Chapters Transcript Video Tips and Tricks for Chronic Venous Disease Back to Symposium Alright, good morning. Um, so by now I think postprandial somnolence should be setting in, so you get me for 30 minutes. Congratulations. Um, feel free to nap away, but I'm gonna talk exclusively about chronic venous disease. I'm gonna talk about some tips and tricks and show some cases. Um, some of the tips and tricks, if not most of them, are things I previously messed up, so feel free to learn from my mistakes, uh, and hopefully not make the same ones. Uh, disclaimer, this is my opinion. Uh, here are my disclosures. I do specifically wanna mention that I do consult for Phillips, so I'm gonna talk about Ibis and, and Bayliss Medical Technologies. I'm gonna talk about the Power wire, uh, so I do have conflicts there. So I wanna review patient and anatomic selection criteria to optimize patient outcomes, and that's something that really we need to focus. I want to discuss tips and tricks for treating chronic venous disease efficiently and successfully, and I think efficiently is also helpful. Uh, 6 and 7 hour cases, uh, results in no good outcomes for either the physician or the patient, in my experience, and I'm gonna give you a couple of case examples. So to me, the most important is patient selection, right? And so I'm gonna show you 3 separate patients that I've treated in recent years. And all of them have severe chronic deep venous disease, specifically with caval occlusions. The truth of the matter is this patient was completely asymptomatic. He was referred to me because he had a PFO and the cardiologist couldn't get in, and so he just needed access. This patient was an elite high school baseball player at 16 years old with zero symptoms and chronic obviously atresia or agenesis, whatever you wanna call it. This patient had chronic severe post thrombotic syndrome and was miserable. And so the truth is only one of these patients probably needs treatment, right? And so what was always taught to me is there's a lot of patients we can help, there's not a damn patient we can't make worse. So we really have to optimize patient selection to get the best result. And so what are we eyeing? We're eyeing post thrombotic syndrome. Post thrombotic syndrome, as you know, is a constellation of things from edema to skin changes to in the worst cases, ulceration, venous claudication, and sometimes really affecting quality of life. Now for those of you we just had some great superficial lectures about reflux and treating uh superficial disease, the question is, well, what if we still have deep reflux disease? Is it worthwhile treating these patients knowing we're not repairing the valves outside of some clinical trials? Well, studies have shown that persistent venous obstruction, not the reflux, is often predictive of chronic symptoms. And so these patients do benefit if you can ameliorate the obstruction, restore flow, even if there's persistent reflux. Are they're gonna get zero symptoms? Of course not. Not every patient's gonna get a 100% cure, but these patients do tremendously well if you can alleviate the obstruction. I will make a pitch for using objective scales in your clinical practice as part of the patient selection technique not only to sort of guide your treatment strategy but also to monitor the patients. I practice in North Carolina. I have very nice hospitable. Patients and so I have patients come in and say, oh, I, I feel great. I feel great, no problem, and I do a Valto score or whatever it is, and I'm like, really, because it's not changed, and they just don't wanna tell me or vice versa. You have patients who are like, I'm miserable. I'm still miserable, and I show them a picture. your wound looked like this, and now it's healed. Oh right, I guess the wound's better. And so, and it's nothing bad, it's just sort of a little bit of cognitive dissonance, right? And so I think having objective criteria both for arterial and venous disease is really critically important. And then finally a word on patient selection. Beware inflow disease, OK? Again, doing nothing is not the worst option. Sometimes it's the best treatment plan, we can make these patients worse and so being really judicious about patient selection, who can tolerate a stent, who's gonna keep it open, because if you ask any person in this room, we all know that we would much rather treat a native vein occlusion than a native venous stent occlusion. And so be cautious stenting patients that aren't going to tolerate it, and there's no harm in taking a patient to procedure and saying, you know what, this ain't working and I'm gonna make you worse. I'm going to stop and think about what we're doing. OK, so once you have established that you have a patient that deserves treatment that warrants treatment, um, and that you are gonna help them and not harm them, now the question is how do we actually get to the damn thing, uh, how do we cross the conclusion and so support is key. Uh, the phrase that I was taught is take the fight to the site when I get referrals from outside institutions, uh, failures. Not infrequently I will look at their procedure and I see a lone little sad glide wire, a catheter, and a sheath a mile away. All right, you're never gonna cross any chronic difficult occlusion without support. So for me it's at least a triaxial system, so that means an 8 French or higher. It means a guide catheter, a diagnostic catheter, and then a hydrophilic or CTO wire. So really robust support and it goes all the way to the occlusion, OK, it's not just a short catheter hanging out in the femoral vein while I'm trying to cross a renal occlusion or a super renal IVC occlusion. Um, I will tell you I actually have moved over the past, you know, 5 to 10 years. Um, always start with an 035 system. However, I do have some success with the 018, um, CTO systems, um, the 30-40 gram tip wires, um, so I'll give a shout out to that, um, and then planning, right? So part of my tip is all this planning should happen before the patient hits your table. All these patients have cross sectional imaging in my practice, um, and so where do we access? And since we're surgeons and interventionalists, we can access anywhere we can access the arm, the neck, the direct IVC. I've had to do reconstructions through the liver, um, so we have these options so figure out sort of what trajectory works best. And to that point, don't waste time. Move very quickly to bi-directional access, in fact. And this is true if any of you do arterial work, same thing with pedal access. Have it prepped ahead of time. The inertia of being in a case, trying to get through and saying this ain't working, let's switch to the neck, and hearing your techs and nurses go, fine. Alright, let's take off the scrub, let's do this, let's re-prep. OK, let me try a little bit more from the femoral, and then all of a sudden you've wasted another 20-30 minutes. Have everything prepped ahead of time. Have the foot prepped in arterial cases, uh, for wounds. Have the neck prep. Have the groin prepped. Have whatever it is, alright, so use, uh, don't waste time. Use bidirectional techniques. Another tip, don't waste efforts. So when you're crossing bilateral iliac and IVC occlusions, often one side is easy or easier and the other side is hard. Use that to your advantage. So, and I'm gonna ask you to play the videos here please because uh some of them aren't gonna play automatically I think. Um, if you could play this one I believe is a video. Um, you just click on all these. So here's an example where I was able to go through the right side pretty easily, but I really struggled with the left. And so what you can do is, if the left won't go up to the IVC, but it would go up and over, right? I'm gonna go back one here, it would go up and over, snare that wire. And if you snare that wire, well now you can take a system and push that wire all the way into the IVC and so I'm not gonna waste time trying to cross from the left, uh, from scratch if I already have on the right, I can just sort of push my entire system from the left and so use one side to your advantage. This is another example where again I was easy to cross on the left, I could not cross on the right, but that's OK, angioplasty up and over, and that creates a common fenestration, a common channel, so now I can sort of. Now I can convert my right-sided access into the IVC. So really think about how do I maximize what I've already accomplished rather than starting from scratch when you're doing bilateral disease. If you could play this video please. Um, the other, uh, tip I would say is get comfortable with alternative techniques, OK? And so again, a lot of times we're gonna get, especially if you're here and you're obviously running more complicated practices, you're gonna get patients that other people can't or won't treat, and so a stiff glide wire is not gonna be the answer. There are other techniques out there that work very well, um, specifically the RF wire, which I'll talk a little bit about, and this can make a 6 hour case into a 2 hour case or, more importantly, a failure into a success. And so really start getting comfortable with alternative techniques including sharp needle recantalization RF wire, which again is a talk unto itself. Uh, just in brief, the way I do alternative techniques, I, in my practice, I always have bidirectional access. I will not do this blind. Um, I always have some sort of target whether it's a balloon or a snare or something, um, and the term I like to teach, and this is especially true in the chest, I do a lot of chest recantalizations, meticulous triangulation technique. And so I move very slowly. I look AP bilateral obliques, and my techs know it is OK, good, go oblique and now the other side, and I move a millimeter or two. Do it again, and then I move 1 millimeter or two, do it again, OK? And so meticulous triangulation technique to do this safely, you snare it and you have, uh, floss wax access here. So once you've crossed, now how do we treat it? So I guess the question is, why do stents fail in the first place, right, because if we know that, then we know how to avoid it. Well, it's usually three things technical, hematologic, and flow. We can't change all these things. I can't take away factor 5 Leiden. I can't take away a non-compliant patient. I cannot treat them, but sometimes I don't know, but I can do my best to mitigate technical and flow related issues. And so as Mr. Miyagi says, the best way to not get hit, no be there, OK? And so the best way to avoid stent occlusions is don't stent unnecessarily. Many of our societies, SIR SVS has guidelines as to who should sort of probably be treated for chronic deep venous disease. Adhere to that, follow the rules, because there's nothing more devastating than having a patient who probably didn't need a stent with a stent occlusion, OK? So the number one, no be there if you don't have to be. If you have to be. How do we make options the most palatable and the best for the patient? Well, we talk a lot about jailing other sides. Um, so here's an example of a patient of mine that was referred. Someone jailed the contralateral brachocephalic vein with a covered stent. Um, obviously we've seen jailing of the contralateral iliac vein by bare metal stents all the time. These are not risk-free, um, and so you have to be careful where you're stenting. And so there are some really good papers about how to land your stent perfectly and now that we've got Vinovo and dedicated venous stents, you know, the excuses of, well, it's a wall stent. I, you know, it just happened to go into the jugular. OK, well that fine. You really don't have that excuse with venous stents anymore. They land on a dime. Um, and so we really, um, uh, try to do this. So there's some good papers. Jerry O'Sullivan published this nice paper on how to do this fluoroscopically, but you all know what we're gonna say. The answer is Ibis. Ibis should be 100% of the time. Um, it not only tells you the sizing and landing zone, um, contralateral inflow disease, uh, ipsilateral inflow disease, it's, it's really a tool that I think is, is, um, essential. This was actually shown in the video trial that actually looked at Ibis versus fluoroscopy alone for venous stenting, and it did show that um Ibis actually changed decision making so it wasn't just, oh it's kind of cool to see, it's like no I'm gonna do something different based on the ibis. uh, again, I think Ibis not always know to where to stent, but here's a patient with an IVC occlusion or stenosis. This patient needs a stent like stat. No, actually, when you put Ibis there it's dynamic, right? And you can see this is just physiologic respiration and in fact this patient's IVC was quite open and the stent was not needed so Ibis in this case helped me not stent, uh, which is really important. Uh, when you're stenting the iliac confluence, there's obviously different techniques. You can double barrel, uh, you can do this sort of T stent or fenestrated stent, and you can do, uh, what I call a venous CR where you put in a big IVC stent and then either go up to that stent with iliac stents or go into that stent. Um, you know, there's no right answer here. Obviously the fenestrated Y, if you can avoid it, is not the best answer. Other than that, no one, excuse me, really knows what the answer is. Um, you know, to say a word about filter bearing chronic occlusions. If you run a Venus practice, you're gonna basically run a filter practice too, uh, because we always see these kind of go in tandem. And so I will say I know I, I think there's a lot of people who make the argument just stent through filters. I don't like that as a first option. I would not want that for me or my family as a first option. Do I do it sometimes? Yeah, of course you have to sometimes, but I do think you should get comfortable with advanced filter retrieval techniques. There was a paper that looked at stenting through filters. I encourage you to read that paper. There's a lot of limitations. There's a lot of poor follow up. I'm not sure I buy that they've actually proven that it's as safe as we think it is, especially when you're talking about a patient who's got a 40 year life expectancy. Um, so with respect to stenting, you know, obviously you wanna cover all disease. If you could play the next, um, slide here, this includes, uh, here's an example of a double barrel going into the IVC. It does ovalize, um, but, you know, sometimes stays intact, um, but the idea is that you wanna cover all the disease. This includes, as Doctor Dunleavy says, going to below the inguinal ligament, going to where the inflow is optimized, and this can really be done with IbisS if you are sticking with respect to access. Don't forget, if you're sticking the common femoral vein. There is a chance you are blocking your access to where that stent is going now it's fine. You can just go through the jugular and complete the stent, but my preferred access is to sort of go mid femoral or below or certainly sometimes pop, and this way you have the entire circuit in front of you rather than sticking where you're like, oh crap, I need to stent that part and then you have to take the sheath out. In terms of stenting across the renal veins, the moral of the story is cover the disease. It doesn't matter where it is. Studies have shown that there's not a deleterious effect on kidney function if you have to stent across the renal veins, and don't forget, the reason you're stenting across the renal veins is because that juxtarenal IVC is garbage and so cover all disease. Don't be afraid to do this if you have to. And then finally I'll say I think you need to know when to quit again. There's no shame in bailing and saying I'm gonna harm this patient. Let's stop and reconsider our options. Um, there's a lot of patients I see that have endo trash. I could spend 7 hours. I say I can cross any occlusion, any occlusion I can cross. And it will have a 12 2nd patency, so what's the point, right? So think about other options, um, think outside the box. Anticipate, prepare for, and prevent complications before they happen. The left iliac vein monsters lurk there, OK? There's a big artery sticking right there. So if you're doing sharp rectalization techniques, you've got to be very cautious. Now there are ways to mitigate this, um, things like, uh, here's an example. The patient we actually had a surgical ligation of the iliac vein, had chronic, uh, symptoms for 10 years, and this patient, we actually had to go in, stent graft the iliac artery, protect it with a balloon, and then we used the RF wire to recantanalyze that, and, uh, that worked very well, but these are dangerous sort of areas, um. Again, be prepared, right? So every case I do, especially SVC, I always have a stent graft in the room. I always have occlusion balloons, you know, if you're prepared for a complication. The complications less severe. If you're not prepared, minor complications become severe complications. And that's it. And then finally I would say after the procedure, you know, you're, you're not done with the patient, uh, be, be vigilant about anticoagulation and patient compliance. Um, actually, uh, uh, Doctor Hoffman's group has done a very nice work on anticoagulation after, um, stent placement, and so we do sort of lean a little bit toward low molecular weight heparin or DOAC, um, for at least 4 weeks. And then consider lifelong or low dose um follow up all patients don't get tunnel vision, right? If they have recurrence, think well maybe my intervention didn't work maybe there's recurrence of of my intervention or maybe something else happened maybe they got mixed disease with arterial insufficiency, maybe they've got vasculitis or or rheumatologic disease, you know, sort of think outside the box that's really important. So in summary, patient selection and technique are critical to optimizing outcomes. Most venous occlusions can be crossed, but meticulous attention to details really mandatory to optimize efficacy and safety, and then post procedure care is probably as important, uh, or possibly more important than the procedure itself. Published Created by
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