CHRONIC ILIOFEMORAL DVT NEVER TOO LATE Stephen F. Daugherty, MD, FACS, RVT, RPhS Clarksville, Tennessee ACP NOVEMBER, 2012

NO CONFLICT OF INTEREST THE DESCRIBED USES OF STENTS ARE NOT FDA-APPROVED USES.

SEQUELAE OF ILIOFEMORAL DVT VENOUS CLAUDICATION POST-THROMBOTIC SYNDROME VENOUS LEG ULCERS

44% DEVELOP VENOUS CLAUDICATION 15% VENOUS CLAUDICATION INTERRUPTS WALKING Delis KT, Bountouroglou D, Mansfield AO, Ann Surg. 2004;239(1):

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21% of patients with LE DVT develop PTS with 66 month follow-up At the initial presentation, iliofemoral DVT was the single variable closely associated with PTS, odds ration 3.4 Yamaki T, et al. Eur J Vasc Endovasc Surg 2011;41:

MOST CLOSELY ASSOCIATED WITH PTS AT 6 MONTHS VENOUS OCCLUSION POPLITEAL VEIN REFLUX ELEVATED PEAK REFLUX VELOCITY POPLITEAL CALF MUSCLE PUMP DYSFUNCTION

OBSTRUCTION - OCCLUSIVE - NON-OCCLUSIVE WEBS SYNECHIAE LONG STENOSIS DUE TO FIBROSIS

80% OF ILIOFEMORAL DVT HAVE AN UNDERLYING EXTRINSIC ILIAC VEIN COMPRESSION Chang, et al.JVIR;15:

MAY-THURNER IVC FILTER OCCLUSION ANEURYSMS, ARTERIAL GRAFTS TUMORS,CYSTS SURGICAL INJURY RADIATION FIBROSIS HYPOPLASTIC KLIPPEL-TRENAUNAY

LE VENOUS DUPLEX US REFLUX OBSTRUCTION CFVDOPPLER FLOW CONTINUOUS? ASYMMETRY? FEMORAL VEIN COLLATERALS

ABDOMINAL/PELVIC DUPLEX FLOW AND ANATOMY STENOSIS MINOR DIAMETER REDUCTION ELEVATED PEAK VENOUS VELOCITY RATIO >2.5 FLOW REVERSAL GONADAL, ASCENDING LUMBAR, PELVIC VARICOSITIES

CT/MR VENOGRAMS - HELP WITH ANATOMIC DETAIL - DO NOT EVALUATE FLOW - DEPENDENT UPON FACILITY AND RADIOLOGIST INTEREST - CT— TIMING OF CONTRAST INJECTION/FLOW ISSUES

AUTOGENOUS SAPHENOUS VEIN FEM-FEM BYPASS 4 YEAR PATENCY 83% ePTFE BYPASS 2 YEAR SECONDARY PATENCY 54% SURGICAL APPROACHES Jost CJ, et al. J Vasc Surg 2001; 33(2):

Chronic non-malignant obstruction 177 limbs stented iliac vein into CFV Focal in-stent stenosis at inguinal ligament 7% (all 50%)5% Stent fractures0 Stent compression0 ILIOFEMORAL VENOUS STENTING Neglen P, Tackett TP, Raju S. J Vasc Surg 2008; 48(5):

CUMULATIVE SECONDARY PATENCY AT 54 MONTHS NONTHROMBOTIC100% THROMBOTIC CEPHALAD TO INGUINAL CREASE90% CAUDAD TO INGUINAL CREASE84% NON-OCCLUSIVE ONSTRUCTION95% OCCLUSIVE OBSTRUCTION77%

16 PATIENTS C3-6 10/16 INCAPACITATING VENOUS CLAUDICATION AFTER STENTING (8.4 MONTHS MEAN F/U) 0/16 WITH INCAPACITATING VENOUS CLAUDICATION IMPROVED VENOUS OUTFLOW IMPROVED CALF MUSCLE PUMP FUNCTION INCREASED VENOUS REFLUX CHRONIC ILIOFEMORAL VENOUS OBSTRUCTION

Mean C3 (pre-treatment) Mean C2 (post-treatment) Delis KY, et al. Ann Surg 2007; 245:

INFLOW IS ESSENTIAL MAY EXTEND STENTS INTO COMMON FEMORAL VEIN FEMORAL VEIN PROFUNDA FEMORIS VEIN

ENDOPHLEBECTOMY OF CFV, FV STENT IVC, ILIAC, CFV Vogel D, Comerota AJ, et al. J Vasc Surg 2012; 55: HYBRID PROCEDURES

DEFINITIVE DIAGNOSTIC/THERAPEUTIC PROCEDURES VENOGRAMS UG sheath placement Femoral, Pop, PTV Flow, Collaterals

FEMORAL INFLOW FILLING DEFECTS WILL MISS SOME STENOSES, WEBS VENOGRAMS

THE ANATOMIC GOLD STANDARD USUALLY BILATERAL IFV/IVC CHOOSE DIAMETER/LENGTH OF BALLOON/STENT POST-STENTING ASSESSMENT INTRAVASCULAR ULTRASOUND

OBSERVE OVERNIGHT ANTICOAGULATION LMWH WARFARIN COMPRESSION HOSE, mm Hg EARLY AMBULATION POST-OP STENTS

<1 WEEKOFFICE VISIT 3-4 WEEKSABD/PELVIC US/OV 3, 6, 9, 12 MONTHS AND ANNUALLYABD/PELVIC US/OV FOLLOW-UP

1

FLOW-LIMITING IN-STENT SENOSISPTBA NEW STENOSIS OUTSIDE STENTPTBA/STENT THROMBOSIS CONSIDER LYSIS EVALUATE INFLOW AND OUTFLOW AND ADEQUACY OF ANTICOAGULATION SECONDARY PROCEDURES