alone � 30-50% long-term risk of leg swelling and PTS � Up to 15% long-term risk of venous ulcers Venous Hypertension Pain & Venous Lipodermato- Venous Claudication sclerosis ulcers 7

May-Thurner with DVT May-Thurner with DVT Chronic Iliocaval Occlusion Chronic Iliocaval Occlusion 8

Results in the Literature Results in the Literature 37% non-thrombotic 16 studies with 2,373 T 54% post-thrombotic and 2,586 NT pts 9% combined “Quality of evidence is Freedom from Ulcer Swelling Relief Symptom Relief Recurrence currently weak” “promising and safe” “low risk” Many issues unanswered � 528 Limbs, all with deep system reflux � 69% with associated superficial or perforator vein reflux � Only treatment was stenting of IVUS-determined iliac lesions Unanswered Questions & Surgical Management of Venous Future Directions Occlusive Disease • Stenting across the Inguinal Ligament • Evolution of Optimal Stent Design 9

Stenting across Inguinal Ligament Stenting across Inguinal Ligament � Stent fractures and restenosis is not the same in the CFV as it is in the CFA � Stenting across the inguinal ligament is HIP FLEX 90 ° HIP FLEX 90 ° less of a concern than leaving untreated HIP STRAIGHT HIP STRAIGHT stenotic disease Stenting across Inguinal Ligament Venous Stent Design Sinus-Venous (Optimed) Zilver Vena (Cook) 54month Secondary Patency Non-thrombotic pts = 100% Thrombotic pts = 84% • 12-18mm Diameter • 14-16mm Diameter • 60-150mm length • 60-140mm length • 10Fr • 7Fr • Laser-cut Nitinol • Laser-cut Nitinol 10

Venous Stent Design Venous Stent Design Loss of radial force at ends Vici Venous (Veniti) Wallstent (Boston Scientific) Ideal Venous Stent Properties • High crush resistance • Uniform crush resistence • Low Profile • 12-18mm Diameter • Conformability • 14-24mm Diameter • 60-150mm length • 60-120mm length • Wide range of diameters • 10Fr • 10Fr • Large diameters • Laser-cut Nitinol • Braided stainless steel Conclusions Conclusions Venous angioplasty and stenting : • Patients with May-Thurner Syndrome • Is a safe and effective treatment modality � Leg swelling and venous claudication / DVT � Complete resolution of symptoms in most patients • Is associated with excellent primary and secondary patency rates • Patients with post-thrombotic iliocaval occlusions • Can reduce the life-long symptoms of DVT � History of prior DVT and IVC filter placement and venous occlusive disease, and can � Technically challenging, lower success rates contribute to venous ulcer healing � Dramatic symptom improvement when successful 11

Technique and Lessons Learned Use of intravascular ultrasound • � Essential for stent sizing and positioning � Post-stent assessment for residual stenosis or wall ULCA Division of apposition Vascular Surgery • Aggressive anticoagulation David Geffen School of � Glycosaminoglycan (Arixtra) for 4-6 weeks in Thrombotic MT patients postop (before transition Medicine at UCLA to Coumadin) � Full antiplatelet therapy in Non-thrombotic MT UCLA Ronald Reagan patients Medical Center Correct all underlying venous lesions • � Extend stent into IVC Thank You � Extend with nitinol stents into CFV if needed � Aggressive lysis to improve inflow (from femoral vein / PFV) 12