CHRONIC ILIOFEMORAL DVT NEVER TOO LATE Stephen F

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CHRONIC ILIOFEMORAL DVT NEVER TOO LATE Stephen F. Daugherty, MD, FACS, RVT, RPh. S

CHRONIC ILIOFEMORAL DVT NEVER TOO LATE Stephen F. Daugherty, MD, FACS, RVT, RPh. S Clarksville, Tennessee ACP NOVEMBER, 2012

NO CONFLICT OF INTEREST THE DESCRIBED USES OF STENTS ARE NOT FDA-APPROVED USES.

NO CONFLICT OF INTEREST THE DESCRIBED USES OF STENTS ARE NOT FDA-APPROVED USES.

SEQUELAE OF ILIOFEMORAL DVT VENOUS CLAUDICATION POST-THROMBOTIC SYNDROME VENOUS LEG ULCERS

SEQUELAE OF ILIOFEMORAL DVT VENOUS CLAUDICATION POST-THROMBOTIC SYNDROME VENOUS LEG ULCERS

44% DEVELOP VENOUS CLAUDICATION 15% VENOUS CLAUDICATION INTERRUPTS WALKING Delis KT, Bountouroglou D, Mansfield

44% DEVELOP VENOUS CLAUDICATION 15% VENOUS CLAUDICATION INTERRUPTS WALKING Delis KT, Bountouroglou D, Mansfield AO, Ann Surg. 2004; 239(1): 118 -26.

9/14/11

9/14/11

21% of patients with LE DVT develop PTS with 66 month follow -up At

21% of patients with LE DVT develop PTS with 66 month follow -up At the initial presentation, iliofemoral DVT was the single variable closely associated with PTS, odds ration 3. 4 Yamaki T, et al. Eur J Vasc Endovasc Surg 2011; 41: 126 -33.

MOST CLOSELY ASSOCIATED WITH PTS AT 6 MONTHS VENOUS OCCLUSION POPLITEAL VEIN REFLUX ELEVATED

MOST CLOSELY ASSOCIATED WITH PTS AT 6 MONTHS VENOUS OCCLUSION POPLITEAL VEIN REFLUX ELEVATED PEAK REFLUX VELOCITY POPLITEAL CALF MUSCLE PUMP DYSFUNCTION

OBSTRUCTION - OCCLUSIVE - NON-OCCLUSIVE WEBS SYNECHIAE LONG STENOSIS DUE TO FIBROSIS

OBSTRUCTION - OCCLUSIVE - NON-OCCLUSIVE WEBS SYNECHIAE LONG STENOSIS DUE TO FIBROSIS

80% OF ILIOFEMORAL DVT HAVE AN UNDERLYING EXTRINSIC ILIAC VEIN COMPRESSION Chang, et al.

80% OF ILIOFEMORAL DVT HAVE AN UNDERLYING EXTRINSIC ILIAC VEIN COMPRESSION Chang, et al. JVIR; 15: 249 -56.

MAY-THURNER IVC FILTER OCCLUSION ANEURYSMS, ARTERIAL GRAFTS TUMORS, CYSTS SURGICAL INJURY RADIATION FIBROSIS HYPOPLASTIC

MAY-THURNER IVC FILTER OCCLUSION ANEURYSMS, ARTERIAL GRAFTS TUMORS, CYSTS SURGICAL INJURY RADIATION FIBROSIS HYPOPLASTIC KLIPPEL-TRENAUNAY

LE VENOUS DUPLEX US REFLUX OBSTRUCTION CFV DOPPLER FLOW CONTINUOUS? ASYMMETRY? FEMORAL VEIN COLLATERALS

LE VENOUS DUPLEX US REFLUX OBSTRUCTION CFV DOPPLER FLOW CONTINUOUS? ASYMMETRY? FEMORAL VEIN COLLATERALS

ABDOMINAL/PELVIC DUPLEX FLOW AND ANATOMY STENOSIS MINOR DIAMETER REDUCTION ELEVATED PEAK VENOUS VELOCITY RATIO

ABDOMINAL/PELVIC DUPLEX FLOW AND ANATOMY STENOSIS MINOR DIAMETER REDUCTION ELEVATED PEAK VENOUS VELOCITY RATIO >2. 5 FLOW REVERSAL GONADAL, ASCENDING LUMBAR, PELVIC VARICOSITIES

CT/MR VENOGRAMS - HELP WITH ANATOMIC DETAIL - DO NOT EVALUATE FLOW - DEPENDENT

CT/MR VENOGRAMS - HELP WITH ANATOMIC DETAIL - DO NOT EVALUATE FLOW - DEPENDENT UPON FACILITY AND RADIOLOGIST INTEREST - CT— TIMING OF CONTRAST INJECTION/FLOW ISSUES

SURGICAL APPROACHES AUTOGENOUS SAPHENOUS VEIN FEM-FEM BYPASS 4 YEAR PATENCY 83% e. PTFE BYPASS

SURGICAL APPROACHES AUTOGENOUS SAPHENOUS VEIN FEM-FEM BYPASS 4 YEAR PATENCY 83% e. PTFE BYPASS 2 YEAR SECONDARY PATENCY 54% Jost CJ, et al. J Vasc Surg 2001; 33(2): 320 -27.

ILIOFEMORAL VENOUS STENTING Chronic non-malignant obstruction 177 limbs stented iliac vein into CFV Focal

ILIOFEMORAL VENOUS STENTING Chronic non-malignant obstruction 177 limbs stented iliac vein into CFV Focal in-stent stenosis at inguinal ligament 7% (all <50%) In-stent restenosis (>50%) 5% Stent fractures 0 Stent compression 0 Neglen P, Tackett TP, Raju S. J Vasc Surg 2008; 48(5): 1255 -61.

CUMULATIVE SECONDARY PATENCY AT 54 MONTHS NONTHROMBOTIC 100% THROMBOTIC CEPHALAD TO INGUINAL CREASE 90%

CUMULATIVE SECONDARY PATENCY AT 54 MONTHS NONTHROMBOTIC 100% THROMBOTIC CEPHALAD TO INGUINAL CREASE 90% CAUDAD TO INGUINAL CREASE 84% NON-OCCLUSIVE ONSTRUCTION 95% OCCLUSIVE OBSTRUCTION 77%

CHRONIC ILIOFEMORAL VENOUS OBSTRUCTION 16 PATIENTS C 3 -6 10/16 INCAPACITATING VENOUS CLAUDICATION AFTER

CHRONIC ILIOFEMORAL VENOUS OBSTRUCTION 16 PATIENTS C 3 -6 10/16 INCAPACITATING VENOUS CLAUDICATION AFTER STENTING (8. 4 MONTHS MEAN F/U) 0/16 WITH INCAPACITATING VENOUS CLAUDICATION IMPROVED VENOUS OUTFLOW IMPROVED CALF MUSCLE PUMP FUNCTION INCREASED VENOUS REFLUX

Mean C 3 (pre-treatment) Mean C 2 (post-treatment) Delis KY, et al. Ann Surg

Mean C 3 (pre-treatment) Mean C 2 (post-treatment) Delis KY, et al. Ann Surg 2007; 245: 130 -39.

INFLOW IS ESSENTIAL MAY EXTEND STENTS INTO COMMON FEMORAL VEIN PROFUNDA FEMORIS VEIN

INFLOW IS ESSENTIAL MAY EXTEND STENTS INTO COMMON FEMORAL VEIN PROFUNDA FEMORIS VEIN

HYBRID PROCEDURES ENDOPHLEBECTOMY OF CFV, FV STENT IVC, ILIAC, CFV Vogel D, Comerota AJ,

HYBRID PROCEDURES ENDOPHLEBECTOMY OF CFV, FV STENT IVC, ILIAC, CFV Vogel D, Comerota AJ, et al. J Vasc Surg 2012; 55: 129 -135.

DEFINITIVE DIAGNOSTIC/THERAPEUTIC PROCEDURES VENOGRAMS UG sheath placement Femoral, Pop, PTV Flow, Collaterals

DEFINITIVE DIAGNOSTIC/THERAPEUTIC PROCEDURES VENOGRAMS UG sheath placement Femoral, Pop, PTV Flow, Collaterals

VENOGRAMS FEMORAL INFLOW FILLING DEFECTS WILL MISS SOME STENOSES, WEBS

VENOGRAMS FEMORAL INFLOW FILLING DEFECTS WILL MISS SOME STENOSES, WEBS

INTRAVASCULAR ULTRASOUND THE ANATOMIC GOLD STANDARD USUALLY BILATERAL IFV/IVC CHOOSE DIAMETER/LENGTH OF BALLOON/STENT POST-STENTING

INTRAVASCULAR ULTRASOUND THE ANATOMIC GOLD STANDARD USUALLY BILATERAL IFV/IVC CHOOSE DIAMETER/LENGTH OF BALLOON/STENT POST-STENTING ASSESSMENT

POST-OP STENTS OBSERVE OVERNIGHT ANTICOAGULATION LMWH WARFARIN COMPRESSION HOSE, 30 -40 mm Hg EARLY

POST-OP STENTS OBSERVE OVERNIGHT ANTICOAGULATION LMWH WARFARIN COMPRESSION HOSE, 30 -40 mm Hg EARLY AMBULATION

FOLLOW-UP <1 WEEK 3 -4 WEEKS US/OV 3, 6, 9, 12 MONTHS AND ANNUALLY

FOLLOW-UP <1 WEEK 3 -4 WEEKS US/OV 3, 6, 9, 12 MONTHS AND ANNUALLY US/OV OFFICE VISIT ABD/PELVIC

1

1

SECONDARY PROCEDURES FLOW-LIMITING IN-STENT SENOSIS PTBA NEW STENOSIS OUTSIDE STENT PTBA/STENT THROMBOSIS CONSIDER LYSIS

SECONDARY PROCEDURES FLOW-LIMITING IN-STENT SENOSIS PTBA NEW STENOSIS OUTSIDE STENT PTBA/STENT THROMBOSIS CONSIDER LYSIS EVALUATE INFLOW AND OUTFLOW AND ADEQUACY OF ANTICOAGULATION

Its never too early or too late toIts never too early or too late to
Too Much Too Little Too Late A CriticalToo Much Too Little Too Late A Critical
DVT VARICOSE VEINS DVT It is the mostDVT VARICOSE VEINS DVT It is the most
TOO TOO ADJECTIVE TOO can be followed byTOO TOO ADJECTIVE TOO can be followed by
NGLZCE TOO ENOUGH 1 NGLZCE TOO ENOUGH TOONGLZCE TOO ENOUGH 1 NGLZCE TOO ENOUGH TOO
too and enough too and enough Both tootoo and enough too and enough Both too
It is never too late to learn AnswerIt is never too late to learn Answer
Its Never too late to learn Increasing theIts Never too late to learn Increasing the
ITS NEVER TOO LATE TO CHANGE Timelist MissionITS NEVER TOO LATE TO CHANGE Timelist Mission
MINDSET It Is Never Too Late To ChangeMINDSET It Is Never Too Late To Change
No matter your age its never too lateNo matter your age its never too late
Its Never Too Late To Apologize Grade 9Its Never Too Late To Apologize Grade 9
Never too late to start now Livingston UnitedNever too late to start now Livingston United
Saving and Investing It is never too lateSaving and Investing It is never too late
IT IS NEVER TOO LATE TO COME HomecomingIT IS NEVER TOO LATE TO COME Homecoming
Hitlers Secret Weapons Too Little Too Late V1Hitlers Secret Weapons Too Little Too Late V1
Too little too late responses to the HIVAIDSToo little too late responses to the HIVAIDS
CRT 2012 Venous Disease Acute and Chronic DVTCRT 2012 Venous Disease Acute and Chronic DVT
CHRONIC DIARRHEA Chronic Diarrhea o Chronic diarrhea definedCHRONIC DIARRHEA Chronic Diarrhea o Chronic diarrhea defined
Chronic leukemias Chronic leukemias n Chronic myelogenous granulocyticChronic leukemias Chronic leukemias n Chronic myelogenous granulocytic
CHRONIC LEUKEMIA AND MULTIPLE MYELOMA Chronic Leukemia ChronicCHRONIC LEUKEMIA AND MULTIPLE MYELOMA Chronic Leukemia Chronic
Chronic leukaemias l Chronic myelogenous leukaemia l ChronicChronic leukaemias l Chronic myelogenous leukaemia l Chronic
Chronic venous insufficiency Management Chronic venous insufficiency ChronicChronic venous insufficiency Management Chronic venous insufficiency Chronic
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