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CHRONIC ILIOFEMORAL DVTNEVER TOO LATE
Stephen F. Daugherty,
MD, FACS, RVT, RPhSClarksville, Tennessee
ACP NOVEMBER, 2012
44% DEVELOP VENOUS
CLAUDICATION
15% VENOUS CLAUDICATION
INTERRUPTS WALKING
Delis KT, Bountouroglou D, Mansfield AO, Ann Surg. 2004;239(1):118-26.
21% of patients with LE DVTdevelop PTS with 66 month follow-up
At the initial presentation, iliofemoral DVT was the single variable closely associated with PTS,odds ration 3.4
Yamaki T, et al. Eur J Vasc Endovasc Surg 2011;41:126-33.
MOST CLOSELY ASSOCIATED WITH PTS AT 6 MONTHS
VENOUS OCCLUSIONPOPLITEAL VEIN REFLUX
ELEVATED PEAK REFLUX VELOCITY POPLITEAL
CALF MUSCLE PUMP DYSFUNCTION
80% OF ILIOFEMORAL DVT HAVE AN UNDERLYING EXTRINSIC ILIAC VEIN COMPRESSIONChang, et al.JVIR;15:249-56.
MAY-THURNERIVC FILTER OCCLUSIONANEURYSMS, ARTERIAL
GRAFTSTUMORS,CYSTS
SURGICAL INJURYRADIATION FIBROSIS
HYPOPLASTICKLIPPEL-TRENAUNAY
LE VENOUS DUPLEX USREFLUX
OBSTRUCTIONCFV DOPPLER FLOW
CONTINUOUS?
ASYMMETRY?FEMORAL VEIN COLLATERALS
ABDOMINAL/PELVIC DUPLEXFLOW AND ANATOMY
STENOSISMINOR DIAMETER
REDUCTIONELEVATED PEAK VENOUS
VELOCITY RATIO >2.5FLOW REVERSALGONADAL, ASCENDING LUMBAR,
PELVIC VARICOSITIES
CT/MR VENOGRAMS- HELP WITH ANATOMIC DETAIL
- DO NOT EVALUATE FLOW- DEPENDENT UPON FACILITY AND RADIOLOGIST INTEREST
- CT— TIMING OF CONTRAST
INJECTION/FLOW ISSUES
AUTOGENOUS SAPHENOUS VEIN
FEM-FEM BYPASS4 YEAR PATENCY 83%
ePTFE BYPASS2 YEAR SECONDARY PATENCY 54%
SURGICAL APPROACHES
Jost CJ, et al. J Vasc Surg 2001; 33(2):320-27.
Chronic non-malignant obstruction
177 limbs stented iliac vein into CFV
Focal in-stent stenosis at inguinal ligament
7% (all <50%)In-stent restenosis (>50%) 5%Stent fractures 0Stent compression 0
ILIOFEMORAL VENOUS STENTING
Neglen P, Tackett TP, Raju S. J Vasc Surg 2008; 48(5):1255-61.
CUMULATIVE SECONDARY PATENCY
AT 54 MONTHS
NONTHROMBOTIC 100%
THROMBOTIC
CEPHALAD TO INGUINAL CREASE90%
CAUDAD TO INGUINAL CREASE84%
NON-OCCLUSIVE ONSTRUCTION 95%
OCCLUSIVE OBSTRUCTION 77%
16 PATIENTS C3-610/16 INCAPACITATING VENOUS CLAUDICATIONAFTER STENTING (8.4 MONTHS MEAN F/U)
0/16 WITH INCAPACITATING VENOUS CLAUDICATION
IMPROVED VENOUS OUTFLOWIMPROVED CALF MUSCLE PUMP FUNCTIONINCREASED VENOUS REFLUX
CHRONIC ILIOFEMORAL
VENOUS OBSTRUCTION
ENDOPHLEBECTOMY OF CFV, FV
STENT IVC, ILIAC, CFV
Vogel D, Comerota AJ, et al. J Vasc Surg 2012; 55: 129-135.
HYBRID PROCEDURES
DEFINITIVEDIAGNOSTIC/THERAPEUTICPROCEDURES
VENOGRAMSUG sheath placement
Femoral, Pop, PTVFlow, Collaterals
THE ANATOMIC GOLD STANDARDUSUALLY BILATERAL IFV/IVCCHOOSE DIAMETER/LENGTH OF
BALLOON/STENTPOST-STENTING ASSESSMENT
INTRAVASCULARULTRASOUND
OBSERVE OVERNIGHTANTICOAGULATION LMWH
WARFARINCOMPRESSION HOSE, 30-40 mm HgEARLY AMBULATION
POST-OP STENTS
<1 WEEK OFFICE VISIT3-4 WEEKSABD/PELVIC US/OV3, 6, 9, 12 MONTHS AND ANNUALLYABD/PELVIC US/OV
FOLLOW-UP
FLOW-LIMITING IN-STENT SENOSIS PTBA
NEW STENOSIS OUTSIDE STENT
PTBA/STENT
THROMBOSIS CONSIDER LYSIS
EVALUATE INFLOW AND OUTFLOW AND
ADEQUACY OF ANTICOAGULATION
SECONDARY PROCEDURES