Interventional Radiology Iliac Vein Compression Syndrome Left CIV - - PowerPoint PPT Presentation

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Interventional Radiology Iliac Vein Compression Syndrome Left CIV - - PowerPoint PPT Presentation

Nov 06, 2023 273 likes •839 views

Michael Meuse, M.D. Vascular and Interventional Radiology Iliac Vein Compression Syndrome Left CIV compressed by right CIA Virchow 1851: DVT L>R May and Thurner 1954: venous spurs Cockett and Thomas 1965: iliocaval

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Michael Meuse, M.D. Vascular and Interventional Radiology

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 Iliac Vein Compression Syndrome

  • Left CIV compressed by right CIA
  • Virchow 1851: DVT L>R
  • May and Thurner 1954: venous “spurs”
  • Cockett and Thomas 1965: iliocaval compression

 Primary Axillosubclavian Vein Thrombosis

  • Activity-induced thrombosis (“Effort” Thrombosis)
  • Paget (1875), von Schroetter (1884)

 Paget-Schroetter Syndrome,

  • Compression at thoracic inlet (TOS)
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 LCIV compressed between RCIA/spine  Chronic irritation-->endothelial

proliferation

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 Typically young women  Following period of inactivity

  • e.g. surgery, pregnancy, illness

 Acute: Iliofemoral DVT

  • Swelling, pain, erythema
  • Phlegmasia cerulea dolens

 Chronic: venous stasis, chronic DVT

  • Swelling, pain, venous claudication
  • varicose veins, skin changes
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 H&P key to diagnosis  Classic venographic findings  With DVT

  • Acute: lesion unmasked by thrombolysis
  • Chronic: R/O other causes of iliac vein occlusion

 Without DVT

  • Venogram
  • Typical symptomatology
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 Duplex Ultrasound

  • Reliable diagnosis of femoropopliteal DVT
  • non-phasic signal  obstruction
  • evaluation of reflux

 Magnetic Resonance Imaging

  • Diagnosis of iliofemoral DVT with MRV
  • Cross-sectional images - CIV compression

 Impedance/Strain-gauge/Air Plethysmography

  • diagnosis of DVT
  • Maximal Venous Outflow - CVI
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 Ascending Venography

  • Gold standard for diagnosis of iliofemoral DVT
  • Depicts CIV compression and collaterals

 Intravascular Ultrasound (IVUS)

  • Depicts vein “spurs”, clot
  • Accurate measurement of vessel diameter

 Intravascular Manometry

  • > 3 mm Hg probably significant
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 Chronic Venous Insufficiency

  • valvular incompetence 2° to dilation/destruction
  • PTS in 2/3 of patients despite anticoagulation
  • Strandness et al (JAMA 1983), 39 month f/u

 pain and swelling 67 %  pigmentation 23 %  ulceration 5 %

 Socioeconomic effects

  • health care costs
  • occupational disability
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 Conservative

  • anticoagulation
  • compression stockings

 Surgical

  • cross-femoral saphenous vein bypass with AVF
  • venotomy/transposition with CIA sling/bridge
  • RCIA transposition w/wo interposition graft

 Percutaneous/endovascular

  • thrombolysis
  • stent placement
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 Access site (US guided)

  • Popliteal/post. tib. vein if iliofemoral DVT present
  • CFV if no DVT present

 Mechanical thrombectomy

  • Debulking
  • exposure of clot to lytic agent
  • rate of lysis

 Lytic agent via multi-sidehole catheter  Check progress venographically every 12 hrs

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 Self expanding stent  Technical Success

  • Venographic flow
  • Pressure gradient < 2mm Hg
  • IVUS
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 Post-procedure

  • Clopidogrel bisulfate (Plavix) 4-6 wks
  • Warfarin sodium (Coumadin) for DVT 3-6 mons

 Follow up

  • Clinical/Duplex
  • Venogram/IVUS for recurrent/persistent symptoms
  • Reintervention if required (PTA/Stenting)
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MAY-THURNER SYNDROME

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COMPLETION DSA

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100% 100% 100% 8

Binkert (1998)

79% 94% 100% 17

Hurst (2001)

90% 100% 100% 10

Patel (2000)

92% 85% 87% 35

O’Sullivan (1999) 1-3 year patency Clin success Tech success n

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 Synonyms:

  • Primary axillosubclavian vein thrombosis
  • Effort vein thrombosis

 >90% AS thrombosis are secondary  Thoracic Outlet Syndrome (TOS)

  • Most pts. have neurologic and/or arterial symptoms
  • 2-10% have symptomatic venous obstruction
  • compression of neurovascular bundle by clavicle,

1st rib, scalenus muscles (+cervical rib, ligaments)

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 Acute

  • Young patient with acute AS thrombosis following

strenuous exercise

  • Average age 34 years, M > F, R > L
  • Pain, swelling, venous engorgement, cyanosis
  • phlegmasia cerulea dolens

 Chronic (less common)

  • symptoms of venous stasis

 If untreated 75% develop permanent disability  Small but not insignificant rate of PE

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 H&P is key  Axillosubclavian vein thrombosis  R/O other causes of thrombosis

  • central venous catheter
  • malignancy
  • trauma
  • coagulopathy

 arterial/neurogenic symptoms may suggest

classic TOS

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 Duplex Ultrasound

  • diagnosis of DVT

 Conventional Venography

  • gold standard: DVT & collaterals
  • typical lesion unmasked following thrombolysis

 MRV/MRI

  • demonstrates DVT and surrounding soft tissue
  • parasagittal images may show SV compression

 IVUS

  • venous abnormalities, clot
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Images courtesy of Daniel Sze, M.D.

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Images courtesy of Daniel Sze, M.D.

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IVUS

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 Catheter-directed thrombolysis

  • Access via basilic or brachial vein
  • Lytic agent infused via multi-sidehole catheter
  • Additional mechanical thrombectomy
  • Recanalization/limited PTA (poss. rethrombosis)

 Anticoagulation for approx. 1-6 months

  • Resolution of phlebitis
  • Ptn. may become asymptomatic  collaterals
  • Duration of anticoagulation controversial
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 Surgical decompression

  • 1st/cervial rib resection, medial clavicle resection
  • Subclavius/scalenus muscle division/resection
  • Supra/sub clavicular or transaxillary approaches
  • Ideal method controversial

 Repeat venogram

  • PTA of residual stenoses
  • Limited role for stents
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PTA RESIDUAL STENOSIS NORMAL VEIN VENOGRAM RIB RESECTION SYMPTOMATIC / ABNORMALITY ASYMPTOMATIC / NO ABNORMALITY EVALUATION ANTICOAGULATION THROMBOLYSIS THROMBOSIS COMPRESSION VENOGRAPHY

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N LYSIS SURGERY PTA/STENT F/U**

  • Machleder 1993

50 20/24 36 9/0 83%/38m

  • Adelman 1995

18 1217 11 0/0 100%/21m

  • Beygui 1997

13 9/13 8 0/0 na

  • Sheeran 1997

14 13/14 8 2/0 57%/24m

  • Lee 1998

11 9/11 11 0/0 81%/na

  • Urschel 2000

241 239/241 241* 0/0 89%/na

  • Feugier 2001

10 3/7 10* 0/0 80%/45m

  • Kreienberg 2001

23 23/23 23* 23/14 74%/48m

  • Coletta 2001

19 /18 18* 2/6 89%/38m

  • Angle 2001

18 17/18 18* 5/0 100%/na

*early surgical decompression without interval anticoagulation **asymptomatic/mean follow-up

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 Early and complete thrombolysis  Limited PTA prior to surgery  Staged vs. early surgical decompression  Method and approach of surgery  Staged stress venogram following surgery

with possible PTA (avoid stenting if possible)

 Anticoagulation vs. no anticoagulation

following surgery

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 H&P key to diagnosing iliac vein and thoracic

  • utlet venous compression syndromes

 US, MRV, IVUS, Venography useful for

confirming diagnosis and planning therapy

 Aggressive management can prevent long-term

sequelae of DVT and avoid disability

 Good mid-term results with endovascular

treatment of iliac vein compression syndrome

 Good long-term results with multidisciplinary

management of Effort thrombosis