Vascular Surgery and Transplant Unit University of Catania. Pierfrancesco Veroux

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1 Vascular Surgery and Transplant Unit University of Catania Pierfrancesco Veroux Bologna-Palazzo dei Congressi, 23 Ottobre 2017

2 Disclosure Speaker name: Prof. Pierfrancesco Veroux I have the following potential conflicts of interest to report: Consulting Employment in industry Shareholder in a healthcare company Owner of a healthcare company Other(s) X I do not have any potential conflict of interest

3 CVSO Is most commonly secondary to malingnacy and more recently to benign etiology. The precise mechanisms of CVSO development, in cases of benign etiology are still not known, although the vein injury seems linked to increasing use of endovenous central device. Endovenous permanent catheter induces trauma, inflammation, intimal hyperplasia and fibrotic response of vein wall.

4 There is some scarce evidence of central vein stenosis in patients without a history of catheter placement. Negative predictor factors are: the sliding movements of catheter with respiration, head and neck movements, subclavian veins or left internal jugular vein access site. In cases of prolonged endovenous catheter use, as observed for CVC and pace maker implantation, were documented endothelial denudation and following chronic irritation of the vein intima. Vein wall thickening results from intimal hyperplasia with presence of fibrous tissue, smooth muscle cell proliferation and thrombi.

5 Thoracic Outlet Syndrome Secondary Obstructive Vein disease: (Related to Central Venous Catheter and Pacemaker)

6 The most common sign and simptoms are: upper extremity swelling, dilated chest vein collateral pathways, neck or chest swelling. Mittal V,Indian J Urol. 2016;32:

7 Symptoms could be enhanced by the lack of effective collateral pathways, and presence of ipsilateral AVF Literature Review

8 Balloon Venoplasty Stenotic ring lesion Digital subtraction venography remains a fundamental method for identifying the site of venous stenosis and for the evaluation of the hemodynamic and morphological results

9 Intravascular ultrasound (IVUS) is an imaging modality that provides both quantitative and qualitative data of vessel anatomy including lesion morphology, vessel diameters and thrombus detection. IVUS represent a more accurate method than catheter venography for assessing lesion severity and proper venous stent size due to the veins collapsibility propriety of the vein that often assume an elliptical cross-sectional area, while a stented vein segment assumes a more cylindrical configuration. Unlike venography, IVUS can display vein perimeter, so assuring a more accurate assessment of venous lesions and appropriate sizing of a venous stent.

10 EVT Role of Balloon Venoplasty Pseudo occlusion of junction between right Subclavian and Innominate vein Result after progressive balloon dilatations Severe angulations between the right subclavian vein and brachiocephalic trunk determines a greater vein wall wall

11 Occlusion of Left Innominate vein at Pirogof confluence Natural angulations between the left brachiocephalic trunk and superior vena cava results in a greater vessel wall injury and incidence of stenosis.

12 EVT Role of Balloon Venoplasty No compliant balloon venoplasty Presence of fibrotic ring CV showing good outflow Residual stenosis

13 Endovascolar Treatment of CVSO Bakken et al, 2007: 47 pz treated using PTA - 12month Primary and Secondary patency of 45 and 58%. Haage, 1999: 50 pz treated using BMS - 6 month Primary and Secondary patency of 85% e del 97%. Bakken, 2007: no difference in patency between PTA vs BMS Ozkan et al, 2013: 21 pz treated with BMS - 1 year Primary and Secondary patency % Balloon venoplasty is often poor effective in relief symptoms and is associated with high rate of clinical recurrence Need for high rate of TLR

14 EVT Role of Stenting Right Innominate vein Occlusion Stenting has become the first option for the treatment of CVSO Venoplasty Stenting

15 Veroux P; Eur Radiol 2002 Thrombolysis and venoplasty

16 5 years good morphological and hemodynamic result with no more retrograde flow into the azygos vein and complete resolution of severe clinical status

17 Case 1 Patients with Severe Oedema and due to high flow AVF and CVSO. He already underwent surgical reduction of anostomosis and banding of venous line

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19 Near occlusion of the right Subclavian Vein No compliant Balloon Angioplasty Residual stenosis

20 Case 2 Patient with Severe Oedema of left upper extremity and CVSO Occlusion of left SV At the site of Thoracic Outlet

21 Occlusion of left SV - Thoracic Outlet Syndrome Final result Stenting SV

22 Case 3 Patients with right upper extremity outflow occlusion CVC right side -Pace Maker left side Occlusion of RIV and SV Predilatation

23 Poor result after PTA Second Stent First Stent Final results

24 Before 1 month later 8 month later

25 Conclusions Upper limb oedema can develop in presence of obstructive disease of central vein. Extension of obstructive disease and lack of effective collateral pathways play a key role in determining the severity of clinical status Symptoms could be enhanced by the presence of ipsilateral AVF Endovascular treatment have been showed promising results assuring in the majority of patients the AVF preservation

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