1. Dr.Ata Firouzi Rajaee Heart Center

2. Percutaneous venous interventions  Inferior vena caval filters  Venous thrombolysis  Venous angioplasty  Venous stenting  Mechanical thrombectomy  Varicose vein interventions  Central Vein Intervention  Dialysis access intervention

3. The Problem of DVT: Statistics DVT occurs in approx. 2 million Americans each year. Approx 1/3 develop PEDVT occurs in approx. 2 million Americans each year. Approx 1/3 develop PE The combined annual incidence for DVT is approximately 2.5%-5% of the adult populationThe combined annual incidence for DVT is approximately 2.5%-5% of the adult population DVT recurs in 5-10% of patients the year after anticoagulationDVT recurs in 5-10% of patients the year after anticoagulation DVT recurs in 30% of patients eight years after anticoagulationDVT recurs in 30% of patients eight years after anticoagulation 1996 American Heart Association Scientific Statement on DVT

4. Risk Factors for DVT  Age >40 years  Cancer  Obesity  Previous or family history of DVT/PE  Recent surgery  Paralysis or immobility  Contraceptives/Hormone replacement therapy  Pregnancy  Serious illness: CHF, MI, sepsis  Coagulation disorders 4

5. DVT: Clinical Presentation  Calf pain/tenderness  Swelling  Calor, rubor  Cyanosis or pallor  Superficial venous dilatation  Loss of pulses in severe DVT 5

6. DVT Treatment Strategies: Timing Sooner is Better!  < 3 Weeks Good  < 1 Week Better  < 3 Days Best 6

7. Rationale for Early Treatment of DVT  Early treatment increases probability of maintaining normal valve function Damaged valves lead to venous insufficiency  Decrease recurrent DVT risk Restore normal venous flow Clear thrombogenic substrate  Decrease risk for PE Asymptomatic PE occurs in majority of patients with DVT 7

8. Delayed Complications: Post-Phlebitic Syndrome  Post-Phlebitic Syndrome - Result of venous hypertension  Venous hypertension Venous insufficiency- valve damage Venous occlusion- Chronic DVT/ Scarring 8

9. Delayed Complications: Post-Phlebitic Syndrome  Post-Phlebitic Syndrome -- spectrum symptoms seen after DVT pain edema pigmentation ulcer  Occurs in 50 to 70% cases proximal DVT  Prevalence estimated to be as high as 2 percent in the general population 9

10. Treatment Strategies: Investigational New treatments to rapidly remove thrombus:  Mechanical Thrombectomy Physical removal of clot burden Often used in combination with lytics  Power Pulse Spray Accelerated thrombolysis delivered by AngioJet system 10

13. Varicose vein interventions

14. CEAP Classification of Chronic Venous Insufficiency  C: Clinical C1-spider telangiectasia, C2 varicose veins, C3 edema, C4 lipodermatosclerosis (pigmentation changes),C5 healed ulcer, C6 active ulcer.  E: Etiology: congenital, primary, or secondary  A: Anatomic: superficial, deep, or perforator  P: Pathophysiology: reflux, obstruction, or both

15. Treatment options  Compression therapy ( cornerstone of therapy)  Sclerotherapy ( foam or liquid)  Laser ablation  RF ablation  Steam ablation  Mechanochemical ablation (ClariVein device)

16. Deep Venous Thrombosis  LET (Lower extremity thrombosis) classification

18. Standard care in DVT  Complications of standard DVT treatment: Pulmonary embolism (5% lethality) Recurrent thrombosis (30%) Overall 25% PTS within 1 year  Iliofemoral thrombosis is associated with a twofold increased risk of developing PTS(> 50%).

19. Post-Thrombotic Syndrome (PTS) Risk Factors  Age  Obesity  Female Gender  Previous ipsilateral DVT  DVT involving common femoral or iliac veins

23.  − The Angiojet thrombectomy catheter (Medrad Interventional/Possis) is a rheolytic device that simultaneously uses high-power jets to macerate clot while aspirating clot debris through the central channel of the catheter.

25.  Prolonged activation of the rheolytic thrombectomy catheter (>10 min) has been associated with hemoglobinuria, renal failure, and death.

26.  − The Trellis Catheter (Bacchus Medical) is a hybrid mechanical-aspirating dual balloon device designed for regional fibrinolytic infusion. The two balloons are separated by a variable distance that is selected to match the length of vessel to be treated. By isolating the region of fibrinolytic infusion, the systemic effects of the pharmaceutical agent can be reduced. Between the balloons the catheter can be angulated and rotated to macerate the clot.

27.  − The Trerotola device (Arrow Medical) is a mechanical thrombectomy catheter with a rotating basket that spins at relatively high velocity when attached to the disposable handle motor.

28.  Aspirex device (pure mechanical)

29.  Balloons ranging in diameter from 8 to 20 mm should be available with a minimum length of 4 cm.  Self-expandable stents should be used. Diameters ranging from 10 to 20 mm should be available with a minimum length of 5 cm.  Stents are generally not used below the level of the lesser trochanter.

32. Iliac vein Compression Lesions

35. Candidates for Endovascular Therapy: Clinical Criteria  Presence of chronic venous insufficiency Quality-of-life limiting venous claudication and other symptoms of venous hypertension Skin changes (Varicosis, Hyperpigmentation, Lipodermatosclerosis) Ulcers  Occlusion of common femoral vein, or iliac vein, or inferior vena cava

36. Useful Tests prior to Intervention  Vein plethysmography (to verify chronic venous insufficiency)  Exercise testing (to quantify venous claudication)  Duplex sonography (access site femoral vs popliteal)  MR or CT Phlebography (assess extent of venous obstruction and rule out congenital disorders)

37. Imaging and planning  MR venography Extend of obstruction and inflow  Endophlebectomy and AV fistula Plan a hybride procedure  Access Femoral, contralateral or jugular

40. Tips and tricks  Best performed in hybrid room  General anesthesia for angioplasty and stenting  Therapeutic anticoagulation pre-, per-, and post procedure  INR< 3  Ultrasound-guided access Femoral, thigh, popliteal, jugular, contralateral

41.  Hydrophilic wire for crossing  Small extravasations are not important  Large extravasations: stop then repeat the procedure 3-4 week later  After entering IVC change with superstiff wire  Sometimes start with small balloons( 5-10 mm)  Up to 30 atm pressure for predilatation  Use 10%-20% stent oversize

42.  At least 2 cm stent overlap  Stent can across inguinal ligament  Stent is deployed at least 1-2 cm into the IVC  Bilateral stenting at iliac confluence is not mandatory ( sometimes needed)  Aggressive postdilation

43.  Collateral disappearance is a sign of success.  Persistence of collaterals or slow flow are indications for the construction of AV fistula.

44. Requirements for stents per segment  The vein geometry should dictate the shape of the stent. Flexibility  The stent must be able to treat the underlining pathology Radial Force  Location dependent : IVC: High radial force, low flexibility, large diameter. CIV, EIV and CFV: High radial force, high flexibility, large diameters

48. Stent Selection for Venous Intervention IVC (18, 20, 22 mm): Sinus XL stent (Optimed) Iliac veins (14-18 mm): Sinus XL Flex Stent (Optimed) Sinus Venous Stent (Optimed) Zilver Vena Stent (Cook) Femoral veins (12-14 mm): Sinus Superflex Stent (Optimed) Zilver Vena Stent (Cook) Wallstent (Boston Scientific)

49. Evaluation and follow-up  Stent configuration: IVUS or rotation angio  Anticoagulation: LMWH -> vit K antagonist  Pneumatic compression  DUPLEX following day before discharge  Regular office visits (2W, 6W, 3M, 6M, annual)

50. No. 3 : Is doppler sono enough? A 32 y/o man with complaint of sudden intolerable swelling of left thigh presented to another center. Obviously DVT was in top of him differential diagnosis, although doppler sonography revealed nothing.

55. Left femoral vein injection showed totally occluded left common iliac vein and patent IVC. Catheter-directed thrombolysis (CDT) was performed.

56. Second-Session Procedure

60. Stenting of left common iliac vein was done with 16*66 SINUS XL stent and post-dilation performed with perfect final result ( BIB balloon, outer diameter of 4-5 ).

62. A 47 years-old hairdresser lady Dx : extensive vein thrombosis of iliofemoral system according to duplex ultrasound Past history was not striking anyway

63. MR venography Filling defects in the left common and external iliac, common and.superficial femoral and popliteal veins ( acute extensive DVT) IVC diameter and shape was intact without thrombosis.

64. Reasons for intervention : massive burden of thrombosis - Ongoing and annoying course of patient symptoms – fear of future PTS -

65. Access site : Ipsilateral popliteal vein with the patient prone on the angiography table under ultrasound guidance.

66. Next step :  installation of ultrasound-based infusion system, Lysus Infusion System (EKOS corporation, Bothell, WA) which delivered alteplase via a catheter with one central lumen and three separate infusion ports. It combines high-frequency lower-power ultrasound with simultaneous catheter-directed thrombolytics to accelerate clot dissolution[2]. Also heparin was infused (250 U/hour) in conjunction.

68. venography at following day revealed :