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4/4/2019 1 Iliac vein interventions: Indications, evaluation and treatment Rajabrata Sarkar M.D. Ph.D. Barbara Baur Dunlap Professor of Surgery and Physiology Interim Chair, Dept. of Surgery Chief, Division of Vascular Surgery University of Maryland Disclosures None Off label use of stents in iliac veins 1 2

Iliac vein interventions: Indications, evaluation and treatment Sarkar...Left Common Iliac Vein Tightest Stenosis Pre-Stenting Pre-Treatment Tightest Stenosis = 69.8 mm2 Treated with

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Page 1: Iliac vein interventions: Indications, evaluation and treatment Sarkar...Left Common Iliac Vein Tightest Stenosis Pre-Stenting Pre-Treatment Tightest Stenosis = 69.8 mm2 Treated with

4/4/2019

1

Iliac vein interventions: Indications, evaluation and

treatment

Rajabrata Sarkar M.D. Ph.D.Barbara Baur Dunlap Professor of

Surgery and PhysiologyInterim Chair, Dept. of Surgery

Chief, Division of Vascular SurgeryUniversity of Maryland

Disclosures

None

Off label use of stents in iliac veins

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Classification of venous disease

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Complications of DVT

1 million new DVT patients/year in USA

25-65% of those with proximal DVT will develop post-thrombotic syndrome within 2-3 years

Severe post-thrombotic syndrome is highly disabling

Anticoagulation does not prevent post-thrombotic syndrome

Iliac vein interventions: Indications

• Acute DVT?

• ATTRACT trial results negative for prevention of post-thrombotic syndrome

• Vendantham, NEJM 2017

• Phlegmasia (IVC filter thrombosis)

• Post-op kidney/pancreas transplant (rare)

• Chronic venous insufficiency

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ATTRACT trial • NIH-funded multicenter trial that randomized 692

pts with iliofemoral DVT to either anticoagulation or pharmacomechanical thrombectomy plus anticoagulation

• At 2 years, no difference in post-thrombotic syndrome (47% vs. 48%)

• Increased bleeding (non-fatal) in the thrombectomy group (1.7% vs. 0.3%)

• Decreased enthusiasm for intervention for acute iliofemoral DVT for prophylaxis

• Vendantham, NEJM 2017

Caval Thrombosis

• Almost always seen in setting of prior IVC filter

• Only 8% of retrievable filters are actually retrieved nationally

• Predisposes to extensive ileocavalthrombosis

• Patients very symptomatic and may have phlegmasia, renal dysfunction, etc.

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Caval thrombosis

Caval thrombosis: approach

• Consider second suprarenal filter if thrombus extends through existing filter

• Pharmocomechanical rather than purely pharmacologic thrombectomy (large thrombus burden, severe symptoms)

• Re-establish some flow channel from groin through filter

• Accept residual thrombus in IVC/filter rather than prolonged TPA therapy

• Effective anticoagulation (LMWH) and hydration essential to prevent early rethrombosis

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Caval thrombosis

Caval thrombosis

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Caval thrombosis

Caval thrombosis

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Caval thrombosis

Caval thrombosis

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Post-transplant iliac DVT

• Can present days to years after kidney or pancreas transplant

• Often associated with graft dysfunction (elevated Cr) and mild unilateral edema

• Graft dysfunction normalizes with restoration of venous outflow

• Aggressive approach to correcting underlying venous stenosis (iliac, caval) to prevent recurrence

Post-transplant iliac DVT: iliac stent

Khalifeh, J Vasc Surg Cases Innov Tech. 2019 Mar; 5(1): 7–11.

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Post-transplant iliac DVT: May-Thurner

Khalifeh, J Vasc Surg Cases Innov Tech. 2019 Mar; 5(1): 7–11.

Post-transplant iliac DVT: IVC filter thrombosis

Khalifeh, J Vasc Surg Cases Innov Tech. 2019 Mar; 5(1): 7–11.

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Chronic venous ulcersConventional treatments not effective

compression therapy, perforator ligation, etc.

Few pts with post-thrombotic ulcers have correctable reflux

Leads to a nihilistic outlook for patients based on irreversible loss of valve function

Advances in care of Post-thrombotic syndrome

Unexpected major role for venous stenting in deep reflux disease

S Raju, J Vasc Surg, 2010

504 patients with reflux (54% post DVT)

37% had normal venogram but all had >50% stenosis by intravascular ultrasound

88% free from ulcers at 5 yrs.

2009 SVS discussion: “challenges all the previous concepts of pathogenesis and treatment of chronic venous insufficiency”

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Chronic venous disease

Fundamental paradigm shift towards proximal obstructive lesions in post-thrombotic and non-thrombotic patients (S. Raju)

Importance of intravascular ultrasound over other modalities (CT, venogram, etc.)

Small differences in area (50%) can cause symptoms

Small improvements in area (50-75%) can heal ulcers

Diagnostic IVUS Pullback

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Nonthrombotic Iliac Vein Lesion

in Proximal Common Iliac Vein

Tightest Stenosis = 69.8 mm2

• Reference Area = 216.7 mm2

Pre-Treatment Reduction

of Cross-Sectional Area = 68%

Approximate Lesion Length = 4.5 cm

601-0100.93/001

https://clinicaltrials.gov/ct2/show/NCT02142062 Venogram vs. Intravascular Ultrasound (IVUS) for Diagnosing Iliac Vein Obstruction (VIDIO)

Case details , images, and footage courtesy of Robert Tahara, MD. Dr. Tahara is the investigator of VIDIO, a Volcano sponsored study.

Results from this case study are not predictive of future results. Data on file at Volcano clinical affairs department.

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Iliac Vein

Treatment Informed by IVUS Findings

Left Common Iliac Vein

Tightest Stenosis

Post-Stenting

Left Common Iliac

Vein

Tightest Stenosis

Pre-Stenting

Pre-Treatment Tightest Stenosis = 69.8 mm2

Treated with two 18 x 90 mm Overlapping Stents, extending into IVC

Post-Treatment Cross-Sectional Area = 179.5 mm2

Luminal Gain of 110mm2 or 157%

25601-0100.93/001

https://clinicaltrials.gov/ct2/show/NCT02142062 Venogram vs. Intravascular Ultrasound (IVUS) for Diagnosing Iliac Vein Obstruction (VIDIO)

Case details , images, and footage courtesy of Robert Tahara, MD. Dr. Tahara is the investigator of VIDIO, a Volcano sponsored study.

Results from this case study are not predictive of future results. Data on file at Volcano clinical affairs department.

• 68 year old male

with severe

bilateral venous

ulcers

(circumferential)

• S/P bilateral DVT,

numerous

procedures for

superficial reflux

• Weekly Unaboot

changes in clinic

for 3 years by me,

• 5 years by my

partners before

R Hussein. Chronic Venous Ulcers An End Of Long

Term Suffering. The Internet Journal of Plastic Surgery.

2007 Volume 5 Number 1.

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“Poor opacification of the iliac veins limits assessment of

thrombus. Possible compression of left iliac vein by

artery”

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Evaluation of venous ulcers

• Rule out arterial disease

• Wound care

• Nutrition evaluation

• Venous duplex examination with reflux

• Iliac venogram or ablation of reflux first?

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Evaluation of venous ulcers

• Treated GSV reflux when diameter > 5 mm

• Otherwise iliac venogram and stenting of all lesions >50% decrease in area

• All patients with ulcer and leg swelling received iliac venogram

• How does iliac vein stenting compare with saphenous ablation?

• Raju S, J Vasc Surg Venous Lymphat Disord. 2013 Apr;1(2):165-72

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Technical Points

• Puncture femoral vein or GSV mid-thigh or lower, not common femoral vein to keep tip of sheath low enough to allow stenting down to common femoral vein

• Know normal sizes of external and common iliac veins to identify long tubular stenosis or chronically shrunken veins

• Unlike arterial disease, stent into common femoral vein if needed

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Iliac interventions: Followup

• Postoperative ASA+clopidigrel for 90 days then ASA 81 mg only

• IVC/iliac Duplex and office visit every six months

• Encourage stocking use, exercise and weight loss

• For ulcers, aggressive wound care (referral to wound care center)

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