Michael Meuse, M.D. Vascular and Interventional Radiology

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Transcription:

Michael Meuse, M.D. Vascular and Interventional Radiology

Iliac Vein Compression Syndrome Left CIV compressed by right CIA Virchow 1851: DVT L>R May and Thurner 1954: venous spurs Cockett and Thomas 1965: iliocaval compression Primary Axillosubclavian Vein Thrombosis Activity-induced thrombosis ( Effort Thrombosis) Paget (1875), von Schroetter (1884) Paget-Schroetter Syndrome, Compression at thoracic inlet (TOS)

LCIV compressed between RCIA/spine Chronic irritation-->endothelial proliferation

Typically young women Following period of inactivity e.g. surgery, pregnancy, illness Acute: Iliofemoral DVT Swelling, pain, erythema Phlegmasia cerulea dolens Chronic: venous stasis, chronic DVT Swelling, pain, venous claudication varicose veins, skin changes

H&P key to diagnosis Classic venographic findings With DVT Acute: lesion unmasked by thrombolysis Chronic: R/O other causes of iliac vein occlusion Without DVT Venogram Typical symptomatology

Duplex Ultrasound Reliable diagnosis of femoropopliteal DVT non-phasic signal obstruction evaluation of reflux Magnetic Resonance Imaging Diagnosis of iliofemoral DVT with MRV Cross-sectional images - CIV compression Impedance/Strain-gauge/Air Plethysmography diagnosis of DVT Maximal Venous Outflow - CVI

Ascending Venography Gold standard for diagnosis of iliofemoral DVT Depicts CIV compression and collaterals Intravascular Ultrasound (IVUS) Depicts vein spurs, clot Accurate measurement of vessel diameter Intravascular Manometry > 3 mm Hg probably significant

Chronic Venous Insufficiency valvular incompetence 2 to dilation/destruction PTS in 2/3 of patients despite anticoagulation Strandness et al (JAMA 1983), 39 month f/u pain and swelling 67 % pigmentation 23 % ulceration 5 % Socioeconomic effects health care costs occupational disability

Conservative anticoagulation compression stockings Surgical cross-femoral saphenous vein bypass with AVF venotomy/transposition with CIA sling/bridge RCIA transposition w/wo interposition graft Percutaneous/endovascular thrombolysis stent placement

Access site (US guided) Popliteal/post. tib. vein if iliofemoral DVT present CFV if no DVT present Mechanical thrombectomy Debulking exposure of clot to lytic agent rate of lysis Lytic agent via multi-sidehole catheter Check progress venographically every 12 hrs

Self expanding stent Technical Success Venographic flow Pressure gradient < 2mm Hg IVUS

Post-procedure Clopidogrel bisulfate (Plavix) 4-6 wks Warfarin sodium (Coumadin) for DVT 3-6 mons Follow up Clinical/Duplex Venogram/IVUS for recurrent/persistent symptoms Reintervention if required (PTA/Stenting)

MAY-THURNER SYNDROME

COMPLETION DSA

n Tech success Clin success 1-3 year patency Binkert (1998) 8 100% 100% 100% O Sullivan (1999) 35 87% 85% 92% Patel (2000) 10 100% 100% 90% Hurst (2001) 17 100% 94% 79%

Synonyms: Primary axillosubclavian vein thrombosis Effort vein thrombosis >90% AS thrombosis are secondary Thoracic Outlet Syndrome (TOS) Most pts. have neurologic and/or arterial symptoms 2-10% have symptomatic venous obstruction compression of neurovascular bundle by clavicle, 1st rib, scalenus muscles (+cervical rib, ligaments)

Acute Young patient with acute AS thrombosis following strenuous exercise Average age 34 years, M > F, R > L Pain, swelling, venous engorgement, cyanosis phlegmasia cerulea dolens Chronic (less common) symptoms of venous stasis If untreated 75% develop permanent disability Small but not insignificant rate of PE

H&P is key Axillosubclavian vein thrombosis R/O other causes of thrombosis central venous catheter malignancy trauma coagulopathy arterial/neurogenic symptoms may suggest classic TOS

Duplex Ultrasound diagnosis of DVT Conventional Venography gold standard: DVT & collaterals typical lesion unmasked following thrombolysis MRV/MRI demonstrates DVT and surrounding soft tissue parasagittal images may show SV compression IVUS venous abnormalities, clot

Images courtesy of Daniel Sze, M.D.

Images courtesy of Daniel Sze, M.D.

IVUS

Catheter-directed thrombolysis Access via basilic or brachial vein Lytic agent infused via multi-sidehole catheter Additional mechanical thrombectomy Recanalization/limited PTA (poss. rethrombosis) Anticoagulation for approx. 1-6 months Resolution of phlebitis Ptn. may become asymptomatic collaterals Duration of anticoagulation controversial

Surgical decompression 1st/cervial rib resection, medial clavicle resection Subclavius/scalenus muscle division/resection Supra/sub clavicular or transaxillary approaches Ideal method controversial Repeat venogram PTA of residual stenoses Limited role for stents

VENOGRAPHY THROMBOSIS COMPRESSION THROMBOLYSIS ANTICOAGULATION EVALUATION SYMPTOMATIC / ABNORMALITY ASYMPTOMATIC / NO ABNORMALITY RIB RESECTION VENOGRAM RESIDUAL STENOSIS NORMAL VEIN PTA

N LYSIS SURGERY PTA/STENT F/U** Machleder 1993 50 20/24 36 9/0 83%/38m Adelman 1995 18 1217 11 0/0 100%/21m Beygui 1997 13 9/13 8 0/0 na Sheeran 1997 14 13/14 8 2/0 57%/24m Lee 1998 11 9/11 11 0/0 81%/na Urschel 2000 241 239/241 241* 0/0 89%/na Feugier 2001 10 3/7 10* 0/0 80%/45m Kreienberg 2001 23 23/23 23* 23/14 74%/48m Coletta 2001 19 /18 18* 2/6 89%/38m Angle 2001 18 17/18 18* 5/0 100%/na *early surgical decompression without interval anticoagulation **asymptomatic/mean follow-up

Early and complete thrombolysis Limited PTA prior to surgery Staged vs. early surgical decompression Method and approach of surgery Staged stress venogram following surgery with possible PTA (avoid stenting if possible) Anticoagulation vs. no anticoagulation following surgery

H&P key to diagnosing iliac vein and thoracic outlet venous compression syndromes US, MRV, IVUS, Venography useful for confirming diagnosis and planning therapy Aggressive management can prevent long-term sequelae of DVT and avoid disability Good mid-term results with endovascular treatment of iliac vein compression syndrome Good long-term results with multidisciplinary management of Effort thrombosis

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