No disclosures Warren Gasper MD UCSF Vascular Surgery 4/14/2016 2 - - PowerPoint PPT Presentation

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 1

Challenging Cases in Venous Obstructive Disease

4/14/2016

Warren Gasper MD UCSF Vascular Surgery

No disclosures

2 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

Challenging Case #1

30 year old man with chronic back pain who is otherwise healthy suffered a left common iliac vein injury during L5-S1 anterior lumbar interbody fusion (ALIF)

• Primary repair of the vein with PTFE patch

Postoperatively he had leg swelling initially treated with leg elevation and compression 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

Challenging Case #1

Patient continued to have significant, painful left leg swelling that interfered with walking

• No evidence of arterial disease
• Intermittent pneumatic compression was started with minimal improvement
• Anticoagulation was continued

4 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 2

Ambulatory left dorsal foot vein pressure measurement

5 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

20 40 60 80 100 120 15 30 45 60 75 90

Venous pressure (mmHg) Time (seconds)

30 toe-ups

Challenging Case #1

Over the next several years, he continued his compression regimen and had a gradual improvement in and stabilization of his symptoms At some point, he stopped his anticoagulation 8 years after the initial operation he presented with a painful, blue left leg. He was started on anticoagulation An ultrasound showed acute thrombus in the left common femoral and femoral veins

6 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

Challenging Case #1

He had a left leg venogram from the left popliteal vein

• Patent mid to distal

femoral vein and popliteal vein

7 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

Challenging Case #1

Thrombus in the proximal femoral, common femoral and deep femoral veins Treated with pharmacomechanical thrombectomy and balloon angioplasty

8 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 3

Challenging Case #1

Occlusion of the external iliac vein with filling of pelvic and internal iliac veins via collaterals with eventual opacification of the IVC

9 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

Challenging Case #1

Several attempts were made to cross the iliac vein

• cclusion without success

10 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

Challenging Case #1

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

11 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 J Vasc Surg: Venous and Lym Dis 2016;4:95-6

Palma procedure results

12 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 J Vasc Surg 2001;33:320-8.

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 4

Technical tips for Palma procedure

Autogenous saphenous vein >4mm is preferable. PTFE is an acceptable alternative Creation of an AVF to the superficial femoral artery improves patency. Can usually be ligated in 6 months Avoid in patients with “poor venous inflow,” i.e. extensive infrainguinal venous occlusive disease Avoid in patients with “poor venous outflow,” ie extensive outflow iliac vein and/or IVC

13 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 J Vasc Surg 2001;33:320-8 J Vasc Surg 2011;53: 383-93

Challenging Case #1

Patient had an immediate improvement in his symptoms He has continued on anticoagulation and his regimen of compression stockings and a pneumatic compression device An open ligation of the fistula was performed 1 year after surgery Bypass has now been patent for 10 years

14 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

Repeat Ambulatory left dorsal foot vein pressure

15 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

20 40 60 80 100 120 15 30 45 60 75 90

Venous pressure (mmHg) Time (seconds)

Pre-Palma 9y after Palma 30 toe-ups

16 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 5

Challenging Case #2

50 year old man with non-provoked bilateral lower extremity DVTs

• Started on anticoagulation, compression
• Hypercoagulable workup negative for malignancy, anti-phospholipid

syndrome, factor V Leiden, protein C deficiency, protein S deficiency, prothrombin G20210A mutation 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 4/14/2016

Challenging Case #2

1 year after placement of the IVC filter, he was hospitalized with acute leg swelling with extensive bilateral DVT

• Anticoagulated
• IVC filter was found to have migrated caudally and could not be removed
• Bilateral common iliac stents placed

18 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 19 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

Challenging Case #2

4 years later, with poor compliance on anticoagulation, he returned with bilateral leg swelling, worse on the left Venogram showed stenosis

• f both iliac stents

20 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

L

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 6

Challenging Case #2

Balloon angioplasty of both common iliac vein stents was performed with improvement

• n the right

Left iliac vein stent was relined with Wallstents

21 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

Challenging Case #2

2 years later, still with poor compliance on anticoagulation, he returned with acute left leg swelling Duplex ultrasound showed left common femoral and femoral vein DVT

22 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

Challenging Case #2

Acute thrombus in the common femoral and femoral veins treated with pharmacomechanical thrombolysis (Angiojet) and catheter-directed thrombolysis with tPA

23 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

Challenging Case #2

Additional Wall stents were placed in the left common femoral and femoral veins

24 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 7

Challenging Case #2

11 months later he returns with an acutely swollen left leg

25 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

Challenging Case #2

11 months later he returns with an acutely swollen left leg

26 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

Challenging Case #2

11 months later he returns with an acutely swollen left leg Wallgrafts placed within the

• ld Wallstents to treat

neointimal hyperplasia But then it thromboses

27 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 28

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 8

Challenging Case #2

Taken to the OR Pharmacomechanical thrombolysis (Angiojet) Venogram appears similar to before IVUS shows a 10+ mm lumen within the stents with severe compression/narrowing (3mm) of the cephalad end of the stent Stented with 10mm iCast

29 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016

Challenging Case #2

Recent systematic review found an approximately 75% mid-term (3-5 year) patency rate for iliac stenting after iliofemoral DVT A story of all the small factors that add up to iliac vein stenting failures

• Initial stenting from common femoral vein into the external iliacs – often

extension to the common femoral vein is necessary

• Leaving a gap between common iliac and common femoral vein stents –

creates an area that has a very high rate of stenosis

• Heavy reliance on venogram, which frequently underestimates the extent of

disease or degree of stenosis – adjunctive use of IVUS helps identify the proper treatment

30 Challenging Venous Obstruction | UCSF Vascular Symposium 2016 4/14/2016 J Vasc Surg 2009;49:511-8 J Vasc Surg 2013;57:1163-9