Starting with deep venous treatment
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1 Starting with deep venous treatment Carsten Arnoldussen, MD Interventional Radiologist Maastricht University Medical Centre, Maastricht VieCuri Medical Centre, Venlo The Netherlands
2 Background Maastricht University Medical Centre Patients referred to dedicated venous outpatient clinic with multidisciplinairy team of vascular surgeons, interventional radiologists and vascular technicians VieCuri Medical Centre General hospital, business case in cooperation with vascular surgery - radiology vascular medicine Additional cases from dermatologists, phlebologists and gynaecologist
3 Starting Inform your colleagues Which patients Which treatment options Highlight the outcome of treatment for patients (QoL ++) Patient selection Vascular surgery / dermatology recurrent varicosis / suspicion of venous ulcerations, venous claudication Internal medicine iliofemoral DVT cases, recurrent (iliofemoral) DVT cases Gynaecology pelvic congestion
4 Selecting Basic selection criteria C4-C5-C6 disease Varicosities in the groin extending contralaterally or ascending across the abdomen Fast recurrent varicosities after treatment (< 1 yr) Persisting venous ulcerations despite adequate compression therapy Venous claudication limping / swelling / pain due to inadequate venous draining
5 Assessment Clinical Venous claudication Social impact (QoL) Ulcerations Prior history of DVT, Pulmonary Emboli, Venous surgery (superficial and/or deep system) DVT causes (pregnancy, immobility, surgery, trauma, known coagulation disorder) Family history DVT / varicosities Compression therapy Medication (Anti-coagulant therapy) Intoxication (Alcohol, Smoking, Drug abuse) CEAP, Villalta
6 Assessment Imaging Duplex ultrasound MR-Venography CT-Venography Conventional Flebography IVUS Aim: non-invasive assessment of the entire deep vein system prior to any invasive (treatment) approach
7 Assessment Imaging key points Identify inferior vena cava, common / external iliac vein obstruction When starting, select patients with isolated Identify external components in the pelvis that contribute to iliac common and/or external iliac vein obstruction obstruction (May-Thurner s disease, iliac aneurysms, lymfoceles) Avoid common femoral, femoral and profunda femoral (total) occlusions Evaluate the remaining patency of the common femoral, femoral and profunda femoral veins and their primary outflow tract Rule out acute deep vein thrombosis
8 Periprocedural Sedation Depends on local situation Local anesthesia access point(s) Mild / deep sedation for recanalisation» Anesthesiologist» Anesthesiology nurse» Independent Pain medication peri- and post procedural
9 Medication Peri- and post procedural pain medication Anti-inflammatory drugs Anti-coagulation (3-6 months therapeutic levels) Compressive stockings Post-procedural Class 2 stockings, thigh-high» 2 weeks, remove if comfortable without If available pneumatic compression stockings» Ambulant period Follow up Postprocedural Post-procedural follow up Duplex on day 1 & 14, then after 6 months
10 Example case
11 Example Case Female, 37 yrs, referred by vascular surgeon - Fast recurrent varicosities after treatment by phlebologist - On clinical examination oedema of left leg (upper and lower) with mild pigmentation (C3-C4) - Venous claudication during work (standing ++) - DVT after 2 nd pregnancy at 29 yrs of age - Progressive complaints since superficial treatment
12 Example Case Duplex: Obstruction of the left common and external iliac tract (May-Thurner +) Minor post-thrombotic changes proximal common femoral vein Mild insufficiency proximal femoral Vein Insufficient remnant side branch of greater saphenous vein
13 Example Case MR Venography Obstruction of the left common and external iliac tract with presacral collaterals Minor post-thrombotic remnants In the proximal common femoral vein with groin collaterals (including labia) Open femoral and profunda femoral vein
14 Example Case
15 Example Case Treatment: Rekanalisation + Stenting
16 Follow up Duplex ultrasound - Stent patency - Signs of inflow or outflow limitation - Thrombosis?
17 Follow up Conventional X-ray - Stent geometry - Kinking/ crushing
18 Conclusion - Reach out to your colleagues involved with venous disease (vascular surgery, phlebology, dermatology, vascular medicine, gynaecology) Be selective - Inform them to about avoid the early potential failures benefits for their patients (increased QoL, less chronic symptoms, phlebologists can continue superficial vein treatment afterwards)
19 Thank you for your attention Carsten Arnoldussen, M.D. Interventional Radiologist
20 Starting with deep venous treatment Carsten Arnoldussen, MD Interventional Radiologist Maastricht University Medical Centre, Maastricht VieCuri Medical Centre, Venlo The Netherlands
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