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Erin H. Murphy, MD
How: Imaging to Optimize Outcomes in Venous Stenting
Rane Center
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Disclosure
Speaker name: Erin H. Murphy
.................................................................................
I have the following potential conflicts of interest to report:
X Consulting: Medtronic, Boston Scientific, Cook Medical
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
I do not have any potential conflict of interest
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Clinical Outcomes in Venous Stenting
Results can be dramatic
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0 6 12 18 24 30 36 42 48 54 60 66 720
10
20
30
40
50
60
70
80
90
100
Primary
Assisted-primary/Secondary
302 192 143 120 96 80 65 55 43 34 24 16302 189 135 110 87 72 54 45 36 26 18 11
Months
Pa
ten
cy
Ra
tes
(%
)
100%
79%
Patency – Non-Thrombotic Obstruction
Durability is obtainable and expected
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0 6 12 18 24 30 36 42 48 54 60 66 720
10
20
30
40
50
60
70
80
90
100
Primary
Assisted-primary
Secondary
303 191 147 123 99 87 74 59 45 35 29 18303 189 144 122 99 87 74 59 45 35 29 18303 184 132 107 89 74 59 45 32 26 21 13
Months
Pa
ten
cy
Ra
tes
(%
)
86%
80%
57%
Patency – Thrombotic Obstruction
Durability less but still good
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Clinical Outcomes in Venous Stenting
• Results and durability depend on attention to
detail and technique
• Imaging essential at ALL steps:
• Access
• Degree of stenosis & extent of disease
• Delineation of venous anatomy: Iliocaval
confluence, profunda, healthy stent landing zones
• Detect early stent problems
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Access – Duplex Ultrasound
Ultrasound guidance – lateral/below femoral artery
Femoral vein - upper 1/3 of thigh
Enough running room to treat as low as lesser trocanter
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Initial Venogram – Roadmap
Iliac Iliocaval / IVCF occlusion
Evaluate overall patency, collateralization & flow
Initial Roadmap – Target string sign when present
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Initial Venogram
Non-occlusive Disease: Clues for underlying pathology Discrete Lesions or signs of underlying stenosis
PancakingCollateralsLesions
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Initial Venogram
PancakingCollateralsLesions
Can NOT completely characterize extent of disease or determine degree of stenosis accurately
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Limitations of Venography
• Rokitansky Stenosis:
• Diffuse long segment
stenosis w/o focal narrowing
• May be present in up to 50%
of PTS patients
Sensitivity of Venography for identification of iliac lesions ≈50%
+ Findings -> Helpful - Findings -> Do NOT r/o disease
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Intravascular Ultrasound (IVUS)
CIV: 16 mm -> 200 mm2
EIV: 14 mm -> 150 mm2
CFV: 12 mm -> 125 mm2
NOT ADJACENT SEGMENTS!
Gold Standard: Detection and classification of disease
Should be considered mandatory
Diagnostic Sensitivity of 85%
Determine degree of stenosis compared to anatomic normals
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Venogram vs. IVUS
Normal CIV: 200mm2
CIV (PTS): 67 mm2
Degree of Stenosis: 67%
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VIDIO TRIAL
Venogram Versus Intravascular Ultrasound for Diagnosing and
Treating Iliofemoral Vein Obstruction
• July 2014 – June 2015: 100 patients with CEAP 4 – 6
• Pre-intervention multiplaner venography (AP, RAO, LAO) performed
intervention strategy planned
• Pre-intervention IVUS performed and final treatment plan decided
Multicenter, Prospective Study
Results
• IVUS detected 88% > Lesions (124 vs. 66)
• 29% of patients detected (-) by venography were (+) by IVUS Gan
ep
, et
al. A
bst
ract
. J
Vas
cSu
rg2
01
6.
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Inadequacies of Venography
• Raju & Neglen: Venography sensitivity 66% (34% with lesions appear normal) vs. IVUS >90% sensitivity
• Interventionists reviewed transfemoral venograms obtained in serial CEAP 3 or > patients undergoing intervention for chronic venous disease and compared results with IVUS performed intraoperatively
• Results: Location (CIV, EIV, CFV) & degree of maximal stenosis (n=159)
• Venogram missed disease in 25% and underestimated degree of stenosis in 69%
Inadequacies of venographic assessment of anatomic
variables in iliocaval disease
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IVUS
In rare cases lesions may be missed by IVUS (15%)
Usually at bifurcations – probe not coaxial to lumen
Often appears as missing border
Occasionally will miss webs
Low pressure compliant balloon will identify missed stenoses
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Venous Stenting
Determine disease extent and stent landing zones
Must land stents in healthy vein proximally and distally
Most important step to prevent post-op stent occlusion
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Proximal Landing Zone – Iliac Confluence
Identify iliac confluence
May appear as missing border
Iliac Confluence
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Inadequacies of venographic assessment of anatomic
variables in iliocaval disease
Transfemoral venography in serial patients undergoing intervention for chronic venous disease VS IVUS
Location of the iliocaval confluence (n=162)
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Location of confluence was
recorded according to its
reference bony location from
the bottom of L5 to the top
of L3
L3
L4
L5
987654321
Inadequacies of venographic assessment of anatomic
variables in iliocaval disease
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Identification: IVUS 100% (n=162) & venogram 94% (n=152)
Confluence range: L3 – L5
Correct identification: 11% (n=16/152) of venograms
Avg difference: ONE VERTEBRAL BODY!!
Inadequacies of venographic assessment of anatomic
variables in iliocaval disease
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Proximal Landing Zone
Venogram = Lower confluence in 78% (n=118)
Landing = Missed Proximal Lesions
Wallstents at Iliocaval Junction = Collapse
Coning –Stenosis/Occlusion
Stent CompressionWatermelon Seeding
Distal Migration
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Cava Extension with Wallstents
Wallstent – CavalExtension
Contralateral DVT
Venogram = Higher confluence in 12% (18)
Landing = Risk Contralateral DVT
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a
b
Z Stent – Caval Extension
Current practice
Cava Extension with Z-stents
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0 6 12 18 24 30 36 42 48 5485
90
95
100
105
Z-Stent (n=588)
Wall-Stent (n=478)
91%
99%
P< 0.001
IVC Extension with Wallstents vs Z-Stents
Freedom From Contralateral DVT
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Caval Extension of Stents
*Ok to cross renal/hepatic veins*
Infrarenal Suprarenal Thoracic
Thoracic
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Proximal Landing Zone – Case Example
T12
*Determine landing zones prior to venoplasty*
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Proximal Landing Zone – Case Example
TAKE - BACK
Proximal Stent Extension
*Determine landing zones prior to venoplasty*
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Distal Stent Landing Zone
*Must stent to healthy vein: Ok to cross inguinal ligament*
*Required in almost all patients*
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Distal Stent Landing Zone
*Must stent to healthy vein: Ok to cross inguinal ligament*
Stent Occlusion Post – PMT / Lysis Stent extension Post - Venogram
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1: Common Iliac Vein
2: External Iliac Vein
3-6: Common Femoral Vein
3: Pubic Ramus
4: Bottom Femoral Head
5: Ischi
6: Lesser Trochanter
Ideal distal landing zone chosen between IVUS & venogram
Inadequacies of venographic assessment of anatomic
variables in iliocaval disease
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•Ideal landing zone matched in 29% (24/84)
•IVUS determined a lower landing zone in 44/84 (52%) = RISK OF MISSED DISTAL LESIONS
Inadequacies of venographic assessment of anatomic
variables in iliocaval disease
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•US access: goal -> visualize entire CFV
•Venogram for guidance
•IVUS
•Need to stent: Disease Severity
•Proximal and distal Landing zones
•Next: Balloon and Stenting – the easy part
Where are we….
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Venoplasty and Stenting
• Pre-dilate: Large, noncompliant, high pressure balloons to size of intended stent
• Stent from inflow to outflow determined by IVUS beforeballooning
• Large stents: IVC 20-24 mm, Iliac 16-18 mm
• Understenting = occlusion!
• Post-dilation
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Completion Imaging
Final VenogramFinal IVUS
• No shelving, thrombus, good flow
• Snowflakes on IVUS– slow flow
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Conclusions
• Excellent results and durability is achievable and
expected with iliac vein stenting
• Use of imaging is essential for good outcomes
• IVUS remains imperative for accurate diagnosis, disease
characterization, & intraoperative treatment guidance
including proximal & distal stent landing zones
• New stent technology will hopefully continue to improve
ease of stenting and clinical outcomes
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Erin H. Murphy, MD
How: Imaging to Optimize Outcomes in Venous Stenting
Rane Center