ΚΑΘΗΓΗΤΗΣ ΑΓΓΕΙΟΧΕΙΡΟΥΡΓΙΚΗΣ ΕΚΠΑ Ενδαγγειακή Αντιμετώπιση Της Oξειας και Χρόνιας Απόφραξης Της Λαγόνιας Φλέβας ΓΕΩΡΓΙΟΣ ΓΕΡΟΥΛΑΚΟΣ ΚΑΘΗΓΗΤΗΣ ΑΓΓΕΙΟΧΕΙΡΟΥΡΓΙΚΗΣ ΕΚΠΑ Διευθυντής Αγγειοχειρουργικής Κλινικής Πανεπιστημίου Αθηνών, ΠΓΝ “ΑΤΤΙΚΟΝ”

Pharmacomechanical thrombolysis for DVT (Attract trial) Τhe Attract trial that evaluated pharmaco-mechanical catheter directed thrombolysis (PCDT) in patients with proximal deep vein thrombosis. It showed that PCDT did not prevent PTS over 2 years, it increased major bleeding and did not influence health related quality of life or recurrent venous thromboembolism. Ii improved leg swelling and pain in 30 days. Vedantham, 2017 N.Eng.J.Med

Surgical bypass for occluded iliac veins has now been largely replaced by endovenous stenting.

Iliac/ IVC vein stenting is a recent development Many of the endovenous techniques that are used are based on prior arterial experience

Morphologic and pathologic features of venous lesions are different from those of arterial stenosis. Modification of standard techniques used in the management of arterial stenosis is necessary to obtain best results in endovascular interventions in the venous system.

Definitions It is not known at what degree venous stenosis is haemodynamically significant Morphological obstruction >50% as measured by IVUS has arbitrarily been chosen for stenting.

Fig. 7. A: a positive correlation between CWS/WSS and IH is shown in the +10% sizing case (R2 = 0.68, P < 0.005). B: a positive correlation between CWS/WSS and IH is shown in the +20% sizing case (R2 = 0.64, P < 0.005). C: effect of stent sizing on the extent of IH quantified as the maximum percent area stenosis in the stented region for all the data. Published in: Henry Y. Chen; Anjan K. Sinha; Jenny S. Choy; Hai Zheng; Michael Sturek; Brian Bigelow; Deepak L. Bhatt; Ghassan S. Kassab; American Journal of Physiology-Heart and Circulatory Physiology  2011, 301, H2254-H2263. DOI: 10.1152/ajpheart.00240.2011

Fig 6 A ‘hard’ instent lesion without evident inflow/outflow problems has a prediclection for the external iliac vein. The common iliac vein and the femoral vein are less frequently involved and less profusely; the inferior vena cava portion of the stent is seldom affected. Journal of Vascular Surgery 2009 49, 511-518DOI: (10.1016/j.jvs.2008.08.003) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

Fig 9 Placement of undersized stents can result in persistent symptoms due to inadequate decompression of the limb (left) or outright stent occlusion (right). In both cases, 10 mm stents were placed in the common iliac vein (desirable size 16). Journal of Vascular Surgery 2009 49, 511-518DOI: (10.1016/j.jvs.2008.08.003) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

Migration of venous stents into the heart location treatment outcome Mullens, 2006 1 Right ventricle Open heart surgical removal, Tricuspid valvuloplasty good Steinberg, 2017 Right atrium Perforation intraatrial septum, sudden death Holst, 2018 Open heart surgical removal

T.Holst et al; THORAC CARDIOV SURG Reports 2018 Acute Stent Migration into the Right Ventricle in a Patient with Iliac Vein Stenting

Common iliac vein stenting is prone to migration/compression of the upper end requiring reinterventions. Extension of the stent to the vena cava to avoid this problem contributes to partial jailing of the contralateral flow and is associated with 2,4% DVT  (Caliste et al, Ann Vasc Surg 2014). We present a bail out for this complication.

Final position of the pigtail catheter for thrombolysis

Systemic review of endovenous stenting in chronic venous disease secondary to iliac vein obstruction. Conclusion: The quality of evidence to support this is weak, with the main flaw being the lack of control groups to illustrate the observed benefits are not part of natural history progression of CVD. Seager et al; Eur J Vasc Endovasc Surg 2016

The ATTRACT randomised controlled trial, showed that the addition of catheter-based intervention to anticoagulation failed to significantly decrease the occurrence of post-thrombotic syndrome in DVT patients who received this treatment strategy when compared to its occurrence in patients who received anticoagulation alone (F-Up 6-24 months).

Stenting for total occlusions of the iliac vein In a 9 year period 167 limbs in 159 post-thrombotic patients with total chronic occlusions of the iliac vein were treated. Technical success: 83% Cumulative pain relief at 3 years: 79% Cumulative swelling relief at 3 years: 66% Ulcer healing at 33 months: 56% Raju, J Vasc Surg 2009

Venous stenting across inguinal ligament Arterial stenting is not recommended across the inguinal ligament because of increased risk of focal neointimal hyperplasia or compression/fracture. Venous stents can safely be placed across the inguinal ligament with no effect on log term patency.

Venous stenting across inguinal ligament 177 limbs had stents placed in the iliofemoral venous outflow across the inguinal ligament into the common femoral vein. Results compared with outcomes of 316 limbs with stents terminating above inguinal ligament. Cumulative patency was similar for both groups (7% occlusions versus 11% respectively) Neglen, J Vasc Surg 2008

9 had severe ovarian vein reflux Venous angioplasty and stenting improve pelvic congestion syndrome caused by venous outflow obstruction. 19 patients with combined severe non thrombotic venous outflow obstruction of the CIV or IVC and symptoms of pelvic congection syndrome were studied. 9 had severe ovarian vein reflux Daugherty et al 2015, J Vasc Surg Venous Lymphat Disord

Follow-up of 1 to 59 months (median, 11 months) Venous angioplasty and stenting improve pelvic congestion syndrome caused by venous outflow obstruction. Follow-up of 1 to 59 months (median, 11 months) complete resolution of pelvic pain in 15 of 19 patients and of dyspareunia in 14 of 17 sexually active patients. Of the 15 patients who experienced left lower extremity pain or edema before treatment, 13 experienced complete resolution after treatment.

mL/s Reflux & Obstruction Venous filling index VFI = 90VV / VFT90 Venous drainage index VDI = 90VDV/VDT90 mL/s

Josef Pflug Vascular Laboratory, Ealing Hospital & Imperial College Venous drainage improves significantly after iliac stenting but this may result in faster venous filling Lattimer CR Kalodiki E Azzam M Schnatterbeck P Geroulakos G Josef Pflug Vascular Laboratory, Ealing Hospital & Imperial College http://josefpflugvascular.com No Disclosures

Iliac vein occlusion

Conclusion Iliac venous stenting for chronic venous disease is largely trouble free with only a small number of complications that require reinterventions. Reinterventions are worthwhile as they provide improvement from symptoms.

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