Challenging deep venous interventions: case review and

recorded cases

Prof. Nils Kucher University Hospital Bern

Switzerland nils.kucher@insel.ch

nilskucher.com

Venous Intervention

Acute DVT treatment Catheter-directed thrombolysis

+/- Stenting

Chronic venous obstruction Endovascular reconstruction

Stenting

Venous Intervention

Acute DVT treatment Catheter-directed thrombolysis

+/- Stenting

Chronic venous obstruction Endovascular reconstruction

Stenting

Candidates for Endovascular Therapy:

Clinical & Anatomical Criteria

• Clinical criteria: Presence of the post-thrombotic syndrome – Venous claudication

– Skin changes (Varicosis, Hyperpigmentation, Lipodermatosclerosis)

– Ulcers

– Pelvic congestion symptoms

– Varicocele

– Recurrent thrombophlebitis

• Anatomical criteria: Occlusion of common femoral vein, or

Occlusion of iliac vein, or

Occlusion of inferior vena cava

Useful Tests prior to Venous Intervention

• Vein plethysmography (to verify chronic venous insufficiency)

• Exercise testing (to quantify venous claudication)

• Duplex sonography (access site femoral vs popliteal)

• MR or CT Phlebography (to quantify extent of venous occlusion)

Author Nr limbs Technical success

Primary Patency % after month

Secondary Patency % after month

Nazarian et al 56 92 50 at 48m 75 at 48m

Raju et al 104 93 58 at 24m 82 at 24m

Knipp et al 58 100 38 at 60m 73 at 60m

Neglen et al 982 ns 67 at 72m 93 at 72m

Hartung et al 43 95 78 at 120m 90 at 120m

Hartung et al 46 100 86 at 42m 97 et 42m

Nazarian GK et al 1996, Radiology Raju S et al 2006, J Vasc Surg Knipp BS et al 2007, J Vasc Surg Neglen P et al 2008, J Vasc Surg Hartung et al 2008, Eur J Vsac Endovasc Surg

Studies including >40 patients

Patency after Endovascular Treatment

For Chronic Iliocaval Venous Obstructions

Iliofemoral Venous Intervention (male, 50 yrs B-F)

Infrarenal VCI occlusion

MR: chronic total occlusion of infrarenal IVC and iliac veins

Iliocaval Venous Intervention (male, 58 yrs W-U)

Iliocaval Venous Intervention (male, 58 yrs W-U)

Iliocaval Venous Intervention (male, 58 yrs W-U)

Challenge for stents to treat May Thurner (MT) syndrome

• The majority of iliofemoral DVTs are caused by iliac vein compression (May-Thurner Syndrome)

• Focal external compression and vicinity to the ilio-caval bifurcation hampers venous stenting using conventional stents.

Ideal MT stent: radial force at the compression site and flexibility to accommodate the

anatomy of the curved iliac vein.

Iliac vein anatomy: Lateral view 90 ° hip flexion

90° kinking VIC 90° kinking VIC

sinus-Obliquus® stent

Distal open cell design: • Provides flexibility and less radial force for

accomodating the curved anatomy of iliac veins during hip flexion

Proximal closed cell design: • Provides high radial force at compression site • Oblique design (35°) prevents jailing off the

contralateral iliac vein • 4 markers for correct rotational positioning

sinus-Obliquus® stent Visualized from behind

Implantation of sinus-Obliquus® stent

Implantation of sinus-Obliquus® stent

IVUS pre and post sinus-Obliquus Stenting

Pre Stenting Post Stenting

Left VIC compression (May Thurner)

sinus-Obliquus in left VIC (May Thurner) Right AIC

Right AIC

Bern Venous Stent Registry

• The Bern Venous Stent Registry is a prospective ongoing registry including >500 patients with venous stents at the University Clinic of Angiology in Bern, Switzerland

• Between December 2014 and July 2015

23 patients with common iliac vein compression were treated with sinus-Obliquus stent:® - 9 patients with acute iliofemoral thrombosis after catheter-directed thrombolysis - 10 patients with postthrombotic syndrome (PTS) - 4 patients with non-thrombotic iliac vein compression.

sinus-Obliquus® stent: Outcomes at 3 months

• Primary patency rate: 100% (23/23) • Clinical symptoms:

completely resolved in 39%, improved in 52%, unchanged in 9%

• In patients with postthrombotic Syndrome: Villalta score decreased by 4.7 ±3.5 points (P=0.002) Revised Venous Clinical Severity score (rVCSS) decreased by 2.7 ± 2.5 points (P= .007)

• No procedural complication 2 patients minor bleeding (popliteal hematoma, and hypermenorrhea)

*Stuck AK, Kunz S, Baumgartner I, Kucher N.: Short-term Patency Rates and Clinical Outcomes of Patients with Common Iliac Vein Compression Treated with a Dedicated Venous Self-expanding Oblique Hybrid Nitinol Stent; submitted 2016.

Venous Intervention

Acute DVT treatment Catheter-directed thrombolysis

+/- Stenting

Chronic DVT treatment (PTS) Endovascular reconstruction

Stenting

Nils.kucher@insel.ch nilskucher.com

Challenging deep venous interventions: case review and

recorded cases

Prof. Nils Kucher University Hospital Bern

Switzerland nils.kucher@insel.ch

nilskucher.com