How to best approach chronic venous occlusions?
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- Percival Carr
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1 How to best approach chronic venous occlusions? Prof. Nils Kucher Director Venous Thromboembolism Reseach Group University Hospital Bern nilskucher.com
2 Disclosure Speaker name: Nils Kucher X X I have the following potential conflicts of interest to report: Consulting/Honoraria: BTG, Optimed, Cook, Volcano, BSCI Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest
3 Venous Intervention Acute DVT treatment Catheter-directed thrombolysis +/- Stenting Chronic DVT treatment (PTS) Endovascular reconstruction Stenting nilskucher.com
4 How to best approach chronic venous occlusions? Performance of old generation stents Patient selection Testing prior to intervention Key points interventional approach Postinterventional care
5 Most commonly used iliofemoral venous stents - Wallstent - EverFlex - Luninexx - Lifestent - SMART stent - Zilver Vena stent Mahmood K. Razavi et al. Circ Cardiovasc Interv. 2015;8:e002772
6 Primary patency of non-dedicated iliofemoral vein stents Nonthrombotic (N=1122) Acute thrombosis (N=629) Chronic postthrombotic (N=1118) Mahmood K. Razavi et al. Circ Cardiovasc Interv. 2015;8:e002772
7 Clinical outcomes of iliofemoral venous stents Major bleeding Nonthrombotic 0.3% Acute thrombosis 1.1% Chronic postthrombotic 0.9% Mahmood K. Razavi et al. Circ Cardiovasc Interv. 2015;8:e002772
8 Clinical outcomes of iliofemoral venous stents Pulmonary embolism Nonthrombotic 0.2% Acute thrombosis 0.9% Chronic postthrombotic 0.6% Mahmood K. Razavi et al. Circ Cardiovasc Interv. 2015;8:e002772
9 Clinical outcomes of iliofemoral venous stents Early stent thrombosis Nonthrombotic 1.0% Acute thrombosis 6.5% Chronic postthrombotic 6.8% Mahmood K. Razavi et al. Circ Cardiovasc Interv. 2015;8:e002772
10 Clinical outcomes of iliofemoral venous stents Complete pain relief Nonthrombotic 81.5% Acute thrombosis 100% Chronic postthrombotic 69.3% Mahmood K. Razavi et al. Circ Cardiovasc Interv. 2015;8:e002772
11 Clinical outcomes of iliofemoral venous stents Complete edema relief Nonthrombotic 68.0% Acute thrombosis 100% Chronic postthrombotic 63.6% Mahmood K. Razavi et al. Circ Cardiovasc Interv. 2015;8:e002772
12 Clinical outcomes of iliofemoral venous stents Complete ulcer healing Nonthrombotic 81.1% Acute thrombosis - Chronic postthrombotic 70.8% Mahmood K. Razavi et al. Circ Cardiovasc Interv. 2015;8:e002772
13 Candidates for Endovascular Therapy of PTS: Clinical & Anatomical Criteria Clinical: Presence of the post-thrombotic syndrome Quality-of-life limiting venous claudication and other symptoms of venous leg hypertension Skin changes (Varicosis, Hyperpigmentation, Lipodermatosclerosis) Ulcers Pelvic congestion symptoms Varicocele Recurrent thrombophlebitis Anatomical: Occlusion of common femoral vein, or iliac vein, or inferior vena cava
14 Useful Tests prior to Intervention Vein plethysmography (to verify chronic venous insufficiency) Exercise testing (to quantify venous claudication) Duplex sonography (access site femoral vs popliteal) MR or CT Phlebography
15 Key Points Interventional approach (1) Contrast-enhanced CT or MR are essential for planning the procedure Do not use common femoral access for most cases because common femoral vein ist often postthrombotic Stiff exchange length glide wires for crossing venous occlusions (in rare cases CTO wire: Asahi Astato 30)
16 Key Points Interventional approach (2) IVUS may be helpful for planning stent implantation, particularly if the common femoral vein is involved Nominal diameter predilation Stent from normal inflow to normal outflow Stenting across the inguinal ligament may be necessary when common femoral vein is postthrombotic High pressure ballooning of all implanted stents
17 Postinterventional care All patients need at least 3 months of anticoagulation therapy post stenting The role of antiplatelet agents is unknown Definite duration of anticoagulation depends on VTE risk factors Regular postinterventional clinical and Duplex monitoring at 3, 6, and 12 months, and than once yearly
18
19 Take home Endovascular therapy of iliofemoral obstruction is the treatment of choice for patients with PTS Most patients have improvement of PTS symptoms and signs and better quality of life Primary patency rates with old-generation stents are 60% at 5 years Patency rates with new generation dedicated venous stents are being investigated
20 Venous Intervention Acute DVT treatment Catheter-directed thrombolysis +/- Stenting Chronic DVT treatment (PTS) Endovascular reconstruction Stenting nilskucher.com
21 How to best approach chronic venous occlusions? Prof. Nils Kucher Director Venous Thromboembolism Reseach Group University Hospital Bern nilskucher.com
The evidence for venous interventions is evolving- many patients do actually benefit. Nils Kucher University Hospital Bern Switzerland
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