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• W4382753296 abstract "Chronic iliocaval long segment occlusions significantly impact quality of life and present several challenges. These challenges include the fact that intimal hyperplasia is more pronounced in the venous system and no current covered stents are approved for the treatment of chronic venous occlusions, as well as the difficulty in establishing adequate inflow and outflow. Since the venous system is low flow, it is naturally predisposed towards thrombogenicity, which is an additional hurdle in the treatment of this clinical entity. When important vessels are involved, the decision to jail these can also be controversial. Despite this, endovascular management with angioplasty and stenting provides good long-term patency and improves symptoms in the majority of patients and is currently the technique of choice1Hartung O. Loundou A.D. Barthelemy P. Arnoux D. Boufi M. Alimi Y.S. Endovascular management of chronic disabling ilio-caval obstructive lesions: long-term results.Eur J Vasc Endovasc Surg. 2009; 38: 118-124Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar. Surgery should be considered only if endovascular management fails. We present a case of long segment inferior vena cava (IVC) occlusion with involvement from the suprahepatic, intrathoracic inferior vena cava to the external iliac veins bilaterally. The patient consented to the publication of this case. This is a 40-year-old female patient with a history of multiple recurrent bilateral lower extremity deep venous thromboses and antiphospholipid syndrome on lifelong anticoagulation with warfarin. They presented with a complaint of bilateral lower extremity swelling and burning pain, and a recalcitrant, nonhealing, left lower extremity venous stasis ulcer that had previously failed multiple compression treatments over time. Their initial Villalta score was 21 and Venous Clinical Severity Score (VCSS) score was 19. Workup with computed tomography venography (CTV) showed a diminutive and occluded IVC extending from the suprahepatic inferior vena cava, down to the bilateral external iliac veins, with well-developed collaterals. Hyperdense material was noted within the diminutive IVC lumen, extending cranially to the hepatic confluence, and no contrast opacification was evident throughout most of its trajectory. Occlusion of the IVC was determined due to the fact that this intraluminal hyperdense material was seen on the CTV, and this was corroborated by the intraoperative findings and need for advanced recanalization techniques. The bilateral femoropopliteal veins were also noted to be patent bilaterally, with nonocclusive chronic thrombosis from the distal third of the left common femoral vein to the middle popliteal vein, with spontaneous and phasic flow on spectral Doppler. Thus, the decision was made to perform endovascular IVC reconstruction. Baseline creatinine was noted to be 0.72 mg/dL. The procedure was performed using bilateral groins and right internal jugular vein (IJV) access. Selective venography of bilateral renal veins was performed to confirm adequate collateralization due to the necessity of crossing both renal veins with open-celled stents. The long segment occlusion was recanalized via the right IJV access with the technique previously described by our group2Rodriguez L.E. Tabrizi R. Malgor R.D. Wohlauer M. Jacobs D.L. Sharp Recanalization with the Upstream GoBack Catheter for Chronic Occlusive Ilio-Caval Thrombosis.Ann Vasc Surg. 2021; 74: 518 e7-e11Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar using the GoBack Reentry Catheter and a V18 heavy-tipped guidewire specific for chronic total occlusions. Intravascular ultrasound (IVUS) was performed for evaluation of disease extent, stent sizing3Raju S. Buck W.J. Crim W. Jayaraj A. Optimal sizing of iliac vein stents.Phlebology. 2018; 33: 451-457Crossref PubMed Scopus (75) Google Scholar and confirmation of stent expansion. The impact of double barrel stenting into the IVC was minimized by performing surface area calculation to provide comparable flow4Jayaraj A. Thaggard D. Lucas M. Technique of stent sizing in patients with symptomatic chronic iliofemoral venous obstruction - The case for IVUS determined inflow channel luminal area-based stenting and associated long term outcomes.J Vasc Surg Venous Lymphat Disord. 2023; Abstract Full Text Full Text PDF Scopus (0) Google Scholar. The patient was discharged on postoperative day 1, with a serum creatinine of 0.67 mg/dL, and was sent home on low-molecular weight heparin (LMWH) and aspirin 81mg daily. They were transitioned back to warfarin after 4 weeks, with an INR of 3.5 and will be maintained on both life-long aspirin and warfarin. 1 month follow-up serum creatinine was 0.76 mg/dL. 3-dimensional multiplanar reconstruction of the 3-month follow-up CT venography shows the full extent of stenting, from the common femoral veins to the lower border of the T10 vertebra as seen in Figure 1. The same CT venography also showed patent stents, decreased abdominal wall and bilateral lower extremity edema, decreased collateral vein size. Also, the patient reported complete resolution of pain and swelling, the venous ulcer had healed, the Villalta score had decreased to 9 from 21 initially, and VCSS to 6 from 19 initially. Follow-up imaging is planned at 6 months, 1 year, and annually thereafter. It was explained to the patient that due to the nature of the disease, multiple follow-up procedures would likely be necessary to maintain patency due to the venous system’s tendency to produce sustained intimal hyperplasia, and that the risk of stent erosion of the venous wall into adjacent structures, while rare, exists. This case illustrates the fundamental role IVUS plays in various aspects of complex venous disease5Gagne P.J. Tahara R.W. Fastabend C.P. Dzieciuchowicz L. Marston W. Vedantham S. et al.Venography versus intravascular ultrasound for diagnosing and treating iliofemoral vein obstruction.J Vasc Surg Venous Lymphat Disord. 2017; 5: 678-687Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar, and underscores the importance of obtaining good outflow. Renal vein jailing to ensure outflow may be appropriate in cases where the IVC is functionally occluded and collateralization is deemed adequate. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI1ZjlkOGQxMDUyZDMwZmI2OGUwZGNiN2Y0ZmI2YTU2MyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg4MjkwNTA4fQ.jByUA4qeIkuNrx8ECkOgV6W4nybAOajqThoUj2cA4UU2zfbVoMT7nm73Vp7zlLhR7ozeempTaTkEJ5kpVdvWKZyI-qmzbKKrJmFvxqVZEWusQTrqnZVpUygM96jhKoHmGQbNd7wT1sj7I0lMXwb0KwC2UksEsLWJZydeQ63f3yDg3yfItGYUqatMNSCJVKAEueP0Uh1fVlbx1vpG5tW7rLKE-QuMmH0_5jFEgPbBIUWEXvnRvjUsqbTVVY5RgWPC5SUehaxu-VrJmi8BBEs7tM2v8N3WOegAfY1LFTjyoWdO82SPmXrK31P4Y3oAD7b8fCqnG6oSV7YH4FfzcWndLA Download .mp4 (124.15 MB) Help with .mp4 files" @default.
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• W4382753296 date "2023-09-01" @default.
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• W4382753296 title "Total iliocaval chronic occlusion recanalization and double barrel stenting across bilateral renal veins" @default.
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