Intervention for Chronic Lower Extremity Venous Obstruction Rabih A. Chaer MD Assistant Professor of Surgery Division of Vascular Surgery University of Pittsburgh Medical Center

Rabih A. Chaer, MD DISCLOSURES I have no real or apparent conflicts of interest to report.

OUTLINE May-Thurner Post-thrombotic- Chronic venous insufficiency

Iliac Venous Obstruction • Post-thrombotic - 53% • Post-thrombotic - 53% • Primary - 47% • Other non-thrombotic causes • Benign/malignant tumors • Irradiation • Retroperitoneal fibrosis • Aneurysmal compression 4

Non-thrombotic Iliac Vein Lesions Majority Pattern - 75% Minority Pattern - 25% Female: Male 4:1 Left: Right 3:1 5

May-Thurner 26 yo woman 10 days post partum Massive LLE swelling Pain Early phlegmasia

Initial angiojet PMT EKOS CDT X12 hrs

PTA Stent

Transfemoral Venography Historical “gold” standard Venographic findings Occlusion / stenosis Contrast thinning / flattening Intraluminal bands / webs Collateralization Multiplanar views required 30% underestimation of stenosis 9

Intravascular Ultrasongraphy (IVUS) Diagnostic test of choice Quantification of stenosis Detection of Webs / synechea Intimal thickening Extrinsic compression 10

IVUS 345 limbs with suspected iliac venous obstruction Venography vs ultrasound (> 70% stenosis) Sensitivity 45% Negative predictive value 49% Neglen; J Vasc Surg 2002 11

Iliac Obstruction - Indications for Treatment Acute Iliofemoral DVT Iliac disease after lysis Stent required in 33% Chronic venous disease Venous claudication Skin changes / Ulceration Diffuse limb pain Swelling High index of suspicion in chronic venous disease 12

Case Presentation 48 yo man with an old previous LLE DVT PTS: Chronic venous insufficiency Venous stasis ulcer Ambulatory venous hypertension Failed Unna boot therapy

HISTORY Previous PE and IVC filter placement Persistent Lupus anticoagulant On coumadin Otherwise healthy On exam: adequate compression stockings CEAP 6, active venous stasis ulceration.

Workup Duplex ultrasound: Chronic DVT Deep system reflux (1.5sec) at the femoral and popliteal veins No perforators Competent GSV Chronic changes in the common femoral vein but phasic flow

ASCENDING VENOGRAM

Pressure Gradient 8mm gradient at rest between the vena cava (15mmHg) and the external iliac vein (23mmHg) 30mg of papaverine delivered in the EIV. Increased pressure in the EIV, unchanged in the IVC, 50% gradient

TREATMENT Venoplasty with a 14mm balloon IVUS unchanged 16x60wallstent Repeat IVUS No gradient

FOLLOW UP Decreased swelling No pain on ambulation Signs of ulcer healing

Venous balloon angioplasty and stenting Nitinol Stents Self expanding Diameters to 14 mm Wallstent Flexible 8 or 10 Fr delivery system lengths up to 90 mm diameters of 5 to 24 mm Z stents for IVC 29

Patency of Iliac Venous Stents 97% 71% • 304 limbs with iliac obstruction • Technical Success • Stenosis - 100% • Occlusion - 81% Raju et al; J Vasc Surg 2002 30

Management of Iliac Venous Obstruction Endovascular approach preferred Arterial techniques NOT directly transferrable Basic principles Contrast imaging inadequate IVUS a required adjunct Angioplasty alone inadequate Recoil always requires stenting Stent ALL disease 31

Venous Interventions - Guidelines Primary stenting always required Self expanding stents preferred CFV & external iliac - 12 mm Common iliac - 14 to 16 mm IVC - 20 to 25 mm (Gianturco) Predilate to planned diameter Avoid overdilation Stent entire area of disease Assure stent apposition with IVUS 32

PITTSBURGH