1. Intervention for Chronic Lower Extremity Venous Obstruction
Rabih A. Chaer MD
Assistant Professor of Surgery
Division of Vascular Surgery
University of Pittsburgh Medical Center

2. Rabih A. Chaer, MD DISCLOSURES
I have no real or apparent conflicts of interest to report.

3. OUTLINE
May-Thurner
Post-thrombotic- Chronic venous insufficiency

4. Iliac Venous Obstruction
• Post-thrombotic - 53%
• Post-thrombotic - 53%
• Primary - 47%
• Other non-thrombotic causes
• Benign/malignant tumors
• Irradiation
• Retroperitoneal fibrosis
• Aneurysmal compression 4

5. Non-thrombotic Iliac Vein Lesions
Majority Pattern - 75%
Minority Pattern - 25%
Female: Male 4:1
Left: Right 3:1 5

6. May-Thurner 26 yo woman 10 days post partum Massive LLE swelling Pain
Early phlegmasia

7. Initial angiojet PMT
EKOS CDT X12 hrs

8. PTA
Stent

9. Transfemoral Venography
Historical “gold” standard
Venographic findings
Occlusion / stenosis
Contrast thinning / flattening
Intraluminal bands / webs
Collateralization
Multiplanar views required
30% underestimation of stenosis 9

10. Intravascular Ultrasongraphy (IVUS)
Diagnostic test of choice
Quantification of stenosis
Detection of
Webs / synechea
Intimal thickening
Extrinsic compression 10

11. IVUS 345 limbs with suspected iliac venous obstruction
Venography vs ultrasound (> 70% stenosis)
Sensitivity 45%
Negative predictive value 49%
Neglen; J Vasc Surg 2002 11

12. Iliac Obstruction - Indications for Treatment
Acute Iliofemoral DVT
Iliac disease after lysis
Stent required in 33%
Chronic venous disease
Venous claudication
Skin changes / Ulceration
Diffuse limb pain
Swelling
High index of suspicion in chronic venous disease 12

13. Case Presentation 48 yo man with an old previous LLE DVT PTS:
Chronic venous insufficiency
Venous stasis ulcer
Ambulatory venous hypertension
Failed Unna boot therapy

14. HISTORY Previous PE and IVC filter placement
Persistent Lupus anticoagulant
On coumadin
Otherwise healthy
On exam: adequate compression stockings
CEAP 6, active venous stasis ulceration.

15. Workup Duplex ultrasound: Chronic DVT
Deep system reflux (1.5sec) at the femoral and popliteal veins
No perforators
Competent GSV
Chronic changes in the common femoral vein but phasic flow

16. ASCENDING VENOGRAM

17. Pressure Gradient
8mm gradient at rest between the vena cava (15mmHg) and the external iliac vein (23mmHg)
30mg of papaverine delivered in the EIV.
Increased pressure in the EIV, unchanged in the IVC, 50% gradient

23. TREATMENT Venoplasty with a 14mm balloon IVUS unchanged 16x60wallstent
Repeat IVUS
No gradient

28. FOLLOW UP Decreased swelling No pain on ambulation
Signs of ulcer healing

29. Venous balloon angioplasty and stenting
Nitinol Stents
Self expanding
Diameters to 14 mm
Wallstent
Flexible
8 or 10 Fr delivery system
lengths up to 90 mm
diameters of 5 to 24 mm
Z stents for IVC 29

30. Patency of Iliac Venous Stents
97%
71%
• 304 limbs with iliac obstruction
• Technical Success
• Stenosis - 100% • Occlusion - 81%
Raju et al; J Vasc Surg 2002 30

31. Management of Iliac Venous Obstruction
Endovascular approach preferred
Arterial techniques NOT directly transferrable
Basic principles
Contrast imaging inadequate
IVUS a required adjunct
Angioplasty alone inadequate
Recoil always requires stenting
Stent ALL disease 31

32. Venous Interventions - Guidelines
Primary stenting always required
Self expanding stents preferred
CFV & external iliac - 12 mm
Common iliac - 14 to 16 mm
IVC - 20 to 25 mm (Gianturco)
Predilate to planned diameter
Avoid overdilation
Stent entire area of disease
Assure stent apposition with IVUS 32

33. PITTSBURGH