Recanilization of Central Venous Total Occlusions Dr. Steven Abramowitz, MD MedStar Washington Hospital Washington, DC

Steven Abramowitz, MD, RPVI   I have no relevant financial relationships

Introduction Venous outflow obstruction Recanilization and Stenting Symptoms Recanilization and Stenting Acute and chronic phase Safe and Efficacious Long-term studies High patency rate Low rate of in-stent restenosis Limited need for reinterventions

General Principles Anesthesia Foley Catheter Position Sedation v General Foley Catheter Position Prone or Supine

Endovascular Supplies Ultrasound Micropuncture kit – 4F Glide wires (0.35) – straight/angled Glide catheters – 4F/5F – straight/angled 0.18 wires Quick-cross catheters Self-expanding stents:12-18mm; 40-90mm High-pressure balloons: 12-18mmx40mm Access Recanalization Treatment

Access US Guided Chronicity Femoral Popliteal Internal jugular May or may not have backbleeding

Crossing Techniques Acute occlusions Chronic occlusions Cross occlusion Thrombolysis Chronic occlusions Cross occlusion – can be challenging Pre-dilate 6-8mm

Crossing Acute Occlusions

Crossing Chronic Occlusions Hydrophilic Wire/Catheter Multiple Access Points Prepare to Snare Adequate System Long Sheath Telescoping Sheaths Patience

Crossing Chronic Occlusions Advanced: Glide/Amplatz Back End Telescoping Catheters Sharp Recanalization (Chiba or Rosch-Uchida)

Crossing Chronic Occlusions Pre-Dilate Use 6-8mm balloons 30sec inflation times Do not dilate to desired diameter Enough to deliver stent

Treatment Stent Sizing Use IVUS Use pre-op imaging Normal segments as guide Contralateral segments as guide Use IVUS Measure diameter and length Proximal and distal landing zones

Treatment Stent Sizes IVC – 20-24mm CIV – 16-18mm EIV – 14-16mm CFV –10-12mm

Treatment No skip lesions Adequate overlap Post-deployment, balloon dilatation is performed to the size appropriate for each segment High-pressure balloons with prolonged inflation

Treatment Defects such as residual compression, incomplete dilatation, and improper stent apposition repeat ballooning Residual untreated significant obstruction (> 50%) stent extension

Results: Neglen, JVS 2007 Cumulative primary, assisted-primary, and secondary patency rates of 603 limbs after iliofemoral stenting. The lower numbers represent limbs at risk for each time interval (all standard error of the mean <10%).

Results: Neglen, JVS 2007 In-stent stenosis occurred in 5% of limbs at 72 months Severe leg pain, swelling, and venous ulcers significantly improved

Treatment: Iliocaval

Treatment: Iliocaval

Treatment: Iliocaval

Treatment: Iliocaval

Treatment: Iliocaval

Results: Neglen, JVS, 2010 A major limitation of the comparison of the stenting techniques in this study is that the techniques are not always interchangeable, but are applied differently, dependent on the extent, degree, and anatomic site of the obstructive lesion, as well as the extent of previous unilateral stenting in staged cases. The stent-related outcome may certainly be affected by these factors and by whether the obstruction is postthrombotic or the procedure is staged

Results: Neglan, JVS, 2010 Stenting of the iliocaval confluence in 115 patients (230 limbs) Primary compressive limbs 141 limbs Post thrombotic lesions 89 limbs Double barrel stents are the most favorable configuration with limited (< 5 cm) involvement of the caudal IVC † Patency at 4 Years

Treatment: IVC stents

Treatment: IVC stents Neglan, J Vasc Surg. 2011 Jul;54(1):153-61.

Results: Neglan, JVS, 2011 Neglan, J Vasc Surg. 2011 Jul;54(1):153-61. The primary and secondary cumulative patency rates at 54 months for limbs with postthrombotic obstruction were with and without IVC filter (38% and 40%; P = .1701 and 79% and 86%; P = .1947, respectively), and for limbs with stenting across the filter (Group X) and stent termination below the filter (Group B; 32% and 42%; P = .3064 and 75% and 84%; P = .2788, respectively), not statistically different. Neglan, J Vasc Surg. 2011 Jul;54(1):153-61.

Results: Neglan, JVS, 2011 25 patients recanalized & stented No IVC tears, bleeding, or embolization

Stent Failure Improper stent selection Undersizing Minimal overlap Failure to stent all disease

Conclusions Endovascular recanalization of chronic venous occlusions are safe and effective Cover all diseased segments Need good inflow and outflow Knowledge of available catheters, wires, stents and IVUS