Challenging Cases in Venous Obstructive Disease No disclosures Warren Gasper MD UCSF Vascular Surgery 4/14/2016 2 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 Challenging Case #1 Challenging Case #1 � 30 year old man with chronic back pain who is otherwise healthy suffered a left � Patient continued to have significant, painful left leg swelling that interfered common iliac vein injury during L5-S1 anterior lumbar interbody fusion (ALIF) with walking • Primary repair of the vein with PTFE patch • No evidence of arterial disease � Postoperatively he had leg swelling initially treated with leg elevation and • Intermittent pneumatic compression was started with minimal improvement compression • Anticoagulation was continued � Several days postoperatively, a duplex ultrasound showed thrombus in the left common femoral and femoral veins � Anticoagulation with heparin and warfarin was started 3 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 4 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 1 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Ambulatory left dorsal foot vein pressure measurement Challenging Case #1 120 30 toe-ups � Over the next several years, he continued his compression regimen and had a Venous pressure (mmHg) 100 gradual improvement in and stabilization of his symptoms 80 � At some point, he stopped his anticoagulation 60 40 � 8 years after the initial operation he presented with a painful, blue left leg. 20 � He was started on anticoagulation � An ultrasound showed acute thrombus in the left common femoral and femoral 0 veins 0 15 30 45 60 75 90 Time (seconds) 5 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 6 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 4/14/2016 Challenging Case #1 Challenging Case #1 � He had a left leg � Thrombus in the proximal venogram from the left femoral, common femoral popliteal vein and deep femoral veins • Patent mid to distal � Treated with femoral vein and pharmacomechanical popliteal vein thrombectomy and balloon angioplasty 7 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 8 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 2 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Challenging Case #1 Challenging Case #1 � Occlusion of the external � Several attempts were made iliac vein with filling of to cross the iliac vein pelvic and internal iliac occlusion without success veins via collaterals with eventual opacification of the IVC 9 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 10 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 4/14/2016 Challenging Case #1 Palma procedure results � Patient underwent a Palma procedure with AVF • Left to right common femoral vein bypass using right GSV. • Additional segment of GSV was used to create an AVF between bypass and left common femoral artery J Vasc Surg 2001;33:320-8. J Vasc Surg: Venous and Lym Dis 2016;4:95-6 11 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 12 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 3 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Technical tips for Palma procedure Challenging Case #1 � Autogenous saphenous vein >4mm is preferable. � Patient had an immediate improvement in his symptoms PTFE is an acceptable alternative � He has continued on anticoagulation and his regimen of compression � Creation of an AVF to the superficial femoral artery stockings and a pneumatic compression device improves patency. Can usually be ligated in 6 � An open ligation of the fistula was performed 1 year after surgery months � Avoid in patients with “poor venous inflow,” i.e. extensive infrainguinal venous occlusive disease � Bypass has now been patent for 10 years � Avoid in patients with “poor venous outflow,” ie extensive outflow iliac vein and/or IVC J Vasc Surg 2001;33:320-8 J Vasc Surg 2011;53: 383-93 13 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 14 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 4/14/2016 Repeat Ambulatory left dorsal foot vein pressure 120 30 toe-ups Pre-Palma Venous pressure (mmHg) 100 9y after Palma 80 60 40 20 0 0 15 30 45 60 75 90 Time (seconds) 15 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 16 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 4 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Challenging Case #2 Challenging Case #2 � 50 year old man with non-provoked bilateral lower extremity DVTs � 1 year after placement of the IVC filter, he was hospitalized with acute leg • Started on anticoagulation, compression swelling with extensive bilateral DVT • Hypercoagulable workup negative for malignancy, anti-phospholipid • Anticoagulated syndrome, factor V Leiden, protein C deficiency, protein S deficiency, • IVC filter was found to have migrated caudally and could not be removed prothrombin G20210A mutation • Bilateral common iliac stents placed � Several years of poor compliance with warfarin led to recurrent episodes of VTE with PE • IVC filter placed 17 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 18 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 4/14/2016 Challenging Case #2 L � 4 years later, with poor compliance on anticoagulation, he returned with bilateral leg swelling, worse on the left � Venogram showed stenosis of both iliac stents 19 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 20 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 5 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Challenging Case #2 Challenging Case #2 � 2 years later, still with poor � Balloon angioplasty of both compliance on common iliac vein stents was anticoagulation, he returned performed with improvement with acute left leg swelling on the right � Duplex ultrasound showed � Left iliac vein stent was left common femoral and relined with Wallstents femoral vein DVT 21 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 22 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 4/14/2016 Challenging Case #2 Challenging Case #2 � Acute thrombus in the � Additional Wall stents were common femoral and femoral placed in the left common veins treated with femoral and femoral veins pharmacomechanical thrombolysis (Angiojet) and catheter-directed thrombolysis with tPA 23 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 24 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 6 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Challenging Case #2 Challenging Case #2 � 11 months later he returns � 11 months later he returns with an acutely swollen left with an acutely swollen left leg leg 25 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 26 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 4/14/2016 Challenging Case #2 � 11 months later he returns with an acutely swollen left leg � Wallgrafts placed within the old Wallstents to treat neointimal hyperplasia � But then it thromboses 27 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 28 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 7 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Challenging Case #2 Challenging Case #2 � Taken to the OR � Recent systematic review found an approximately 75% mid-term (3-5 year) � Pharmacomechanical patency rate for iliac stenting after iliofemoral DVT thrombolysis (Angiojet) � A story of all the small factors that add up to iliac vein stenting failures � Venogram appears similar to • Initial stenting from common femoral vein into the external iliacs – often before extension to the common femoral vein is necessary � IVUS shows a 10+ mm • Leaving a gap between common iliac and common femoral vein stents – lumen within the stents with creates an area that has a very high rate of stenosis severe compression/narrowing • Heavy reliance on venogram, which frequently underestimates the extent of (3mm) of the cephalad end of disease or degree of stenosis – adjunctive use of IVUS helps identify the the stent proper treatment J Vasc Surg 2009;49:511-8 � Stented with 10mm iCast J Vasc Surg 2013;57:1163-9 29 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 30 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 4/14/2016 8 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
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