4/18/2013 Venous Stenting: Different Diseases May-Thurner - - PowerPoint PPT Presentation

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Tips and Tricks for Iliac Vein and IVC Stenting

Robert K. Kerlan Jr., M.D. University of California, San Francisco UCSF Vascular Surgery Symposium April 18, 2013

Venous Stenting: Different Diseases

• May-Thurner
• Malignant Caval Compression
• Complications of IVC Filters
• Post Liver Transplant

– The presence of a hypercoagulable state makes everything more difficult!!!!

Common Themes

• Puncture
• Negotiation of occlusion
• Thrombectomy Catheter
• Fibrinolytics
• Venoplasty
• Stent

TIP 1: Puncture a Gastrocnemius Vein

• When using a lower extremity approach,

puncture a gastrocnemius vein rather than the popliteal vein

– Less muscle to traverse – Less trauma to popliteal

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TIP 2: Aggressive Fibrinolytics

• Be aggressive with fibrinolytics early (20 to 30

mg of tPA per session)

– 10 to 15 mg per station with Trellis (8F 30 cm length)

TIP 3: Aggressive Thrombectomy

• Trellis
• Possis
• Trerotola
• EKOS
• Suction

Trerotola Device in Native Veins

• 25 patients with iliofemoral DVT
• Trerotola thrombectomy catheter used as

primary thrombectomy device

• 1-year clinical success 92%
• 1-year primary patency 85%
• Valvular insufficiency 8%
• No major complications

Lee HK et al JVIR 2006;17:487-95

TIP 4: Stent Early

• It never looks perfect……just stent

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TIP 5: Go Far Enough Into the IVC

• For May-Thurner, extend the stent into the IVC or

it will shorten and require re-stenting TIP 6: Use Long Enough Stents TIP 6: Use Long Enough Stents TIP 7: Use Stents of Sufficient Diameter

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TIP 7: Use Stents of Sufficient Diameter TIP 7: Use Stents of Sufficient Diameter TIP 8: Sharp Dissection Down, Not Up

• For cases of hepatic IVC occlusion, use sharp

dissection away from the heart TIP 8: Sharp Dissection Down, Not Up

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Unresolved Issues

• Stenting across hepatic veins
• Stenting across renal veins
• Stenting across IVC filters

Stents Across Hepatic Veins Stents Across Hepatic Veins Stents Across Renal Veins

• 4 patients
• Wallstents crossing the renal vein ostia
• No evidence of renal failure on follow-up

O’Sullivan GJ et al JVIR 2007;18:905-8

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Stents Across Renal Veins Stents Across Renal Veins Stents Across IVC Filters

Neglen P et al. JVS 2011;54:153-161

Stents Across IVC Filters

• 25 patients with stents placed through IVC filter

were compared with 28 patients where stent was placed immediately below filter Neglen P et al. JVS 2011;54:153-161

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Conclusions

• Use aggressive doses of fibrinolytics coupled

with thrombectomy devices

• It might be safe to stent across hepatic veins
• It might be safe to stent across renal veins
• It is safe to stent across IVC filters, but long-term

patency is less