Complex Iliocaval Reconstruction PNEC. Seattle WA. Bill Marston MD Professor, Div of Vascular Surgery University of N.

Transcription

1 Complex Iliocaval Reconstruction 2017 PNEC. Seattle WA Bill Marston MD Professor, Div of Vascular Surgery University of N. Carolina

2 DISCLOSURES William Marston, MD Consultant/Advisory Board: Veniti, Cardinal Healthcare, Tactile Medical, Factor Therapeutics, Volcano Inc Stock: Veniti Inc

3 Chronic nonhealing leg ulcer 52 YO male w h/o multiple DVTs starting 11 yrs before initial visit in both legs Prot C deficiency Bilateral edema, worse on L Ulceration on left Unable to work due to symptoms

4 Venous diagnostics VEIN EXAMINED LEFT Common Femoral Vein 2.45 sec Superficial Femoral Vein 2.81 sec Popliteal Vein 3.22 sec Great Saphenous (SFJ) 1.68 sec Great Saphenous (knee) 5.03 sec Small Saphenous 0.11 sec CFV compressible FV, Pop partially compressible GSV 6-8 mm diameter APG: VFI 12.7 cc/sec 4

5 Duplex of CFV Common femoral vein waveforms studied for evidence of iliac obstruction Lack of respiratory variation No change in velocity with augmentation maneuvers

6 Utility of CFV duplex as a % iliac stenosis on CT/MR screening test % of duplex exams negative for ICVO % of duplex exams positive for ICVO < 50% 100% 0% 50-79% 100% 0% 80% 23% 77% Sensitivity - 77% Specificity - 100% 6

7 Thin cut 3D CT or MR venography 1 mm cuts Examined in multiple planes Max % of narrowing of iliac or IVC recorded

8 ICVO classification system Type II Type IV Type 1 Type III

9 Complex venous reconstrx

10 Technical performance of intervention for ICVO Pre-procedural planning is critical Venous recanalization different from arterial

11 3d CT guidance with merge technology

12 Critical planning questions Inflow adequacy Crossing strategies Managing the iliac confluence

13 The Landing Zones Consider endophlebectomy Outflow is usually not an issue, but inflow to the CFV segment is. Courtesy Dr. A. Comerota

14 DUS guided femoral vein access

15 Traversing the Obstruction Occlusion Recanalization is a challenging procedure and can be quite time-consuming. Patience is the key. For long occlusions, consider GA Raju S, McAllister S and P Neglen. Recanalization of totally occluded iliac and adjacent venous segments. J Vasc Surg 2002;36: Kölbel T et al. Chronic Iliac Vein Occlusion: Midterm results of endovascular recanalization. J Endovasc Ther 2009;16: Rosales A, Sandbaek G, Jӧrgensen JJ. Stenting for Chronic Post-thrombotic Vena Cava and Iliofemoral Venous Occlusions: Mid-term Patency and Clinical Outcome. Eur J Vasc Endovasc Surg 2010;40:

16 Requirements of venous crossing system (not arterial) Long stiff sheath for support 5F for initial cross then 8F to accommodate IVUS Guiding catheter Stiff glide or stiff tipped TCO wire Keep components close together for support Capability for frequent injection to confirm intraluminal position

17 Triaxial Crossing system Stiff Tungsten coated 5F sheath that tapers to 4F at tip Angled guiding catheter Favorite crossing wire But don t lead far out of sheath Can inject through port with system intact

18 Understand anatomy

19 Extraluminal adventures They happen Usually not associated with significant retroperitoneal hematoma

20 Additional crossing adjuncts IJ and femoral access RF hotwire Outback catheter with PTA balloon

21 Once wire across lesion Dilate with small balloon and inject to be sure no extravasation Sequentially dilate to large diameters Once large enough channel created, IVUS

22 Identifying Central and peripheral Landing Zone With IVUS

23 Measure the length of the stented area and plan the length and number of stents to be placed Length by using measuring catheter or measure length of catheter pull back externally Oversize the stent by 2mm as compared to normal vein Pre and post dilate with high pressure balloons Overlap stents at least 2-4 cm (Wallstent), 1cm nitinol stents, to avoid separation/shelfing Don t leave skip areas

24 Special considerations JVS 2008;48:1255 Stent can extend into IVC with low risk of contralateral thrombosis 13 cases in 980 patients Stent can be extended inferiorly into CFV without high risk of fractures/recurrent thrombosis

25 Managing the iliac confluence

26 Managing the iliac confluence

27 Gianturco stents for bilateral iliac stenting

28 Full dilation of outflow tract 16 mm stent = 201 mm2 12 mm stent = 113 mm2

29 Post-procedure anticoagulation MTS, non-occlusive lesions Antiplatelet therapy Complex recanalizations Anticoagulate 3-6 months Favor LMWH

30 UNC ICVO intervention in Class 5-6 patients N=47 Median age 47 Median ulcer size 63 sq cm Median ulcer duration 2.2 years 90% post-thrombotic 87% class 3 or 4 21% reintervention rate at 12 months

31 Ulcer recurrence after intervention vs compression Eschar Trial Data UNC Data n=37

32 Summary PTS and other deep vein issues are common Patient QOL severely affected Much we can now do to positively affect QOL (we think) Specific tool set and techniques required Can t just apply arterial methods Future studies to clearly define benefit to patients

33 Questions?