Chapters Transcript Video Case-Based Learning- Chronic Scenarios Back to Symposium So I'm gonna launch into some cases if you can open up my next um oh here it is, look at you, you're all over it um and again I will ask you to um click on uh videos if they don't play automatically. So I'm gonna go through some chronic deep venous cases that I think are kind of interesting and maybe some learning points. And I'm gonna start with this one. And so for any, obviously you're in this room, so you do deep venous disease, but for some of you who say, you know, I'm probably not interested, I'm just gonna do arterial work. I'm just gonna do whatever. Prepare for the unexpected. And so here's a patient. I'm not gonna tell you the history, uh, but clearly they've got, you know, some sort of May Thurner non, um, totally thrombotic iliac vein compression. And so this patient needs, uh, it has symptoms except um this is how this patient came to me. She had increased venous pressure and decreased dialysis efficacy and so we actually just stumbled on a deep venous case while doing a dialysis access, um, and so it is good to have these techniques and so the technique is exactly the same as anything else um we get across we II, uh, through the graft in this case, um, we measure, we evaluate and make sure that there is a compression and here's Ibis. Um, we stented this patient with a 16 millimeter Vovo venous scent system, and here's the other interesting teaching point about this case. So I stent her and I look and I say, well, what, what's going on with that segment? Why is it so narrowed? It didn't really look narrowed on Ibis before, and this is a process that if you haven't seen it before, um, it's probably seen you, uh, if you were doing any venous stenting, and it's called the Poisson effect. Poisson effect is what happens when you put a stent in a vein. Um, and you basically get redistribution of longitudinal forces and so you get this stretching. You get the stretching of the vein segments adjacent to the stent, and so that is a normal thing. And I will tell you you will drive yourself crazy and stent from head to toe if you put in a stent and say, well that looks segment looks bad. Oh now that segment looks bad. Oh now that segment looks bad. And so for me it's really important uh before I, and this is true for arteries too, before I start treating, I actually write down on the table what segments I'm treating, what segments deserve to be treated by both venography and geography, uh, IIS, so I don't get tricked at the end because same thing with arteries you put in a stent, you're like that looks beautiful. Well now that looks garbagey, um, so you gotta be careful with that. And then again post Ibis, um, that stent is well opposed and the patient did well, um, and dialysis, she still has this graft. So I'm gonna say a little bit more about filter bearing occlusions which I've um delightfully named Vini Vidivici um or veiny Vidivici. Um and so this is a patient, 59 year old woman with worsening right upper quadrant pain, bilateral lower extremity swelling, cramping, heaviness. Her Valta score kind of fit into a sort of the moderate to high. Um, she had a history of DVT in the 90s. She had a 24 French stainless steel green filled filter. And for reasons I can explain to you offline, she had a 2nd 24 French stainless steel green filled filter in her, OK? And so this is an example where I have to treat, I mean she's not happy, she's pretty miserable, um, I have to do something with her IVC which is severely diseased. I don't like the idea of stenting through these 24 French stainless steel filters. Um, can I get these out? I don't know, but I think it's worth a try. And so this is a total dwell time of 56 years, OK, of IVC filter, um, and I said, you know, let's, let's, let's give it a shot, and so, um, here's an example where I think it's important to get comfortable with advanced filter retrieval techniques. So our technique here was 22 and 18 French coaxial sheaths, and you can see this filter with endobronchial forceps, which again is one of the critical techniques of advanced filter retrievals. Comes out and it came out pretty, pretty straightforward. There was a loose fragment that was extravascular. We did not go after that studies show you do not have to go after extravascular fragments. It's, it's not worth it, um, almost all, you know, most of the time, if not all the time, um. And then uh look afterward you see there is a pseudoaneurysm here, so we actually published on pseudoaneurysms following filter removals. Um, this is usually almost always asymptomatic. That said, we certainly monitor the patients for pain. We monitor the patient's vital signs. The one exception to the two exceptions to that. When a patient has had prior retroperineal surgery, so someone says, oh by the way, I had testicular cancer and I had retroperineal dissection, I had radiation, those are the patients where my confidence of if something happens to the cava, you'll probably be OK goes way down. I'm much more concerned about that with patients. Regardless, I still have stent grafts in the room. I'm still extra cautious, but those I sort of have a heightened awareness if you've had retroperitoneal violation. So just do screen for that anytime you're doing cable work. I think that's important. So her symptoms improved, um, uh, her abdominal pain resolved, excuse me, but her, uh, her symptoms, uh, were still there and so obviously once the filters were, were out we did stage this. We brought her back and did a total, um, cable ileocaval reconstruction. Um, we did a 16 millimeter atlas dilated. Her post PTA looked uh better but obviously with veins you're committed to a stent uh unlike arteries where we talk about leave no metal behind if possible uh with veins it's the opposite really stent all the all the disease that needs to be stent leave no disease behind, um, and so we did stent her. Another teaching point about this, uh, which I thought was really interesting for whatever reason, I don't know if I was distracted that day or just in a hurry. I I when I put in her iliac stents, I ballooned one at a time. I think I, I think we were maybe short on balloons, and I'm like, alright, I'll just do one at a time. And what's interesting is it actually does collapse and so these dedicated venous stents can collapse. Now this is a bonovo, so it actually works out because what we did is we just went back in and kissed the balloons like you should do properly, and it opened right back up and no problem. But keep in mind that if you have two radial force stents, it doesn't mean that they're both gonna. Win at the same time, especially if you sort of push one or the other, and they will ovalize no matter what the stent is, but you can see even kissing this um ovalized minimally and actually did a very nice job keeping the stent open. And so this initial, you know, 14 months later, uh, we saw her and she was wide open. Um, here's another patient with a filter bearing cable occlusion extending into the iliac veins, um, really bad disease. This guy was miserable. He was a, um, uh, worked at the airport, uh, baggage loader, couldn't do his job. So same idea, um, for me, I don't wanna stand across this if I can avoid it, um, filter bearing cable occlusions we try to get rid of, uh, the filter again endo bronchial forceps or in some cases the laser may be required. And so we take this out, stent reconstruct, and the important thing about him is he had disease all the way to the common femoral vein. And so it's really important to stent this patient all the way to his inflow, evaluate his deep femoral inflow, and make sure you have proper, uh, disease. This guy is a 50 year old, you know. Manual labor baggage guy, he was crying in my office when we saw him in follow up. I mean just really a life saving difference, a life quality of life, um, changing difference for this gentleman, and you can see on follow-up CT, uh, kissing stents actually ovalize a little bit but actually do a nice job keeping everything open and stent right to the like inflow or the internal, excuse me, the deep femoral inflow. And then finally we'll talk about, I think it's finally, um, or one of them, we'll talk about a 45 year old gentleman, uh, abdominal swelling, he did have an ulcer, uh, he had chronic DVT, he had an optis filter, he had a wall stent that's been occluded. His Volta was 16, very severe disease, um, he was on all the medications. He had oxycodone because he was in so much pain, 3 layers of compression hose. And so I talked about I love filter retrievals, I think it's important. Do I do it 100% of the time? The answer is no. This is a patient who has a chronically calcified thrombotic occlusion of his biconical IVC filter. And so when I brought him in, um, I was able to get across. I will tell you the left side was super easy, the right side was a bear. I could not get across it with an 035 system. Finally I was able to um take the uh back end of a stiff glide wire um I think it was an 018 stiff, even a 035 stiff glide wire wouldn't go um I tried with a uh starto wire um and then finally was able to get across. Angioplasty, the whole thing and even after angioplasty I still couldn't get any system to tract, so I actually had to downgrade to an 014 system which is very rare in the veins for me but it happens. I was able to get an 014 balloon across this is with a triaxial or quadraxial system, um, and then finally convert into a 35 system. So this obviously took a while. This was certainly one of my longer cases. Um, it was very fibrotic, very difficult to get through. There's that big chunk of calcium. This is an example of why I was a little bit concerned that if I started coming in with the laser for the filter, uh, the, the, um, uh caviclear. That it wasn't a totally collapse around that big calcified chunk and so this is a patient I said, you know, buy conical filters. I feel much more comfortable standing through. I just stented through this cava. I did this IVC filter. I did not try to remove this filter and worry that it was gonna get deformed and trapped by the calcium. I thought that was a reasonable choice. Some of you may have said I would have tried to remove it, um, but the moral of the story is I'm OK not removing some filters, but clearly my preference is to remove what I can. Um, his everything improved, dyspnea, lower extremity swelling, discomfort, and here's his final venogram. You can see on follow-up CT. You can see that crushed filter right next to that uh that stent, um, but his, his stents are patent and he did great. Um, just to follow up on a stent, uh, word about stent occlusions, um, again, uh, these are obviously not desirable. This patient was sent to me, having already had this T stent configuration. Uh, unfortunately he thrombosed the side that was, uh, T stented, and so we had to fix it. In this case, the only option is for the so-called fenestrated Y or inverted Y, right, inverted, yes, inverted Y, um, fenestrated technique where you can go through the interstices, You can balloon them open, um, and you can stent reconstruct. Obviously if you did this de novo, you're not happy with that result, but this is sort of a save for these kinds of techniques, um, and it works reasonably well, um. The other thing about, uh, stent occlusions, sometimes the caps, uh, someone said this the other day which I'd never heard before, a tootsie roll where it's hard on the outside but soft on the inside, uh, sometimes these caps can be hard but it's soft on the inside. Sometimes it's cement all the way up, but for those cases what you can do is access a little bit lower and actually with ahiba needle through the sheath you can directly stick through that, uh, stent or direct puncture it and then from the jugular side you can kind of come from the other direction. But a lot of these cases, you know, the hardest cases for me are ones where you're 40 minutes in and you haven't even started the case yet, right? Like you can't even start the case because I can't get access. I can't even start like my wire, so this sort of mitigates that, um. That situation where you can at least start it direct stick it started and you can always floss your wire from above. Um, again, the back end of the wire, um, sharp rectalization techniques I think are worthwhile knowing. In my hands, uh, back ends of the wire isn't as great, and the reason is I think it's difficult to angle. It can perforate. It's just gonna go blindly. You do need robust support. There are times where I have, you know, my size 14 shoe going like this, and it just bounces right back at me. Uh, these things are like cement, and so this is where I think the power wire is really helpful. Uh, the power wire will go through anything except for calcium and metal. That's good. The bad thing is the power wire will go through anything except for calcium and metal that includes aorta, pulmonary artery, lung, organs, OK? And so you do have to be careful, um, again, meticulous triangulation technique. The nice thing is it does stop on metal, so if you're doing an instant occlusion. And you're getting to the metal and it shuts off, you know you're at the edge of the stent, and so that's helpful rather than just going through it. Now, yes, there is a theoretical risk you could be perfectly through the interstice and never get a metal contact, in which case you probably should play the lottery that day, um, but it is nice. It will shut off with metal, which is a good sign. And so for this patient, if you don't mind playing that video, um, this is a, uh, another example of a biconical filter where the patient, uh, could not get through. In fact, you could see there's a little bit of contrast extravascular. You can see some misadventures, um, but the RF wire, if you don't mind playing these videos, uh, down behind, if not, I'll describe them, um, the RF wire again, aim for the snare, go right through, and it, uh, it works pretty well. You'll have to believe me, this is a great result. This is the greatest result you'll ever see. Unfortunately you can't see it, so we'll just move on. Um, see, I have CT proof, all right? Uh, 8 month follow-up patient's stents were wide open. And that's it. So that's the sort of compendium of uh of cases that you may see, um, and I encourage you to do this work. It can be really sort of uh challenging, uh, but really life life changing. So I appreciate it. Published Created by
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