HowToDevelopaDeepVenousPrac3ceintheOutpa3entLab

PollyKokinos,MD,RPVISouthBayVascularCenterandVeinIns3tute

SanJose,CaliforniaApril1,2017

OutlineofTalk:

Whatistheproblemtotreat?Howbigistheproblem?Wheredoyoufindthesepa3ents?Howdoyougaintheexper3setodothese?Futuredirec3ons

AcuteDVTChronicOcclusion/Post-thrombo3cSyndromeNon-thrombo3ciliacveinocclusion(NIVL)

DeepVenousProblems

WhichShouldyoutrytoTreat?

Targetforsten3ng

May-ThurnerSyndrome

MayandThurnerdescribedthisin1957inabout30%ofcadaverstheyexamined.Compressionof>50%isalsoseeninabout30%ofallabdominalCTscansdoneforunrelatedreasons;>80%inabout20%ThisisaPERMISSIVElesionthatcausesclinicalsymptomsinthePERFECTSTORM!

May-Thurner’sSyndrome

•  Stage1:asymptoma3c•  Stage2:developmentof“spurs”insidevein•  ?Symptoma3casunilaterallegswelling,heaviness,aching,hyperpigmenta3on,non-healingofulcers?

•  Stage3:developmentofileofemoralDVT•  KimD,OrronDE,PorterDH.Venographicanatomy,techniqueandinterpreta3on.In:KimD,OrronDE(eds.)PeripheralVascularImagingand

Interven3on.StLouis(Missouri);Mosby-YearBook;1992,pp269–349.

May-ThurnerSyndrome

•  Thrombo3cComplica3ons

•  IleofemoralDVTsarebelievedtobesignificantlyunderdiagnosed

•  Iliacveincompressionisfelttoberesponsiblefor50-60%ofthesetypesofDVT(seenin30%ofnormalpeople)

•  80%oftheseileofemoralDVTsareonthelekside!

•  >50%ofthesepa3entswilldeveloppost-thrombo3csyndrome—legulcers,persistentswelling,hyperpigmenta3onifnottreatedacutely(WITHIN14DAYS)

•  Non-thrombo3ccomplica3ons•  Heaviness•  Aching•  Swelling•  Non-healingvenousulcera3ons•  Hyperpigmenta3onandexzematousskinchanges

Thesearethesamesymptomscausedbysuperficialvenousreflux

Whatisthefrequencyofiliacveinobstruc3oninpa3entswithahealed(C5)oranac3ve(C6)venousulcer?

!  Of78pa3entswithC5orC6ulcers,reviewedwithCTandMR–  37%hadavenousstenosis>50%–  23%hadavenousstenosis>80%

»  Associatedwithfemales,historyofDVT,deepvenousreflux»  Interes3ngly,nolimb>80%venousstenosisfoundtohavesuperficialvenousreflux.

MarstonW,FishD,etal.Incidenceofandriskfactorsforiliocavalvenousobstruc:oninpa:entswithac:veorhealedvenouslegulcersJVascSurg2011:1303-1308

HowtoBeginFindingthesePa3ents:SCREENyoursuperficialvenousrefluxpa3ents-IVUSposi3veobstruc3velesionsoftheiliacveinarepresentinabout90%ofallpa3entsCEAP4-6Educateyourreferringphysicians—par3cularlyOB/GYNs,Hematology/Oncology,Orthopedic/BackSurgeonsPageonyourwebsiteBrochuresinyourofficeWorkwithawoundcarecenterDVTscreening

ReimbursementintheOPL

AcuteDVT---can’tdripTPAovernight---inadequatereimbursementcurrentlyforthemechanicalthrombectomydevicesattheircurrentpricepointNOTAGOODCASEFOROPL2017!!

ReimbursementintheOPLExcellentreimbursementforiliacveinsten3ng/angioplastyOnlygetreimbursedforangioplastyifdoneBEFOREthesten3ng,notjustforpost-dilata3onIVUSgetsreimbursedasofJanuary2016byMedicareandmostcommercialplans(Aetnaisdifficult)-willalwayslookat2veinsegmentssobillbothNIVLcasecanbedoneinsame3meorquickerthanendovenousabla3onwithlesspa3entdiscomfort

ChronicOcclusionsTechnicallycanbequitechallengingand3meconsumingWHEREISTHATWIRE??????However,notreally“dangerous”asyouareworkingintheretroperitoneuminalowpressuresystemPa3entsVERYgratefulifsuccessful!MUSTuseveryaggressiveintra/post-opera3vean3coagula3on

•  Chooseaccesspoint—popliteal,midFV,GSV,CFV,IJ

•  Helpstohavepre-opera3vemappingwithCTvenogram

•  Usetriaxialsystem–Guidecatheter,hydrophiliccatheter,.035Glidewire(CookmakesTriforce)

•  Persistence

CrossingChronicOcclusions

Clinicalneedforinterven3onalprocedures

•  Localizedvenousobstruc3onisamajorcauseofsymptoms1,2

–  Greaterthan90%ofpost-thrombo3cCVIcaseshaveobstruc3on3

–  Collateralflowonlypar3allypreventssymptomsassociatedwithvenousdisease

•  Sten3ngis“methodofchoice”forchronicvenousobstruc3on2,4

1.  NeglenP,ThrasherTL,RajuS.Venousouslowobstruc3on:anunderes3matedcontributortochronicvenousdiseaseJVascSurg2003;38:879-85.2.Neglen,P.ChronicVenousObstruc3on:Diagnos3cConsidera3onsandTherapeu3cRoleofPercutaneousIliacSten3ng.Vascular.2007;15(5):273-280.3.Raju,S.Venoussten3nginCVD-TipsandTricks,VEITH2008.4.Gillespie.D.StentplacementakerDVTthrombolysisormechanicalthrombectomy.EndovascularToday,July2009.l

For-int

NIVL

•  Spansalldemographics•  Straighsorwardprocedure<1hour•  IVUSisMANDATORYandCRITICALforop3maltreatment:ItisstandardofCare

•  ThereisNOFDAapprovedVenousstentcurrently

DiagnosisofNon-thrombo3ciliacveincompression

•  AbdominalCT-goodformeasuringveinsizebutunabletosee

intraluminalissues•  CTvenogram-3mingofcontrastbolusesdifficult•  Venography-byreportsmissesatleast50%oflesionsevenwith

mul3planarviews•  IVUS-felttobemostreliablemethodinassessingiliacvenous

systemforclot,compression,scarring/webbing

•  TransabdominalUltrasound!

TransabdominalVascularUltrasound

•  Challenges:Hydra3onstatusofpa3ent•  AbdominalGas•  AbdominalGirth•  Narrowpelvis•  Ostomy•  Lackofdefinedcriteria•  Inabilitytoseeallourpartofiliacsystemin

25%ofpa3ents•  EXTREMELYTECHNOLOGISTDEPENDENT!

TransabdominalVascularUltrasound

•  Benefits:Non-invasive•  Inexpensive•  Nocontrastorradia3on•  No3mingissues•  Caneasilyrepeattofollowtreatmentordo

surveillance•  Doesnotrequireanyauthoriza3onformost

insuranceplan•  Allowsfunc3onalaswellasvisualassessmentof

iliacveinsystem

OğuzkurtL,OzkanU,TercanF,etal.Ultrasonographicdiagnosisofiliacveincompression(May-Thurner)syndrome.DiagnIntervRadiol2007;13:152-5

Limita3onsofVenography

ClinicalValue:Diagnos3cInforma3onImagescourtesyofVolcanoCorpora3on

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601-0101.31/001

OPLProcedure•  1.MicropunctureintoipsilateralGSVorproximalFV/CFV

•  2.Changeto9or10FrSheath•  3.Venogramthroughsheath•  4.IVUSmeasurements•  5.Wallstent/PTA•  6.Finalvenogram

.

55yomans/plekGSVabla3on6yearsagowithworseningleklegswelling,hyperpigmenta3on,

andachingoverthelastyear.

Pa3entJA:

41yoICUnurseatStanfordwithsevereswellingandachingbytheendofhershikUSG:Lekleg:NoGSVrefluxbut“slowflowinCFV”andlekCFVrefluxIliacVeinUSG:NarrowingoflekproximalCIVto0.5cm

JAUSGpre-sten3ng

CompressedvsNormalLCIV:ComparisonofIVUSandVenogram

Sten3ngandPTA:

JAUSGimagespoststent

FinalIVUS

Pa3enthadseverebackpainfor72hoursbutthendescribed“drama3c”decreaseintheheavinessandachingandcannowworkherwholeshik

•  136Symptoma3cpa3entsunderwentiliacveinultrasoundscanningbetweenMarch2015andAugust2016.

Ofthese:•  24pa3entshadnon-diagnos3cscansbecauseof

limitedvisibility•  26pa3entswerefelttohave“normal”iliacvein

systems•  74werefoundtohaveevidenceofiliacvein

compressionbecauseofmeasurementsof<0.8cmdiameterorsignificantdifferenceincomparingthelekandtherightside

•  11werefoundtohaveaniliacvein“abnormality”•  1pa3entwasfoundtohaveavenousaneurysm

SBVCResults

SBVCResults

•  75pa3entsweretakentoangiosuiteforIVUSevalua3on

•  67pa3entshad>50%areareduc3onbyIVUS•  67pa3entshadplacementofWallstent(s)intheiliacveinand/orangioplastyofpreviouslyplacedstents

•  1pa3enthadavenousaneurysmthatwasnottreated(butwasseenpre-op)

•  1pa3enthadalek-sidedIVC•  6pa3entshad<50%areareduc3onbyIVUSandnormalvenograms

SBVCResults

Results

Allpa3entsfollowedat2weeks,3months,6months,annuallyThreeacuteocclusionsofstentsinchronicallyoccludedveins(onebymalignantsarcoma)Allotherstentspatentat3-24monthsReliefofswelling:60-70%Ulcerhealing:about60%Reliefofheaviness/aching:70-80%

Technical3psforVenoussten3ng

•  UseIVUStoiden3fyproximalanddistallandingzones.•  •Ensuregoodinflowfrombelowandouslowfrom•  abovetopreventstentthrombosis.•  •Appropriatestentsizingwith2-to4-mmoversizingto

•  preventrecoil.•  •Postdeploymentdilata3onwithappropriatelysized•  high-pressureballoonsandextendedinfla3on3meto•  minimizerecoil.

TechnicalTipsforVenousSten3ng•  •Ifmul3plestentsarerequired,placewith3to5mmofoverlap,andasame-sizedstentshouldbeusedtoprovidesmoothtransi3onpoints.

•  •Performacomple3onIVUStoiden3fyanyresidualdefects.

•  Useproperintra-andpost-opera3vean3coagula3on/an3plateletbasedonunderlyingproblem

Summary

DeepvenousdiseaseisquiteunderdiagnosedbothNIVLandChronicvenousocclusionsSignificantsymptoma3creliefcanbeobtainedinpa3entswhohave“nootherop3ons”berecannalizing/sten3ngtheiriliacveinsProcedureisexcellentfortheOPLasitislowrisk,highlysuccessful,andhashighpa3entsa3sfac3on

Summary•  Developingadeepvenousprac3cerequiresconsideringthisastheunderlyingcauseofsymptomsinpa3entswithsignsofchronicvenousinsufficiency,non-healingwounds,historyofacute/chronicDVT,andunilaterallegswelling

•  No“right”accesspoint,pre-opera3veassessment,stent,etc---thereismuchtolearnintermsofthetechnique,peri/post-procedurean3coagula3on

•  IVUSisnowthegoldstandardforevalua3ngandtrea3ngthis

NothinginvenousdiseaseisAbsolute.OnlyVodkais.CourtesyofDr.PeterNeglen

ASANTE SANA

ChronicVenousOcclusionAn3coagula3on

• Postopcare• Therapeu3cLMWHimmediately.• Two-hoursbedrestfollowedbymobiliza3on.• Con3nueinflatablecompressionbootsandthighcompressionstockingsun3lcompletelymobile.

• Long-termcare• "Whenmobilizedsupplywith20-30mmHgBKcompressionstockings.• "DUSatdischargeor24hourstoconfirmpatencyofstents.• "ContinueLMWHfor2-3weeksbeforestartroutinetransitiontowarfarin.• "Oralanticoagulationfor≥6months.

JHprocedure81yowith3yearhistoryofulceratlekankle.Sentbywoundcarecenteraker4monthsoftreatment,butwereunabletogetwoundhealed.Pa3enthadLekGSVveinstripping5yearsprior.Indailycompressivewraps.

LekCFVpunctureunderIVseda3on,IVUScatheterplaced,Wallstentdeployed.Recovery30minutesthenhome.