Chapters Transcript Video Venous Stenting Back to Symposium All right, perfect, um, so yeah, so rapid fire we're moving into, um, deep venous disease and I'm gonna start similar to with the superficial just to give a, um, layout of where we came from, where we are, what our options are, um, and then we'll go through, you know, some cases to illustrate, you know, what, what our preferences are and what's working for our patients. I did put some, uh, odd animations on here, so I'm just gonna flip through them. Um, uh, and go back, um, so this is the history of where we came from, uh, you know, originally the early, like 1900s, late, you know, early 2000s was the, uh, Pulmo stent. I don't know if most of us had been using much of that for venous disease. Um, I was kind of hitting the tail end of that here and there when I first. Went into Venus, but mostly, um, in the 2000s it switched to wall stent, right? And then at one point there was this push, not every practice did it, but to do the wall stent with the Z stent because the ends of the wall stent are collapsible, um, and when you landed them under the, the artery or too close to a compression point, they would often collapse. So the Z stent, which is a tracheal stent. Um, is, uh, was used in conjunction with that. Come 2019, we finally had dedicated venous stent products coming out, so Vinovo, Vici, um, Silvervina, Aubre, then Duo, and most recently the Gore Fortegra IVC device was approved. So huge advantages across the field, um, certainly treatment expansion before, you know, we had these dedicated stents, the, the amount of centers that were doing venous disease certainly with any, um, skill or frequency was very low. It was hard for patients to find treatment. Um, now I think with the available technologies and the ability to collaborate on educational activities and research initiatives, we have really expanded access to care for venous patients. Some cases almost too much, um, in other cases not enough. We're, we're definitely making progress in the field. Um, the other thing that I, I find is, uh, extremely advantageous with on label stances is competition, right? So we've seen what happens, you know, with like the look at, um, Phillips, you know, um, Ibis, right? We talked about this yesterday. Some of us, it, you know, no competition, there's no drive to make continuous improvements to technology. Once you start having competition, once you have somebody on your heels, people, oh, alright, well how do we keep our market share? What can we do to make our product better, um, and that's just natural. That's not, you know, yes, it's business, but it's also natural, you know, if you have the only thing out there and everyone's using it, you don't think about why, why make it better, um, so I think this competition that also, uh, with multiple stents keeps us on our toes a little bit and moving forward. So what do we have? The classic venous stents, the Boston stent Wall stent, is now on label for venous disease, although I, I don't think it's truly a dedicated venous stent. It wasn't made that way. It doesn't really perform that way. Um, again, it is often used. Of the cookie stent, but that's not on label, um, so we're gonna look at the newer dedicated venous stents, um, and this is what is currently approved. So we have Vinovo, we have Aubrey, we have Silvervina. The Phillips duo is currently still approved, although it's not currently available. Um, they're, they are reworking some things. The Gore Fortegra device again, IVC, um, is approved that can be used with the iliac components. The iliac components by themselves are not. Um, they're similar in. Some of the materials they use and their portfolio but have differences in how they're delivered, their design, um, and some of their properties. So to we'll go through both the needs of a venous stent you can see here, um, and the one linking factor is that these are all nightinol based stents. Um, the property of this metal allows for the things that we need with flexibility, endurance, precision, and strength outside. Of using a braided stent, which is how wall stents got those properties, um, so Nanol has shaped memory, allowing it to expand at body body temperature, but it also has a super elasticity which means that it can fully recover after large deformation. So movements, axial loadings, um, this is more fracture resistant type of metal, um, and it does this by actually changing crystal structure in response. To a load and then a relief of that load, um, and this limits again those that fracture, um, that you would get with a, uh, with a stent that can't do this or a different type of metal. So we, we did have this before with Walston again, but that stent tend to foreshorten it wasn't very precise. You balloon it, it gets bigger and shorter, um, whereas this one is allows for these uh laser cut designs, um, keeping the features that we want. So all of these are Nanol based. Uh, Fortegra also has that, um, gore coding on the Nanol base, um, but the portfolios are pretty similar, um, for again Fortegra is gonna be different for most of this because it's IVC only that we're really discussing when you get into the iliac components. Um, the most commonly used sizes are 1416 across the board, and all stents have that. The lengths, um, longest lengths 120 to 160. Um, Vovo has the longest one at the 160, which can be helpful in certain circumstances, but they all have an adequate. Uh, portfolio to treat the sizes that we need. Vovo does have this flare at the ends and for those of you who use it, um, that can in theory help with some migration resistance, right, and, um, and some, uh, stent wall opposition at those locations, um, delivery systems, uh, 8 to 10 French in general, uh, Aubre's 9 French, Bonovo's varies based on the. Um, diameter of their stent duo is in the same ballpark 9 to 10 French. Those three, stents have really nice, um, delivery systems, at least the first two. The third one is in progress, um, but, uh, Ari and Vova is a nice triaxial system, uh, thumb wheel that we're used to, it's, it's pretty predictable deployment. They're nice systems that you can get what you expect. Um, Silvervina is a pin and pull, uh, which I think, you know, leads to some of its, um, difficulties with accuracy. It's a little bit hard to see, um, but it is the smallest delivery system. It goes, uh, as small as 7 French. Um, the Fortegra is gonna be also a, um, different delivery system which is similar to all of their gore devices which is gonna be a, um, a pull string, a rip cord. The strength, um, is important to understand in venous stents is why we can't use arterial stents in venous, uh, situations is that most arterial products are designed with arterials with radial strength pushing out against plaque and pushing out against the arterial wall which is strong. Um, what we need in veins is radial resistive strength because those those veins are circumferentially scarring in and you have to push against that constant circumferential load that's radial resistive strength and compression resistance, which again isn't really a factor they consider an arterial stent so you're underneath that artery with that constant push or underneath, you know, a mass or something, um, so when we're looking at strength, Aubre duo, Vinovo, um, Fortegra are all probably. On the, on the stronger side, Silvervina is, uh, not, you know, is a little bit weaker. Um, the duo hybrid has a, has a crushed segment at the top which is probably the, uh, stiffest segment, but that's only at the very top where it would be under the, under the artery. Wall stent again is, is a little bit difficult to test even because you have to have the ends fixed to tell how strong it is, um, but the ends are certainly weaker again, arterial strains the stents really are a no go. Um, flexibility they have to be more flexible than arterial stents. When you take a larger stent through the same curve, it actually, um, it, it has a, uh, higher force on it than if you take the smaller arterial stents through it. So this was a design challenge for a while. Um, when we look at flexibility, Silvervina probably is the most flexible. Aubre Vovo do a really nice job. Um, Duo extend, uh, and Fortegra are a little bit on the stiffer side, so we'll have to see how they do over time. Um, endurance-wise with fracture resistance, super important as we know this going in young patients, the standard of testing for arterial stents is 10 years. So, you know, really we should be pushing this testing to 30, 50 years. Um, we haven't clearly done that in patients at this point. Uh, fracture resistance appears to be really high in the ones that we have currently. Abre, Zilvervina, Vinovo, um, Dua and Fortegra we really can't say because again clinical, you know, applicability is where we need to see this, and we've just not seen those long enough, um, to make any opinion there. Um, overall tips with night and all stents, you wanna make sure you're not massively oversizing these with the wall stents. We do silly things like put a 20 in an iliac and it would self-fix itself, you know, you put it as 20 to start with, but it's the size it should be a couple weeks later. Um, and these kind of stents, the nightol will not self-correct. It will always try to get to the size that you put in. Um, so you can have some pretty significant back pain, uh, groin pain with really, really oversized stents. Um, typically I'm using 1 fourteens, sixteens. Um, you wanna plan your overlaps. You wanna, don't try to avoid because they shouldn't fracture, but if you were gonna fracture, you're gonna fracture overlapping on the ligament or overlapping at the pelvic turn at the top of the EIV into the CIV, um, so try to avoid those segments for overlap. I generally overlap in the mid, uh. Pelvis in the EIV where it's straighter segment, um, and these do certainly have more accurate landing you can plan for it to sometimes land just a touch higher than you than you think on your measurements just because IVIS takes the um the straight path with the the stent's gonna take the curve, um, so as it opens, um, and, and is deployed at mainland just, you know, a touch higher but not much, um, when you're looking at the results overall, um, all of the. Trials, ID trials show that there's, you know, very low rate of adverse events. The primary patency at 12 months overall was very similar across. And then even when broken out by the cohorts, what we do see is that the post-thrombotic acute DVT thrombotic populations have a bit lower patency compared to non-thrombotic, but again, pretty similar across the board. Some of the definitions varied by trials. You can't directly compare them all. Um, but they do, you know, what we're seeing is that venous stents do work and patients do get better, right? Um, when you're looking at post thrombotic and acute DVT, these thrombotic groups, they do tend to drop in patency over time. Um, and so that is something we need to pay a lot of attention to to detail in those patients. The most common reasons why these stents fail is we're missing common femoral vein disease. There's still a tendency to stay above the ligament, um, or to not take it as low in the common femoral as we need to. Some of that is access decisions. You can't see it. Um, we have a lot of poor quality inflow vessels, not a lot of good solutions, um, so you need to do what you can to maintain your. Flow, um, we do see technical errors against sticking the common femoral so you can't see that you still need to treat it. We see things like covering the profunda, um, various things, and anticoagulation decisions. If you're treating complex post-thrombotic patients, that's a no go to ever take them off their blood thinner. Um, but I do routinely see, oh, stent looks good, 6 months later, take them off, um, even without checking a clotting panel, but they still have an occluded femoral vein and they still have scar tissue in their profunda. Um, so patients with post-traumatic disease generally still require, uh, long-term anticoagulation. Um, so we do certainly still need some, some education across the field events like this and more to kind of get everybody up to speed, and we still need advancements in technology for these patients because it's not all about us not knowing, you know, all the details. We're, we're limited, right? Like we can treat the inflow, we can balloon the inflow, we can stent right to the profunda, um, but if, you know, at some point we're, we're running out of options for some of these. Patients. But overall, these patients all showed in the trials that there's significant improvements in their life, in their quality of life, and their functional assessments, um, across all cohorts. So from the non-thrombotics to the post-thrombotics and the QTVT, they all generally got better. Um, these can be done with various stents, um, but I do think that, you know, we have developed our, our preferences, um, as we go along. In, in my practice, I'm, you know, using more of the newer dedicated stents, staying away from wall stents. I don't have silvervina in my practice. Um, in summary, I think you can get really good results. Um, just got to really pay attention to details, particularly in the more advanced patients. And we're going to cover some acute DVT tips and tricks and cases and then some chronic, um, tips and tricks and cases and hopefully, um, you'll pick up a, a few things on the way. All right, thanks, everybody. Published Created by
Content on this site is intended for United States Healthcare Professionals Only
