Bilateral stenting at the iliocaval confluence

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Presentation transcript:

Bilateral stenting at the iliocaval confluence Peter Neglén, MD, PhD, Rikki Darcey, BS, Jake Olivier, PhD, Seshadri Raju, MD Journal of Vascular Surgery Volume 51, Issue 6, Pages 1457-1466 (June 2010) DOI: 10.1016/j.jvs.2010.01.056 Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 1 Images of stenting of the iliocaval confluence by the double-barrel technique. A After predilation by “kissing” balloons, same-sized stents are inserted and simultaneously released side-by-side in the inferior vena cava (IVC) and distally into each common iliac vein. B, The stents are dilated simultaneously after insertion, and (C) are shown well expanded with no kinking at the iliocaval junctions. D, This intravascular ultrasound (IVUS) image shows clearly the adjoining stents just above the confluence in the IVC. The black circle inside the stented vein represents the inserted IVUS catheter. Journal of Vascular Surgery 2010 51, 1457-1466DOI: (10.1016/j.jvs.2010.01.056) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 2 A transjugular intrahepatic portosystemic shunt needle, supported by a sheath, is pushed through the stent mesh. A, A stiff Glidewire is inserted through the needle. B, The needle is replaced by a low-profile small-diameter balloon that is inflated to separate the braided steel wires to allow insertion of a larger balloon. C and D, Sequentially larger high-pressure balloons are used to create a window (fenestra). Journal of Vascular Surgery 2010 51, 1457-1466DOI: (10.1016/j.jvs.2010.01.056) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 3 A, The deformation creating a fenestra in the side of the stent is clearly visualized. B, A stent of the same or larger diameter is deployed well into the inferior vena cava and distally to avoid slipping out of the fenestration on dilation. C, Final result after balloon dilation after stent insertion shows the outflow of the contralateral iliac stent limb is “jailed.” Journal of Vascular Surgery 2010 51, 1457-1466DOI: (10.1016/j.jvs.2010.01.056) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 4 A, Fenestration of a stent, which is placed across the outflow of one stented limb after an inverted Y fenestration. Left, A balloon is placed through the side of the stent and dilated, (right) creating a fenestra allowing unimpeded outflow. B, The unilateral dilation may sometimes infringe on the previous created window and result in stenosis. Left, It may be useful to perform balloon dilation at the stent confluence by kissing balloon technique to (right) ensure an uninterrupted outflow from both iliac veins. Journal of Vascular Surgery 2010 51, 1457-1466DOI: (10.1016/j.jvs.2010.01.056) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 5 Stenting of the iliocaval confluence is shown using the apposition technique. A, A unilateral stent is inserted well into the inferior vena cava. B, A contralateral stent is placed as close as possible to the side of the previously inserted stent. The unsupported area is clearly shown, with good outflow through the side of the initially placed stent. Journal of Vascular Surgery 2010 51, 1457-1466DOI: (10.1016/j.jvs.2010.01.056) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 6 The type of stent technique used at the iliocaval confluence and the time interval between the initial and second procedure in patients with intentionally staged procedures (Staged) and in those who underwent a second stenting owing to development of symptoms in the contralateral lower limb (Symptoms). iY, inverted Y fenestration. Journal of Vascular Surgery 2010 51, 1457-1466DOI: (10.1016/j.jvs.2010.01.056) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 7 Cumulative primary, assisted primary, and secondary patency rates are shown for 107 patients with a bilateral stent system. The lower numbers represent limbs at risk at each time interval (all standard of means <10%). Journal of Vascular Surgery 2010 51, 1457-1466DOI: (10.1016/j.jvs.2010.01.056) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 8 Cumulative primary and secondary patency rates of bilateral stent systems in groups undergoing apposition (A), double-barrel (DB), and inverted Y fenestration (iY; see text for definition). The lower numbers represent bilateral stent system at risk at each time interval (standard of means >10% are shown by the error bars). Journal of Vascular Surgery 2010 51, 1457-1466DOI: (10.1016/j.jvs.2010.01.056) Copyright © 2010 Society for Vascular Surgery Terms and Conditions