1. Recanilization of Central Venous Total Occlusions
Dr. Steven Abramowitz, MD
MedStar Washington Hospital
Washington, DC

2. Steven Abramowitz, MD, RPVI
I have no relevant financial relationships

3. Introduction Venous outflow obstruction Recanilization and Stenting
Symptoms
Recanilization and Stenting
Acute and chronic phase
Safe and Efficacious
Long-term studies
High patency rate
Low rate of in-stent restenosis
Limited need for reinterventions

5. General Principles Anesthesia Foley Catheter Position
Sedation v General
Foley Catheter
Position
Prone or Supine

6. Endovascular Supplies
Ultrasound
Micropuncture kit – 4F
Glide wires (0.35) – straight/angled
Glide catheters – 4F/5F – straight/angled
0.18 wires
Quick-cross catheters
Self-expanding stents:12-18mm; 40-90mm
High-pressure balloons: 12-18mmx40mm
Access
Recanalization
Treatment

7. Access US Guided Chronicity Femoral Popliteal Internal jugular
May or may not have
backbleeding

8. Crossing Techniques Acute occlusions Chronic occlusions
Cross occlusion
Thrombolysis
Chronic occlusions
Cross occlusion – can be challenging
Pre-dilate 6-8mm

9. Crossing Acute Occlusions

10. Crossing Chronic Occlusions
Hydrophilic Wire/Catheter
Multiple Access Points
Prepare to Snare
Adequate System
Long Sheath
Telescoping Sheaths
Patience

11. Crossing Chronic Occlusions
Advanced:
Glide/Amplatz Back End
Telescoping Catheters
Sharp Recanalization (Chiba or Rosch-Uchida)

12. Crossing Chronic Occlusions
Pre-Dilate
Use 6-8mm balloons
30sec inflation times
Do not dilate to desired diameter
Enough to deliver stent

13. Treatment Stent Sizing Use IVUS Use pre-op imaging
Normal segments as guide
Contralateral segments as guide
Use IVUS
Measure diameter and length
Proximal and distal landing zones

14. Treatment Stent Sizes IVC – 20-24mm CIV – 16-18mm EIV – 14-16mm
CFV –10-12mm

15. Treatment No skip lesions Adequate overlap
Post-deployment, balloon dilatation is performed to the size appropriate for each segment
High-pressure balloons with prolonged inflation

16. Treatment
Defects such as residual compression, incomplete dilatation, and improper stent apposition
repeat ballooning
Residual untreated significant obstruction (> 50%)
stent extension

17. Results: Neglen, JVS 2007
Cumulative primary, assisted-primary, and secondary patency rates of 603 limbs after iliofemoral stenting. The lower numbers represent limbs at risk for each time interval (all standard error of the mean <10%).

18. Results: Neglen, JVS 2007
In-stent stenosis occurred in 5% of limbs at 72 months Severe leg pain, swelling, and venous ulcers significantly improved

19. Treatment: Iliocaval

20. Treatment: Iliocaval

21. Treatment: Iliocaval

22. Treatment: Iliocaval

23. Treatment: Iliocaval

24. Results: Neglen, JVS, 2010
A major limitation of the comparison of the stenting techniques in this study is that the techniques are not always interchangeable, but are applied differently, dependent on the extent, degree, and anatomic site of the obstructive lesion, as well as the extent of previous unilateral stenting in staged cases. The stent-related outcome may certainly be affected by these factors and by whether the obstruction is postthrombotic or the procedure is staged

25. Results: Neglan, JVS, 2010
Stenting of the iliocaval confluence in 115 patients (230 limbs)
Primary compressive limbs 141 limbs
Post thrombotic lesions 89 limbs
Double barrel stents are the most favorable configuration with limited (< 5 cm) involvement of the caudal IVC
† Patency at 4 Years

26. Treatment: IVC stents

27. Treatment: IVC stents
Neglan, J Vasc Surg Jul;54(1):

28. Results: Neglan, JVS, 2011 Neglan, J Vasc Surg. 2011 Jul;54(1):153-61.
The primary and secondary cumulative patency rates at 54 months for limbs with postthrombotic obstruction were with and without IVC filter (38% and 40%; P = and 79% and 86%; P = .1947, respectively), and for limbs with stenting across the filter (Group X) and stent termination below the filter (Group B; 32% and 42%; P = and 75% and 84%; P = .2788, respectively), not statistically different.
Neglan, J Vasc Surg Jul;54(1):

29. Results: Neglan, JVS, 2011 25 patients recanalized & stented
No IVC tears, bleeding, or embolization

30. Stent Failure Improper stent selection Undersizing Minimal overlap
Failure to stent all disease

31. Conclusions
Endovascular recanalization of chronic venous occlusions are safe and effective
Cover all diseased segments
Need good inflow and outflow
Knowledge of available catheters, wires, stents and IVUS