Imaging, it s central role in planning and guiding intervention. Prof. Luis Izquierdo. MD, PhD, FEBVS
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1 Imaging, it s central role in planning and guiding intervention Prof. Luis Izquierdo. MD, PhD, FEBVS
2 IMPORTANT INFORMATION: These materials are intended to describe common clinical considerations and procedural steps for the on-label use of referenced technologies as well as current standards of care for certain conditions. Of course, patients and their medical circumstances vary, so the clinical considerations and procedural steps described may not be appropriate for every patient or case. As always, decisions surrounding patient care depend on the physician s professional judgment in light of all available information for the case at hand. Boston Scientific Corporation ( BSC ) does not promote or encourage the use of its devices outside their approved labeling. The presenter s experience with BSC products may not be interpreted or relied upon to support clinical claims about BSC devices or product comparison claims regarding BSC and competitive devices. The experiences of other users may vary. Results from case studies are not necessarily predictive of results in other cases. Results in other cases may vary.
3 Disclosure Speaker name: Prof. Luis Izquierdo. MD, PhD, FEBVS... I have the following potential conflicts of interest to report: Consulting: Boston Scientific, Bard Medical, Cook Medical, Terumo, Jotec.
4 Stenting of iliac venous obstructive lesions may provide an important clinical benefit with a low risk of complications To achieve successful treatment and maintain clinical benefits over time, several key points must be evaluated on basis of imaging test
5 Planning Vein access site selection Assesment incoming Inflow Outflow evaluation: Patency of the inferior vena cava Is the inferior vena cava disease-free or should it also be treated? Is the contralateral axis venous flow compromised? Is it also diseased?
6 Intraprocedure Proper imaging techniques allow: Extent of the lesions healthy to a healthy vein Correct sizing (balloons and stents) Confirm good stent deployment Ensure sufficient stent overlap if necessary
7 Duplex Ultrasound Duplex US 1st test (acute DVT, CTO, NIVL) Global vision extension of disease Inflow (femoral, deep femoral, and CFV) Outflow (IVC patency, anatomic variations)
8 Duplex Ultrasound Direct signs Lumen changes (thrombus..) Caliper reductions Trans stenotic flow velocity ratio increments (>2,5) Labropoulos N, Borge M, Pierce K, Pappas PJ. Criteria for defining significant central vein stenosis with duplex ultrasound. J Vasc Surg. 2007;46:
9 Duplex Ultrasound Indirect signs: Reverse flow in IIV or deep pudendal V Cephalad flow in epigastric V Nonphasic flow in the CFV Asymmetrical flow pattern in CFV Nonphasic flow during Valsalva No velocity augmentation in CFV during distal compression Detection of collateral veins Labropoulos N, Borge M, Pierce K, Pappas PJ. Criteria for defining significant central vein stenosis with duplex ultrasound. J Vasc Surg. 2007;46:
10 CT-Venography CTV IVC status Collateral and internal iliac veins Iliac / renal vein compression Non-diagnosed malignancy
11 CT-Venography Indirect CTV Delayed portal phase Factors influencing (cardiac output ) Acute DVT / NiVL Overlook intraluminal lesions
12 CT-Venography Direct CTV Post Thrombotic Chronic Cases Excellent detail Essential tool in planning CTO
13 MR-Venography MRV No radiation Good images Operator dependent Overstimate stenotic lesions
14 Phlebography Phlebography Visualization of patent vein Estimation blood flow rhythm MULTIPLANAR Cone Beam or Dyna CT Techniques If available it should be supplemented with IVUS
15 Phlebography
16 Phlebography
17 IVUS IVUS High-res examination of the vein wall and internal structure Detection and qualitative characterization of lesions Extent of diseased segments NIVL True gold standard
18 IVUS IVUS Wall thickness Intraluminal irregularities Wall movement in respiratory and cardiac cycles
19 IVUS IVUS Sizing balloons and stents Assess correct stent deployment Final aspect after implantation Raju S, Negle n P. High prevalence of nonthrombotic iliac vein lesions in chronic venous disease: a permissive role in pathogenicity. J Vasc Surg 2006; 44: Levitin A. Intravascular ultrasound. Tech Vasc Interv Radiol 2001; 4: Neglen P, Raju S. Intravascular ultrasound scan evaluation of the obstructed vein. J Vasc Surg 2002; 35:
20 IVUS IVUS Flow resistance decreases with the more circular shape of the vessel and stent Aspect Ratio = Maximum Diameter / Minimum Diameter. Greater AR values = greater flow resistance and flow reduction.
21 Message to take home Planning!!! Inflow Outflow Treat all lesions healthy to a healthy vein Sizing Rounder Shape
22
23 Imaging, it s central role in planning and guiding intervention Prof. Luis Izquierdo. MD, PhD, FEBVS
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