Recanalization of Central Venous Total Occlusions Dr Steven

Recanalization of Central Venous Total Occlusions Dr. Steven Abramowitz, MD Med. Star Washington Hospital Washington, DC

Steven Abramowitz, MD I have no relevant financial relationships

Introduction • Venous outflow obstruction – Symptoms • Recanalization and Stenting – Acute and chronic phase • Safe and Efficacious • Long-term studies – High patency rate – Low rate of in-stent restenosis – Limited need for reinterventions

General Principles • Anesthesia – Sedation v General • Foley Catheter • Position – Prone or Supine

Treatment Recanalization Access Endovascular Supplies Ultrasound Micropuncture kit – 4 F Glide wires (0. 35) – straight/angled Glide catheters – 4 F/5 F – straight/angled 0. 18 wires Quick-cross catheters Self-expanding stents: 12 -18 mm; 40 -90 mm High-pressure balloons: 12 -18 mmx 40 mm

Access • US Guided – Femoral – Popliteal – Internal jugular • Chronicity – May or may not have backbleeding

Crossing Techniques • Acute occlusions – Cross occlusion – Thrombolysis • Chronic occlusions – Cross occlusion – can be challenging – Pre-dilate 6 -8 mm

Crossing Acute Occlusions

Crossing Chronic Occlusions • Hydrophilic Wire/Catheter • Multiple Access Points – Prepare to Snare • Adequate System – Long Sheath • Telescoping Sheaths • Patience

Crossing Chronic Occlusions • Crossing – Advanced: • Glide/Amplatz Back End • Telescoping Catheters • Sharp Recanalization (Chiba or Rosch-Uchida)

Crossing Chronic Occlusions • Pre-Dilate – Use 6 -8 mm balloons – 30 sec inflation times – Do not dilate to desired diameter – Enough to deliver stent

Treatment • Stent Sizing – Use pre-op imaging • Normal segments as guide • Contralateral segments as guide • Use IVUS – Measure diameter and length – Proximal and distal landing zones

Treatment • Stent Sizes – IVC – 20 -24 mm – CIV – 16 -18 mm – EIV – 14 -16 mm – CFV – 10 -12 mm

Treatment • No skip lesions • Adequate overlap • Post-deployment, balloon dilatation is performed to the size appropriate for each segment • High-pressure balloons with prolonged inflation

Treatment • Defects such as residual compression, incomplete dilatation, and improper stent apposition – repeat ballooning • Residual untreated significant obstruction (> 50%) – stent extension

Results: Neglen, JVS 2007

Results: Neglen, JVS 2007 In-stent stenosis occurred in 5% of limbs at 72 months Severe leg pain, swelling, and venous ulcers significantly improved

Treatment: Iliocaval

Treatment: Iliocaval

Treatment: Iliocaval

Treatment: Iliocaval

Treatment: Iliocaval

Results: Neglen, JVS, 2010

Results: Neglan, JVS, 2010 • Stenting of the iliocaval confluence in 115 patients (230 limbs) – Primary compressive limbs 141 limbs – Post thrombotic lesions 89 limbs † Patency at 4 Years

Treatment: IVC stents

Treatment: IVC stents Neglan, J Vasc Surg. 2011 Jul; 54(1): 153 -61.

Results: Neglan, JVS, 2011 Neglan, J Vasc Surg. 2011 Jul; 54(1): 153 -61.

Results: Neglan, JVS, 2011 • 25 patients recanalized & stented • No IVC tears, bleeding, or embolization

Stent Failure • • Improper stent selection Undersizing Minimal overlap Failure to stent all disease

Conclusions • Endovascular recanalization of chronic venous occlusions are safe and effective • Cover all diseased segments • Need good inflow and outflow • Knowledge of available catheters, wires, stents and IVUS