Prof. of Vascular Surgery Double Balloon Angioplasty Technique Makes for Unavailable Large Size Venous Balloon Mohamed El-Maadawy, MD Prof. of Vascular Surgery Faculty of Medicine Cairo University It came as no surprise that surgeons are confronted by situations that they are not prepared to

Clinical Vignette A 46 years old male patient Has 4 years ago unprovoked SVC thrombosis Non-tender face edema Elevated non- pulsating EJVs Gradually developed chest and abdomen collateral veins He was kept on warfarin after 10 days of enoxaparin injection Edema subsided over time Chest and abdomen collateral veins enlarged over time He was kept on Warfarin since A 46 years old patient developed painless non tender fasial edema and proved to have un-provoked SVC obstruction. He received enoxaparin for the 1st followed by Warfarin. His fascial edema subsided gradually over time and large caliper collateral veins supervened over his chest and abdomen.

Decision Two months ago After one week of having painless oedema of lower limbs The collateral veins over the chest and abdomen became more prominent Lower limbs were oedematous, non tender and supple Duplex and CTV revealed IVC obstruction Decision Catheter directed thrombolytic therapy was the odd on favorite to treat the patient Proponents for the decision: Acute thrombus Within the therapeutic window for thrombolysis Two months age and after 10 days of having painless edema of lower limbs, the collateral veins over the chest and abdomen became more prominent. His lower limbs wee both supple and non tender and edema was pitting. Duplex U/S and CTV revealed IVC obstruction by a heterogenous thrombus mixed up of hypo- and hyperdense areas; in other words acute and chronic thrombus laden IVC. Catheter directed thrombolytic therapy was the odd on favorite to treat the patient.

Procedure Bilateral Duplex guided CFV access Bilateral Duplex guided CFV access was established under local anesthetic

Crossing the lesion The lower part of IVC was loaded by fresh thrombus while its middle & upper part were ostensibly chronically obstructed. The lesion was too tight that the 4F fountain catheter could not be advanced through. A 3 mm diameter balloon could pave the way for the Fountain catheter to be advanced.

Completion of the 1st session Finally the Fountain catheter reached its desired destination thereafter, Alteplase at a rate of 1 ml /hour was administered.

The second session On the next session, the over night administration of Alteplase was found to establish partial thrombus lysis, certainly in the lower part of the IVC. A zilver vena 16 X 90 mm was deployed. Due to the large rewrap size of the previously used ATB balloon, it could not pass into the stent through the tightest part of the stenosis. A new balloon certainly, could pass through that stenosis but would cost an additional extravagant price.

Second session, continue; A 3 mm balloon was inadequate to pave the rewrapped ATB balloon, but two alongside balloons each was advanced over a separate 0.035 balloon, could. Finally the rewrapped ATB balloon could adequately post-dilate the stent

Completion The completion angiogram

Left innominate vein stenosis Similarly, during the insertion of permeacath, the peel off sheath could not be advanced through the diffusely stenosed left innominate vein due to the presence of fibrinous sheath which was formed around a previously inserted hemodialysis catheter. A balloon which matches the size of innominate vein was unavailable. Furthermore, the available 5 mm balloon inflation was unable to rupture the fibrinous sheath. Instead of aborting the procedure and squandering the opportunity to cross the lesion that often comes once, two wires were advanced alongside.

Left innominate vein stenosis; continue Two 5 mm balloon were advanced, one over each 0.035 wire, their inflation was effective and the peel off sheath could be advanced successfully. In conclusion, Double balloon can solve the quandary when a large sized balloon is unavailable.

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