management of chronic venous occlusion
TRANSCRIPT
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Mahmood Razavi, MD, FSIRMahmood Razavi, MD, FSIR
Director, Director,
Clinical Trials & ResearchClinical Trials & Research
St Joseph Heart & Vascular CenterSt Joseph Heart & Vascular Center
Chronic Venous Occlusion:Chronic Venous Occlusion:Tools & TechniquesTools & Techniques
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Disclosures
Scientific Advisory Board• 480 Biomedical, Abbott Vascular, Bard, Boston
Scientific, Covidien, EmboMedix, Javlin, Mercator, Neuravi, Reflow Medical, Trivascular, Veneti, Walk Vascular
Consultant• Cordis
Grants• NIH, WL Gore
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Central Venous Occlusions
Upper extremity > lower extremity Upper extremity
• Malignant obstruction (majority involve SVC)
• Benign etiologies: dialysis related, CVC, pacer wires, thoracic outlet synd
Lower extremity• Thrombotic/post thrombotic; venous
compression (May-Thurner)
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Central Venous Occlusions
Anatomy: central to thoracic inlet (BCV & SVC) and SFJ (CFV, iliacs, IVC)
Not always symptomatic, sx drive tx Criteria for significant stenosis
• Presence of collateral circulation• Pressure gradient (2-3 mmHg)• Area stenoses > 50%
No support in the literature& not widelyaccepted
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General Rules
More than one access may be required in many cases
Length of procedure unpredictable; may be frustrating or intimidating
Most common elements of success:• Planning, persistence, practice
Current devices not designed for venous occlusions
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General Rules
Sharp recanalization may be needed in many cases
Must be familiar with expected course and curvatures of BCV and iliacs
Angioplasty alone rarely effective (non-dialysis patients)
BMS associated with poor patency in veins peripheral to BCV and SFjxn
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76-Y-O female 76-Y-O female With RUE edemaWith RUE edema
Hx sig for multipleHx sig for multipleRSV & IJ RSV & IJ Catheteriztions & RUECatheteriztions & RUEAVGAVG
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Pitfalls
Main channel not always clearly evident Collaterals: may be mistaken for main
channels!! Rupture also possible if main channel is
over-dilated
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18-year-old female with chronic LLE PTS due to inadequately treated DVT 1 year earlier. DVT was due to a surgical misadventure during lap. appendectomy and injury to L CIV
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Approach
Thrombolysis, anticoagulation, and angioplasty alone are largely ineffective with limited applicability in non-dialysis chronic occlusions
Stents needed in majority of CVO Stents used as last resort in outflow
circuit of dialysis pts (stent-grafts??)
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Stents
Iliacs & CFV: 10-16 mm stents (NiTi stents with higher compression resistance & radial strengths preferred)
IVC: Wallstent (if > 16mm diameter needed) SVC: BE stents, nitinol stents (may need to
be anchored in BCV) BCV: nitinol stents, stent-grafts SCV: avoid stents, S/G preferred if needed
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Stenting of Points of Venous Confluence
Double Barrel CavaDouble Barrel Cava MBZ-configurationMBZ-configuration T- configurationT- configuration
Fenestrated configurationFenestrated configuration
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UE venogram showing bilateral BCV & SVC occlusions & extensive collateral veinsUE venogram showing bilateral BCV & SVC occlusions & extensive collateral veins
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20-year-old female with history of treated lymphoma and multiple central venous catheters presents with chronic UE and cervico-facial edema
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42-year-old female with high altitude exercise intolerance and prominent superficial veins on abdomen and pelvis
Hx sig for prolonged umbilical vein catheterization after birth
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Author Year No. of Pts. Primary Patency
Secondary Patency
Nagata 2007 71 88% 95%Nicholson 1996 76 91% 91%Chatziioannou 2003 18 100% 100%
Courtheoux 2006 20 83% 94%Furui 1995 16 81% N/ALanciego 2009 149 86.6% 93.3%
Hennequin 1995 14 93% 93%Kee 1998 43 79% 93%Smayra 2001 16 74% 74%Tanigawa 1998 23 74% 88%
Thony 1999 24 88% 100%Miller 2000 23 83% 87%TOTALS 493 87% * 94% *
Sample literature on Stenting in Malignant SVCSSample literature on Stenting in Malignant SVCS
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Author Year No. Patients
Primary Patency
Secondary Patency
Bornak 2003 9 67% 100%
Kee 1998 16 77% 85%
Qanadli 1999 12 93% 100%
Smayra 2001 14 29% 64%
Rizvi 2008 32 44% 96%
TOTAL 51 66% * 85% *
Stenting: Benign SVCSStenting: Benign SVCS
* Weighted Value* Weighted Value
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Lower Extremity CVO
Acute technical success 80%-92% Primary patency of stents above SFJ
70%-80% at 1-yr (74% in NVR) Primary patency in non-thrombotic
conditions >80% in the literature
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Outflow Stenting 6-yr primary/secondary patency
• Non-thrombotic dz 79% / 100%• Thrombotic dz 57% / 86%
Significant reduction in pain, swelling, ambulatory venous pressure
Sig improvement in healing of ulcer and QOL
Neglen P. JVS 2007;46:979
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Iliac veins stented in 528 limbs with deep venous reflux
5-yr results: 2° patency 88% Healed active ulcer 54% Improved pain 78% Improved edema 55%
5-yr freedom from: Ulcer recurrence (C5) 88% Dermatitis 81%
Raju S JVS 2010;51:401-8
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Conclusions
Symptomatic CVO require reestablishment of flow
Endovascular approach is the first line of therapy
Familiarity with the venous pathophysiology is a must before attempting to treat