Chapters Transcript Video Tips and Tricks for Acute Venous Interventions Back to Symposium Thank you very much so. You know, I think there's a little bit of overlap and redundancy which is good, um, and but, but they're all, uh, a little bit different so you know with this and, and again you know between the Murphy Dunleavy Leslie practices all, all different, um, and. So if we just say, you know, I was on my way here listening to one of uh the back table conversations with, with Mark and uh thought it was really funny because it was, it was about 7 years ago they were talking about whether you have us, whether you don't, and, and one of the docs is like, you know, some, some crazy overtreating surgeon is, is saying that there are lesions on the right, can you believe that? And so I think it we've come a long way right from just this traditional idea of there's only uh a lesion in the left common iliac vein and nothing else so this patient presents with malignancy, right? They, they actually uh arrive with right lower extremity swelling. This is the first thing that I get to see, right, is that they, they clearly have lung cancer and they have metastatic disease, so. You're already thinking about what, what could be, you know, the etiology of their right leg swelling in there is it their, you know, hypercoagulable state? Is it their venous stasis because they're going through so many treatments, you know, is it the fact that they have some type of extrinsic compression and so. You know, sometimes we talk about the different benefits of SEP and VCSS and Valta and what the appropriateness is of each, and Valta can be a tough one, right? This this is not necessarily someone that we know that has post thrombotic disease, but I tend to try to use as much as we can, um, to support these patients. So oftentimes, right, if someone comes in with a DVT into the emergency department, most practices are trying to get a CT venogram of the abdomen and pelvis and get a lower extremity ultrasound, you know, you can pick your access based on the ultrasound, you know whether you're going to be dealing with a lot of thrombus in the pelvis and in the IVC. Um, in some situations, right, we already know there might be a PE, uh, and so, you know, here it didn't really go that way, uh, they, they already had a CTA runoff and so, you know, even though it was not intended for this purpose, you can follow it down and see that, you know, there's extensive thrombus in the common femoral and the femoral in the pop. And you look higher, right, and, and you can see and sometimes for people that don't look at CT scans every day you can just look at symmetry, right? And so you can see the, the left external iliac vein is normal on the right what what some people thought was the external iliac vein is all lymphadenopathy, right? And there's an extrinsic compression on those tiny areas on each of those images which is the vein. And so you know just thinking about how you could manage this in this situation, you know, brought a a thrombectomy device up and uh try to improve inflow outflow as much as possible, you know there's different, you know, discussions right of of thrombectomy, primary stenting, not whether you do IVIS come back on a different day, um, and, and I appreciate the more conservative approach but. On the other hand, in some situations where you realize that the person has a limited time, right, the quality of life limiting their amount of visits to see us in the hospital is, is a big goal for the patient and the family, you know, in this situation we, we kind of did a a single session case, so, um. After improving inflow, uh, we then did angioplasty. I think it can be helpful, right, to improve things mechanically as much as you can before putting a stent in. Um, and, and then went with kind of the usual, right? So one thing that, that people often talk about, right, is the inguinal ligament whether you should go that low, um, and so you can either identify the greater saphenous vein and profunda with ultrasound, with phonography, or with the ibis. So we try to be redundant, right, and, and see it with phonography, but also identify it with ibis and then just mark that on the screen. And, and from that standpoint then start low, so with a 14 and then uh remeasure and, and identify and make sure that we're targeting appropriately. And so you know sometimes people will talk about there there is a 160 it's super helpful right to have all these choices, um, but oftentimes in a case like this it's nice to be able to say well the common femoral shouldn't be the same size as the common iliac and so, um, having this overlap in these lengths can be ideal in terms of identifying and optimizing laminar flow. And so here was a uh you know, subsequent PT that she had and and she continued to do well all throughout her therapy, but you can see that, you know, the stent was able to maintain the appropriate size despite continuing to have that extrinsic compression on it. Different patient altogether. This is a a nurse that was traveling, right? We know that, uh, for a while we have a lot of traveling nurses and thank goodness we have them and some of them are, are incredibly dedicated and helpful and she couldn't do her job anymore. She said that the severity of her pelvic pain meant that she just really couldn't get through a shift. So as always in my region, um, you know, I'm sent basically anybody that has pelvic pain with the thought that it must be pelvic congestion or pelvic venous insufficiency or ovarian vein incompetence, what you like to call it, um, but you can see that, um, that doesn't really explain her situation. And so you know we go through the process again assessing her legs assessing her pelvis um you know and it it's nice to be able to consider all of that again in in some of these discussions right we say it's all one system and one circuit and you have to understand them all to treat any of them well. And so sometimes we wonder what do we call these patients, right? She probably did have a DVT at some point. Do we call her post thrombotic? She's never been treated for anything, um, never had any anticoagulants, never had any antiplatelets, and functionally she was doing well except she progressively continued to deteriorate. So if you look at her CT scan, obviously you can see she has an extensive amount of left adenaxial varices, uteov vaginal varices, cross-filling collaterals, and if we follow that up, you know, it, it just, at this point looks like a pretty standard May Turner. Um, when you go, and again this is completely outpatient, right, she's not admitted to the hospital, realize that you know this is pretty severe, right? That she has no flow going across common iliac vein into the IVC and so there could be further discussions about which wires and catheters you like to use, but you know, having some type of stability to get across can be very helpful, um. You know, we, we oftentimes to say like can have a whole discussion too on how you do your IVIS and whether the different wires that we choose can can alter what we see on Ibis, but, uh, can be obviously our first goal is to get across and then after that to figure out to what degree, you know, we need to do something and um. I tend to on my outpatients, right, the ones that are just sent to me for what is considered pelvic congestion or just pelvic varices to do diagnostic IIS, um, but in, in these types of situations, obviously once you're across it's kind of silly to let that go, um, there's different discussions, right, of, of how you make sure that you always do a great job, right? so. The worst thing, right, is to put a stent in a bad place, right? So never want to stent with something that's the wrong size just because that's what we have that day or to stent close to what's perfect and so if you look at these images you can see there's different techniques that people have. Some people will just access left, go up and over or inject or, you know, just know where the confluence is. Um, others will use this technique where, you know, you have a 10 French sheath on the left and a 5 French sheath on the right. And when you are ready to deploy your stent you can or even when you're flaring right, you're in your champagne or your wine glass you can inject a little contrast on the right and prove that you're not against the contralateral wall and make sure that you think that you're you're targeting your lesion perfect, uh, but you're also not too high, right? because find that coming back and trying to optimize things later is a lot harder if we didn't do a good job on the first time. And so you know again following this down, you know we're able to use you know a long stent but a single stent um and have great outcomes. And um I actually. Resigned from that practice and the first day I ended up in my new clinic she was there and I said how did you find me? and uh she's very dedicated right so some of these people when you allow them to get back to work and live a normal life they're incredibly appreciative. And she remains a uh a manager that that deals with uh intensive care patients. Published Created by
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