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