CHRONIC ILIOFEMORAL DVT NEVER TOO LATE Stephen F. Daugherty, MD, FACS, RVT, RPhS Clarksville,...

CHRONIC ILIOFEMORAL DVTNEVER TOO LATE

Stephen F. Daugherty,

MD, FACS, RVT, RPhSClarksville, Tennessee

ACP NOVEMBER, 2012

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

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

21% of patients with LE DVTdevelop 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 OCCLUSIONPOPLITEAL VEIN REFLUX

ELEVATED PEAK REFLUX VELOCITY POPLITEAL

CALF MUSCLE PUMP DYSFUNCTION

OBSTRUCTION- OCCLUSIVE- NON-OCCLUSIVE

WEBSSYNECHIAELONG STENOSIS

DUE TO FIBROSIS

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

MAY-THURNERIVC FILTER OCCLUSIONANEURYSMS, ARTERIAL

GRAFTSTUMORS,CYSTS

SURGICAL INJURYRADIATION FIBROSIS

HYPOPLASTICKLIPPEL-TRENAUNAY

LE VENOUS DUPLEX USREFLUX

OBSTRUCTIONCFV DOPPLER FLOW

CONTINUOUS?

ASYMMETRY?FEMORAL VEIN COLLATERALS

ABDOMINAL/PELVIC DUPLEXFLOW AND ANATOMY

STENOSISMINOR DIAMETER

REDUCTIONELEVATED PEAK VENOUS

VELOCITY RATIO >2.5FLOW REVERSALGONADAL, ASCENDING LUMBAR,

PELVIC VARICOSITIES

CT/MR VENOGRAMS- HELP WITH ANATOMIC DETAIL

- DO NOT EVALUATE FLOW- DEPENDENT UPON FACILITY AND RADIOLOGIST INTEREST

- CT— TIMING OF CONTRAST

INJECTION/FLOW ISSUES

AUTOGENOUS SAPHENOUS VEIN

FEM-FEM BYPASS4 YEAR PATENCY 83%

ePTFE BYPASS2 YEAR SECONDARY PATENCY 54%

SURGICAL APPROACHES

Jost CJ, et al. J Vasc Surg 2001; 33(2):320-27.

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 0Stent compression 0

ILIOFEMORAL VENOUS STENTING

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 CREASE90%

CAUDAD TO INGUINAL CREASE84%

NON-OCCLUSIVE ONSTRUCTION 95%

OCCLUSIVE OBSTRUCTION 77%

16 PATIENTS C3-610/16 INCAPACITATING VENOUS CLAUDICATIONAFTER STENTING (8.4 MONTHS MEAN F/U)

0/16 WITH INCAPACITATING VENOUS CLAUDICATION

IMPROVED VENOUS OUTFLOWIMPROVED CALF MUSCLE PUMP FUNCTIONINCREASED VENOUS REFLUX

CHRONIC ILIOFEMORAL

VENOUS OBSTRUCTION

Mean C3 (pre-treatment)

Mean C2 (post-treatment)

Delis KY, et al. Ann Surg 2007; 245: 130-39.

INFLOW IS ESSENTIALMAY EXTEND STENTS

INTOCOMMON FEMORAL

VEINFEMORAL VEINPROFUNDA FEMORIS

VEIN

ENDOPHLEBECTOMY OF CFV, FV

STENT IVC, ILIAC, CFV

Vogel D, Comerota AJ, et al. J Vasc Surg 2012; 55: 129-135.

HYBRID PROCEDURES

DEFINITIVEDIAGNOSTIC/THERAPEUTICPROCEDURES

VENOGRAMSUG sheath placement

Femoral, Pop, PTVFlow, Collaterals

FEMORAL INFLOWFILLING DEFECTS

WILL MISS SOME STENOSES, WEBS

VENOGRAMS

THE ANATOMIC GOLD STANDARDUSUALLY BILATERAL IFV/IVCCHOOSE DIAMETER/LENGTH OF

BALLOON/STENTPOST-STENTING ASSESSMENT

INTRAVASCULARULTRASOUND

OBSERVE OVERNIGHTANTICOAGULATION LMWH

WARFARINCOMPRESSION HOSE, 30-40 mm HgEARLY AMBULATION

POST-OP STENTS

<1 WEEK OFFICE VISIT3-4 WEEKSABD/PELVIC US/OV3, 6, 9, 12 MONTHS AND ANNUALLYABD/PELVIC US/OV

FOLLOW-UP

1

FLOW-LIMITING IN-STENT SENOSIS PTBA

NEW STENOSIS OUTSIDE STENT

PTBA/STENT

THROMBOSIS CONSIDER LYSIS

EVALUATE INFLOW AND OUTFLOW AND

ADEQUACY OF ANTICOAGULATION

SECONDARY PROCEDURES