Iliocaval Reconstruc0on in an OIS William Julien, MD South Florida Vascular Associates Coconut Creek, FL
Disclosures Consultant Cardiovascular Systems Inc Cook
Outline Background Our Data Efficacy, Safety and patency Cases with emphasis on technical and clinical considera0ons Summary
Iliocaval Occlusive Disease liofemoral deep venous thrombosis (DVT) treated with an0coagula0on alone: Over 90% of pa0ents have venous insufficiency 15% have experienced venous ulcera0on 15% have developed venous claudica0on 40% have restricted ambula0on. Severity of posvhrombo0c venous insufficiency is amplified when valvular incompetence and venous obstruc0on coexist. Whereas valvular func0on can be quan0fied through ultrasonography, residual venous obstruc0on oyen goes undetected Iliocaval venous obstruc0on is frequently overlooked. IVC filter occlusion varies from 3.6-11.2% depending on filter and study. Vogel, David et al. Journal of Vascular Surgery, Volume 55, Issue 1, 129-135
Iliocaval Occlusive Disease Percutaneous sten0ng is the method of choice for trea0ng clinically significant chronic venous obstruc0on When sten0ng an obstructed IVC filter, concern about IVC lacera0on/ perfora0on, filter fracture and future pulmonary embolism are raised. Adequate diameter covered stents are cost prohibi0ve in an office se`ng. Neglén, et al. demonstrated the safety of sten0ng chronically obstructed IVC filters in pa0ents with posvhrombo0c disease in a hospital se`ng. * We aimed to study the safety of sten0ng iliocaval occlusions in an Office Interven0onal Suite. *Journal of Vascular Surgery, Volume 54, Issue 1, 153-161
Our Experience Prospec0vely maintained, retrospec0vely evaluated pa0ent database 10 pa0ents treated in office in 18 months Inclusion criteria: long iliac vein or IVC occlusions due to chronic DVT Exclusion criteria: Short occlusions, May-Thurner compression, long segment severe narrowing from chronic DVT, acute occlusion.
Data N= 10 pa0ents; Age range 44-88 (64); Male 7: Female 3 20% with prior PE; 90% with prior LE DVT 6/10 on chronic an0coagula0on 40 % iliac only; 60% IVC and iliac vein occlusion All IVC occlusions related to IVC filter occlusion Concurrent: thrombophilia 10%, DM 70%, CAD 50%, CKD 40% Indica0on: Swelling 10/10, Pain 9/10, Wound 6/10
Data
Data Results: Technical success 100% Clinical Success: Wound healing ayer recanaliza0on in 5/6 Improved pain/swelling in 10/10 Patency 9/9 at 3 months; 6/6 at 6 months; 3/3 at 1 year*
Data Complica0ons: Acute iliac vein occlusion within 2 nd postopera0ve week requiring in office pharmacomechanical thrombectomy and stent extension in one pa0ent. Two procedures required in one pa0ent. No bleeding complica0ons, cardiovascular events, acute limb loss or death within 3 month postopera0ve period. No hospitaliza0ons during immediate postopera0ve period. One pa0ent died 9 months later of unrelated causes.
Case Study DR 45 yo M (former hockey player) with a history of Factor V Leiden and mul0ple prior DVTs and PE. Permanent IVC filter placed 10 years ago Presented to a hospital with severe bilateral leg swelling (picture to follow) and rapid development of wounds Physicians avempted mul0ple days of lysis and thrombectomy and were unsuccessful. Pa0ent was told there was nothing to do...
Hospital Leg Selfie
Venogram Right iliac Vein Pre 02/06/14 DR
Venogram LeY iliac Vein Pre 02/06/14 DR
Venogram IVC Pre 02/06/14 DR
Venogram IVC Post 02/06/14 DR
Venogram Iliac Veins Post 02/06/14 DR
Case Study DR Lost 50 pounds of edema in 1 st week post-op Chronic back pain resolved Chronic dyspnea on exer0on resolved (?) Lost another 50 pounds over ensuing months Follow up CT at 6 months demonstrates patency of stents. All wounds, swelling and erythema resolved.
AM 68 yo M who presents with right plantar surface wound and extensive blistering along right dorsum of foot. Hx: ESRD, DM, prior right ankle fracture (6 mo ago) s/p ORIF complicated by infec0on requiring hardware removal and ankle fusion. Prior IVC filter for DVT Scheduled for Right Leg BKA following week. PE: Severe right >ley leg swelling. Nonpalpable pedal pulses Monophasic signals in PT and DP bilaterally.
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AM 3 wk follow up Healed ayer 5 months of wound care
Conclusions IVC filter and iliocaval occlusion is a underdiagnosed en0ty with significant morbidity Recanaliza0on of iliocaval occlusive disease in an office se`ng: Appears safe Provides significant clinical benefits Challenging and rewarding Further experience necessary to further establish safety
Thank You! SFVA Crew