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

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

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

4. 44% DEVELOP VENOUS CLAUDICATION 15% VENOUS CLAUDICATION INTERRUPTS WALKING Delis KT, Bountouroglou D, Mansfield AO, Ann Surg. 2004;239(1):118-26.

11. 9/14/11

12. 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;41:126-33.

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

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

15. 80% OF ILIOFEMORAL DVT HAVE AN UNDERLYING EXTRINSIC ILIAC VEIN COMPRESSION Chang, et al.JVIR;15:249-56.

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

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

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

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

30. 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):320-27.

31. 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):1255-61.

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

33. 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

34. Mean C3 (pre-treatment) Mean C2 (post-treatment) Delis KY, et al. Ann Surg 2007; 245: 130-39.

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

40. ENDOPHLEBECTOMY OF CFV, FV STENT IVC, ILIAC, CFV Vogel D, Comerota AJ, et al. J Vasc Surg 2012; 55: 129-135. HYBRID PROCEDURES

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

42. FEMORAL INFLOW FILLING DEFECTS WILL MISS SOME STENOSES, WEBS VENOGRAMS

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

44. OBSERVE OVERNIGHT ANTICOAGULATION LMWH WARFARIN COMPRESSION HOSE, 30-40 mm Hg EARLY AMBULATION POST-OP STENTS

45. <1 WEEKOFFICE VISIT 3-4 WEEKSABD/PELVIC US/OV 3, 6, 9, 12 MONTHS AND ANNUALLYABD/PELVIC US/OV FOLLOW-UP

47. 1

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