Date post: | 03-Jul-2015 |
Category: |
Health & Medicine |
Upload: | vein-global |
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Mark J. Garcia MD, MS, FSIR
Chief Interventional Radiology
Medical Director Center for Comprehensive Venous Health
Medical Director, Center for Heart & Vascular Peripheral Labs
Christiana Care Health Services
Newark, DE
Speaker Honoraria:Bayer Medrad, BTG/EKOS, Cook, BSX
Steering Cmt:Bayer/Medrad-PEARL, BTG/EKOS-ACCESS PTS
Consultant:Merit Medical, BSX, Gore, Fusion Medical
Stock Ownership:ELGX, Fusion Medical, Tack It
Research: NIH-ATTRACT, BTG/EKOS-ACCESS PTS, Cook-VIVO, Medtronic-In Pact II, BSX-HTN IV
Modalities:
Doppler US
CTV
MRV
IVUS
Venography
Cost Analysis
Indications
Pros/Cons
Appropriateness/Guidelines
Technique Pearls
Cost Analysis: (Global)
DUS
LE IVC
CTV
Abd/pelvis
MRV
Abd/pelvis
IVUS Venogram
LE IVC
CMS 118
201
Total = 319
807 878 132 95
117
Total = 212
BC/BS 124
135
Total = 259
803 1032 316 95
192
Total = 287
Doppler US:
Indications – Diagnostic tool:
Peripheral > central eval (dec sensitivity peripherally)
r/o DVT
Insuff exam
f/u post intervention
eval peripheral vasc mass
Pros: cheap, quick, easy, no rads, flow physiology
Limitations: tech dependent, false +, early false –,
body habitus, central imaging
CTV:Indications – Diagnostic tool:
Central anatomy:
IVC – thrombosis, atresia, absence
Iliacs – compression, thrombosis
Renals – Nutcracker, PCS
f/u post intervention
Extravascular anatomy (esp compression, masses)
Non-diagnostic US
Pros: Big picture view, quick, easy
Limitations: Rads, contrast, $$, streak artifacts, +/- flow physiology
MRV:Indications – Diagnostic tool:
Central anatomy:
IVC – thrombosis, atresia, absence
Iliacs – compression, thrombosis
Renals – Nutcracker, PCS
f/u post intervention
Extravascular anatomy (compression, masses)
Non-diagnostic US
Pros: Big picture view, no-rads,
Limitations: contrast, $$, motion, metallic voids, technique challenges, time, +/- flow physiology
IVUS:
Indications – Diagnostic tool:
Central anatomy:
IVC – compression
Iliacs – compression ** May-Thurner
Renals – Nutcracker
Intra-op: compression, sizing, localizing, stent apposition
f/u post intervention – lumen size
Pros: Intra-luminal view, non-rads, easy, quick
Limitations: Invasive, additional $, flow physiology
Venography:Indications – Diagnostic tool: Venous Intervention:
identify clot burden,
compression, reflux,
flow physiology
IVC – Atresia, absence, fliter eval
Iliacs – M-T
Renals – Nutcracker, PCS
Pros: Anatomic & Luminal eval, flow physiology (wash-out info, collateral filling)
Limitations: Invasive, rads, $, technique challenges, contrast ARF
Venography:
Renal Issues/Allergies:
Prep – hydration
Limit contrast w/ IVUS, CO2
CO2
Venography:
Indications – If there is any consideration for
intervention…..MUST do.
As a diagnostic tool,
it should be second in line, after non-invasive
diagnotic tool(s) have been utilized.
To maximize flow physiology:
Image thru “wash-out” phase
From leading edge to trailing end of contrast
For “compression” evaluation:
Obtain minimum 2 views
21 yo F with 6 mos onset of swollen Lt leg
No trauma, travel, hx of DVT
DUS – No DVT – abn CFV waveform
CTV – M-T compression
38 yo M with hx of Rt leg DVT since 1999 with
significant, asymmetric swelling (10 cm thigh
differential), mild venous ectasia
DUS – Chronic venous changes Rt fem-pop
Venography 9/13 – Fem strictures w/ very
sluggish flow into profunda collaterals
PTA, EKOS – patent but to & fro though improved
flow
“Rethrombosis of fem-pop veins”
• Patent Fem-pop
• No change in leg size
• Some mild venous ectasia
• No varicosities
65 yo F with longstanding, severe cellulitis &
ulcer Lt leg, persists despite Abx, ECS x > 1 yr
DUS – “No DVT”
VS – felt reflux not sole etiology of issues
CT – Prominent parametrial vessels ? PCS
Venography:
As a diagnostic tool, venography should be second
in line, after non-invasive diagnotic tool(s) have been
utilized.
If non-invasive studies are inconclusive or there is
any consideration for intervention …..MUST do.
Consider alternative agents (CO2), tools (IVUS) in
appropriate setting