Percutaneous recanalization of total occlusions of the iliac vein

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Presentation transcript:

Percutaneous recanalization of total occlusions of the iliac vein Seshadri Raju, MD, Peter Neglén, MD, PhD Journal of Vascular Surgery Volume 50, Issue 2, Pages 360-368 (August 2009) DOI: 10.1016/j.jvs.2009.01.061 Copyright © 2009 Terms and Conditions

Fig 1 The Glidewire passage during recanalization procedure commonly meets resistance at several anatomic chokepoints where the iliac or the hypogastric artery crosses the vein; the inguinal ligament and the diaphragmatic hiatus may also prevent passage. Relevant arterial crossover levels differ slightly between the right and left side, as shown. The Glidewire can veer off course from the main vein through tributaries and collaterals (shown numbered) when meeting resistance. On the right side, the Glidewire may enter medial or lateral collaterals because the iliac vein runs a straighter course to the inferior vena cava. The left iliac vein has a convex curvature, and the Glidewire tends to enter lateral tributaries, usually the ascending lumbar vein. When the suprarenal vena cava is occluded, the azygos and hemiazygos collaterals are enlarged and the Glidewire enters them frequently. 1, Phrenic vein; 2, azygos/hemiazygos complex; 3, prevertebral plexus; 4, hypogastric vein; 5, ascending lumbar vein; 6, tributaries from the iliopsoas muscles; 7, femoral vein tributaries; 8, lumbar veins. Journal of Vascular Surgery 2009 50, 360-368DOI: (10.1016/j.jvs.2009.01.061) Copyright © 2009 Terms and Conditions

Fig 2 Recanalization of an occluded iliac vein. Left panel, Initial venogram. Second panel, Aggressive dilatation of the occluded vein and deployment of a slightly oversized stent is required to achieve a recanalized lumen approximating normal anatomy. This poses no bleeding risk (see text). Third panel, Intravascular ultrasound examination of the recanalized channel after maximal balloon dilatation invariably shows the Glidewire in the middle of the venous channel with intact thick walls. Right panel, Completion venogram shows a stented channel of adequate lumen without residual stenoses, good flow, and absence of previously visualized collaterals. Journal of Vascular Surgery 2009 50, 360-368DOI: (10.1016/j.jvs.2009.01.061) Copyright © 2009 Terms and Conditions

Fig 3 Left, Frontal projections obscure the complex course of the iliac vein through the pelvis. Right, A 50° turn occurs at the L5-S1 vertebral junction (arrow, Left and Right), evident on lateral projection. “Shelving” of stent ends, compromising effective in-stent lumen, may occur if stent overlaps are placed near this location. A strategy to avoid this problem is to center a long (9-cm) stent initially over L5-S1 junction and add proximal and distal stents with overlaps situated away from this point. Journal of Vascular Surgery 2009 50, 360-368DOI: (10.1016/j.jvs.2009.01.061) Copyright © 2009 Terms and Conditions

Fig 4 Staged bilateral recanalization. The left iliac vein and the infrarenal vena cava with an inferior vena cava filter incorporated in the occlusion were recanalized first. The filter was ballooned and stented across. The right iliac vein was recanalized a few weeks later, connecting the two sides through a fenestration (see text). Bilateral excoriative dermatitis with lymph leak healed soon thereafter. This 92-year-old patient was not a candidate for open surgery. Journal of Vascular Surgery 2009 50, 360-368DOI: (10.1016/j.jvs.2009.01.061) Copyright © 2009 Terms and Conditions

Fig 5 Cumulative primary, assisted-primary, and secondary patency rates of femoroiliocaval stents placed in recanalized occluded limbs. The lower numbers represent limbs at risk for each time interval (all standard error of the mean <10%). Journal of Vascular Surgery 2009 50, 360-368DOI: (10.1016/j.jvs.2009.01.061) Copyright © 2009 Terms and Conditions

Fig. 6 Removal of an occluded Wallstent through a limited transverse venotomy. Left, Steady pull on one of the strands under fluoroscopy (arrow) will result in unraveling of the stent weave and (Right) serial removal of all of the strands. The technique may allow repeat recanalization in selected cases. Journal of Vascular Surgery 2009 50, 360-368DOI: (10.1016/j.jvs.2009.01.061) Copyright © 2009 Terms and Conditions

Fig 7 Cumulative partial, defined as ≥3 of 10 on the visual analog scale (VAS), and complete relief of pain after recanalization and stenting. The lower numbers represent limbs at risk for each time interval (all standard error of the mean <10%). Journal of Vascular Surgery 2009 50, 360-368DOI: (10.1016/j.jvs.2009.01.061) Copyright © 2009 Terms and Conditions

Fig 8 Cumulative partial (≥1 grade) and complete relief of swelling after recanalization and stenting. The lower numbers represent limbs at risk for each time interval (all standard error of the mean <10%). Journal of Vascular Surgery 2009 50, 360-368DOI: (10.1016/j.jvs.2009.01.061) Copyright © 2009 Terms and Conditions

Fig 9 The upper curve shows cumulative freedom from dermatitis/ulcer in limbs with clinical severity (C) class 4 and 5 by CEAP after recanalization and stenting. The lower curve shows cumulative rate of healed leg ulcers (C6 in CEAP) after recanalization and stenting. Limbs with ulcers that never healed after stenting were censored at the 3-month follow-up. Ulcers that healed and subsequently recurred were censored at the time of recurrence. The incidence of recurrence is very low after primary healing, resulting in a flat curve. The lower numbers represent limbs at risk for each time interval (all standard error of the mean <10%). Journal of Vascular Surgery 2009 50, 360-368DOI: (10.1016/j.jvs.2009.01.061) Copyright © 2009 Terms and Conditions